Sex, Gender, And Sexuality Diversity Among Autistic Adults

Sex, Gender, And Sexuality Diversity Among Autistic Adults
by Lisa Macafee

Autistic people have been shown through numerous studies to have higher rates of transgender, non-binary, gender diversity, and gender non-conforming identities and there are also heightened rates of autistic traits in the transgender community.  Gender variance in autistic individuals assigned female at birth (AFAB) have the highest rates of gender, sex, and sexuality variance (Kung, 2020).  Biological sex differences present among autistic adults assigned male at birth (AMAB) and AFAB are discussed, including sex trait atypicality and intersex traits more frequently present among AFAB autistics.  Sexuality in autistic adults, including increased rates of asexuality, a-romanticism, pansexuality, demisexuality, bisexuality, gay, lesbian, same-sex-loving, and polyamorous identities is discussed. 

Autism and Gender Diversity

Gender for autistic people is often perceived as a spectrum of many genders rather than a male/female binary and with an understanding that a person’s gender identity will develop differently due to the biological nature of the person, the culture they were raised in, how supported they are in their home, and will change over time and should not be considered static (Ehrensaft, 2018).  Autistic people are six to eight times more likely to be transgender or gender non-conforming (Warrier, et. all, 2020) and transgender people are three to six times more likely to be autistic (Cooper, et. all, 2022).  11.3% of autistic adults express gender variance as compared to 0.7%-5% of the neurotypical population (Pecora, et. all, 2020).  These differences are thought to be due to autistic resistance to social conditioning around gender and not feeling compelled to conform to gender norms as neurotypical individuals may feel the need to do (Cooper, et. all, 2022).  Autistic individuals are 7.76 times more likely than neurotypical individuals to wish they were the opposite sex from what they were assigned at birth, with about 5% of autistic people wishing they were opposite gendered than they are (Janssen, et. all, 2016).  Some of this gender flexibility may be due to rigid thinking associated with autism and a logical deduction that if gender expectations are not 100% met for the autistic person’s assigned sex at birth, then that logically may cause them to adopt a transgender or non-binary gender identity because they don’t fit with gender stereotypes (Pecora, et. all, 2020).

Gender Diversity and AFAB Autistics

Autistic people are more likely to be gender non-conforming or transgender and often experience gender stress and social anxiety due to their gender identity (Ehrensaft, 2018).  Autistic people may not experience gender at all, they may express and experience gender differently as a neurodivergent individual and while understanding they are told they are a boy or a girl, may have very little affinity or alignment with gendered terms until puberty forces a physical reckoning with gendered roles and often a consequent rejection of expectations (Ehrensaft, 2018).  AFAB autistic adults have the highest rates of gender flexibility and often present a masculinized autism profile, while AMAB autistics did not show a feminine autism profile (Kung, 2020).  Gender roles can be confusing or irrelevant to autistic people, and some autistic AFAB people adopt masculine presentation because it is simpler, involves less social navigation, and is easier to navigate than wearing make-up and fashionable women’s clothing (Milner, et. all, 2019).  Impaired social navigation associated with autism may have led to difficulties for AFAB autistics to socialize with women and increase the likelihood of socializing more with men and associating the self more with a male gender identity (Jones, et. all, 2012).  Lastly, AFAB autistics often experience autism related challenges in socialization that make it difficult to maintain friendships with neurotypical girls, which often leads to friendships with men because they typically engage in less small talk, emotional discourse, are more socially forgiving than women, leading to a more male gendered experience (Milner, et. all, 2019). 
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15% of autistic adults report a transgender or non-binary gender identity with 21.6% of AFAB autistics reporting a transgender identity with only 4% of transgender AFAB autistic people identify on the male/female binary, 96% of AFAB transgender autistics identified as non-binary, which leads to speculation regarding why gender identity leans away from the binary in AFAB autistics (Walsh, et. all, 2018).  The gender flexibility that autistic people often experience aligns with the fact that non-binary people have the highest rates of autism as compared to all other gender identity groups, the resistance to social conditioning that autistic people often experience may lend to their adopting unconventional gender identities that neurotypical people may not have felt comfortable acting as, even if they felt aligned to that gender identity (Walsh, et. all, 2018).  It could be simply that autistic people are less prevented from expressing their inner transgender or non-binary identity due to less social constraints and conditioning than neurotypical people.  Autistic AFAB people may express their gender identity in less typical ways due to the lack of inherent social expectation internalization, whether they are transgender (such as being more likely to be non-binary), or if they are cisgender, by being gender non-conforming and engaging in masculine behaviors or gender performance because it is more comfortable or less demanding than the female gender role performance expectations (Janssen, et. all, 2016).

Autism and Transgender Identities

Transgender people overall are about eight times more likely to be autistic than the cisgender population, and youth are more likely to identify outside the gender male/female binary and embrace a gender spectrum instead of a gender binary (Ehrensaft, 2018).  Transgender adults overall are 3.03-6.36 times as likely to be autistic as compared to cisgender people and also reported they did not feel the need to conform to gender stereotypes for their gender identity (Cooper, et. all, 2022).  Transgender AFAB men are 11 times more likely to qualify for an autism diagnosis than cisgender men (Jones, et. all, 2012).  Transgender and non-binary AFAB adults are twice as likely to qualify for an autism diagnosis compared to cisgender women (Nobili, et. all, 2018).  More than a third of transgender AFAB people meet autism diagnostic cut-off rates (Nobili, et. all, 2020), which is much higher than the less than one percent rates of transgender AMAB and cisgender people (Cooper, et. all, 2022; Heylens et al., 2018; Jones et al., 2012; Nobili et al., 2018). 

Transgender men scored 9.02 standard deviations higher and non-binary AFAB scored 8.38 standard deviations higher on the autism quotient survey than cisgender people (Kung, 2020).  15% of transgender men, 19% of non-binary AFAB, 3% of transgender women, and 2% of non-binary AMAB meeting the cut-off point for a likely autism diagnosis (Kung, 2020).  Autism is diagnosed in 6% of transgender individuals, which is six times higher that the typical rate of autism and if criteria is expanded to look at a broader autism phenotype, 19.4% of gender diverse youth have elevated autistic traits (Heylens, et. all, 2018).  Transgender and gender diverse individuals have high rates of autism, other neurodevelopmental disorders such as ADHD, and higher rates of psychiatric diagnosis such as anxiety, depression, obsessions compulsive disorder (Cooper, et. all, 2022; Warrier, et. all, 2020).

Autism and Sexuality

Autistic adults, especially those AFAB, show increased flexibility in sexuality, which can be thought of as a combination of sexual identity, sexual attraction, and sexual contact (Pecora, et. all, 2020).  15%-35% of autistic adults overall reported exclusively gay or bisexual orientations compared to 5.4% of neurotypical adults (Pecora, et. all, 2016).  Some propose that the lack of internalized social rules autistic people experience allows them to engage in acts where neurotypical people prevent themselves from acting differently than they have been taught is socially acceptable.  In a sense, not internalizing social norms may allow autistic people to be more flexible in their thoughts and actions than neurotypical adults.  Autistic adults are associated with higher rates of gender and sexuality diversity, identities that have both increased in frequency, possibly due to increased ability to build online communities that normalize differences and allow discourse and healthy identity building for marginalized groups (Øien, et. all, 2018).

Autism and Lesbian, Gay, Bisexual, and Pansexual Identities

AFAB autistics identify as bisexual four times more frequently than neurotypical women and this is more frequently combined with masculine gender role expression and more of a male gender identity (Pecora, et. all, 2016).  In addition, AFAB autistics are 2.39 times more likely to be gay or lesbian and 2.33 times more likely to be bisexual as compared to neurotypical women (Pecora, et. all, 2020).  AFAB autistic people are more likely to be attracted to multiple genders and be gender non-conforming themselves (Dewinter, et. all, 2017).  Gender flexibility in the self could influence sexuality in that if the individual themself does not abide by binary gender roles, it may be easier to disregard or expand upon which gender a person is attracted to.  About half of AFAB autistic adults are in relationships, most living with their partner (Dewinter, et. all, 2017) but many autistic people experience challenges finding and maintaining sexual and romantic partnerships (Pecora, et. all, 2020).  Many autistic people turn to the internet for sex education, which can further harm their understanding of appropriate behavior in relationships an encourage inappropriate behaviors (Maggio, et. all, 2022).  This lack of sexual access and information could influence some autistic people to broaden their search for partners into genders that, if they were more socially able to find partners, they would not have considered, leading to sexuality flexibility, and in others can lead to inappropriate or dangerous sexual activity (Gilmour, et. all, 2012).  Autistic traits seem to complicate sexual orientation and identification or make it easier to identify outside typical expectations (Maggio, et. all, 2022).  Individuals who identify with bisexual (attracted to both men and women) or pansexual (attracted to all genders) identities often are aware of their sexuality later than gay or lesbian individuals, which could add to confusion or flexibility for autistic adults (Bishop et. all, 2020). 

Autism and Asexual, Aromantic, Polyamorous, and Other Queer Identities

AFAB autistics have less sexual desire, less sexual and romantic functioning, less engagement in sexual activities, combined with higher sexual anxiety, and higher sexual problems when compared to neurotypical women (Pecora, et. all, 2020).  Asexuality, defined as a lack of sexual desire, and objectophilia, a sexual desire for inanimate objects, are more common identities for autistics (Maggio, et. all, 2022).  One study estimated that up to 33% of autistic adults appeared to be asexual, but whether this was situational, or a true lack of desire was not determined, asexual identities may be reported due to difficulties in social communication, challenges attaining and maintaining relationships, and sensory challenges associated with autism rather than lack of desire (Gilmour, et. all, 2012).  More recent studies found autistic adults have the same sexual desire as neurotypical adults (96% of both have sexual desire) (Maggio, et. all, 2022), and autistics AMAB have been found to engage in sexual activity and have more desire as compared to AFAB autistics (Pecora, et. all, 2016).  Autistic lesbian and gay AFAB people are 3.17 times more likely than straight autistic AFAB people to experience unwanted sexual behavior and sexual victimization due to being overly trusting or not picking up on social cues that neurotypical women may perceive more readily as red flags (Pecora, et. all, 2020).  Negative sexual experiences may factor into autistic AFAB people identifying more readily with asexual and aromantic identities, as negative sexual experiences can impact a person’s desire or willingness to engage in situations that have previously been harmful.

Autism and Sex Differences

Contemporary sex definitions are less binary and more malleable than the traditional male/female presented, and youth are more likely to see sex and gender as a spectrum, rather than a binary (Schudson, et. all, 2019).  Considering the ability for people to change their biological sex markers through surgery, it is understandable that people are considering sex as a spectrum instead of a static binary.  Add to this a growing awareness of intersex identities, including hormonal, chromosomal, or secondary sex characteristic development not matching the sex assigned at birth, and sex identity can become much more complex for autistic people who have a higher rate of androgynous features (Roen, 2019).  Research in transgender individuals demonstrates that there may be a biological basis for gender identity that is separate from physical anatomy, such as differences in neuron number and volume in the stria terminalis (Walsh, et. all, 2018).  There are a number of physical anomalies associated with autism that may also influence sexuality and gender identity, including brain function differences, biological sex differences, poly-cystic ovarian syndrome (PCOS), and androgen differences (Gasser, et. all, 2022). 

Biological Sex Differences in Autism

Autistic people have a number of atypical physical traits in addition to their neurology that can complicate identity.  Their hypothalamus, pituitary, and adrenal glands often function at an impaired rate (Gasser, et. all, 2022).  There is an association noted between high birth weight and increased rates of gender non-conformity and autism (Heylens, et. all, 2018) and transgender AFAB autistics have autism profiles more similar to cisgender men than women, which imply causal or correlating factor of gender from autism (Nobili, et. all, 2020).  Autistic brains have less connectivity and dimensional variation from typical brain connectivity, but it is not clear whether these patterns develop because of autism or cause autism themselves (Paul, et. all, 2021).  Higher autistic traits correlate with higher regional structural brain network efficiency, supporting rigidity of logical thought, routines, and structure common to autism along with difficulty with processing new ideas or conflicting information (Paul, et. all, 2021).  Other physical characteristics more common among AFAB autistic adults are more masculine digit ratios, the ring finger being longer than the index finger, and higher facially masculine traits as compared to neurotypical adults (McKenna, et. all, 2021).  Conversely, some autistic men demonstrate more feminine facial features and digit ratios, suggesting androgynous features are an indicator of autism in both AMAB and AFAB adults (McKenna, et. all, 2021).  Facial masculinity has been found to be predictive of neurodevelopmental conditions and both facial masculinity and masculine digit ratios are associated with impaired social functioning (McKenna, et. all, 2021)

Low levels of progesterone are associated with autism and can lead to hirsutism, asexuality, bisexuality, PCOS, irregular menstrual cycle, dysmenorrhea, and higher rates of ovarian, uterine, and prostate cancer in families (Gasser, et. all, 2022).  PCOS, the presence of cysts on the ovaries with increased testosterone levels, and delayed menarche are two testosterone linked medical conditions that are present at elevated rates among AFAB autistics (Jones, et. all, 2012).   11.6% of mothers of autistic children had PCOS while they were pregnant, lending credence to male hormone levels in utero increasing the likelihood of autism (Shah & Bobade, 2018).  Higher testosterone levels in autistic AFAB people may contribute to associating more with male gender roles (Jones, et. all, 2012). 

Androgen and Testosterone Pre-Natal Exposure

Steroid production, especially androgen hormones are atypical in autistic people, with less progesterone and increased androgen levels, and mothers of autistic people reported low progesterone levels during pregnancy (Gasser, et. all, 2022).  Higher rates of male hormones in utero are linked to higher rates of autism diagnosis and higher rates of gender diversity (Heylens, et. all, 2018; McKenna, et. all, 2021).  Testosterone affects social connections and higher testosterone levels can mean less interest in socializing (Nobili, et. all, 2020) while lack of progesterone can inhibit a person’s ability to interact well to support well-being of others (Gasser, et. all, 2022).  In addition to pre-natal androgen exposure, there are also links between testosterone in adults and autism related traits, including impaired language skills (McKenna, et. all, 2021).

The “extreme male brain” theory of autism has been supported in previous studies showing higher androgen exposure rates are associated with increased systematizing tendencies, less typical female gender role presentation, reduced ability to take another person’s perspective (theory of mind), and decreased empathy (Kung, 2020).  For some AFAB autistics, increased rates of testosterone lead to an androgynous physical development that can lead to discrimination and harassment, cause confusion about gender identity, or lead to adopting a transgender or non-binary identity (Jones, 2021).  Another theory to explain AFAB autistic sexual and gender fluidity is heightened prenatal testosterone often present in autistic pregnancies leading to more masculine traits, presentation, gender identity, and sexuality (Pecora, et. all, 2020).  Interestingly, increased pre-natal testosterone is also linked to gay identity development and feminized gender identity for autistic cisgender men (Pecora, et. all, 2020). 

Discussion for Section

Gender non-conformity is prevalent among autistic adults, especially those AFAB, who have higher rates.  Transgender people have higher rates of autism than the cisgender population, with transgender men and non-binary AFAB people having the highest rates of autistic traits (Nobili, et. all, 2018).  A limitation of many studies is relatively small sample sizes in studies with interviews from one study with 21 individuals (Cooper, et. all, 2022) or 22 individuals (Strang, et. all, 2018), and quantitative studies often having sample sizes of less than 100 transgender individuals (Heylens, et. all, 2018; Kung, 2020; Walsh, et. all, 2018).  Many of the research studies looking into gender diversity and autism used the Autism Quotient, a free self-reporting online assessment to determine the degree of autistic traits, which can yield distorted results if respondents mask and change answers to fit expectations or are unsure or ashamed to report their autistic traits (Kung, 2020). 

There is some contention as to the correlations between autism and gender diversity from a transgender perspective, some theorize that autistic traits such as social anxiety, deficits in communication, and rigid thinking may be mimicked by trauma and that transgender people may simple have elevated autistic traits and not be autistic (Nobili, et. all, 2020).  Many studies on the brain function of autistic transgender people could be distorted by elevated rates of anxiety and depression and many of the studies on transgender autistic people viewed transgender identities not as a different and valid way to live but under the gender dysphoria deficit framework that may skew results from research participants who do not feel as comfortable sharing if their words are portrayed in a negative light and may skew interpretation of data collected (Walsh, et. all, 2018).

There is also controversy over the extreme male brain theory of autism, some studies have not been able to verify the correlation between pre-natal androgen exposure and increased rates of autism (Kung, 2020; Heylens, et. all, 2018).  Digit ratio as a measure of androgen exposure may not be a reliable measure as it is found that digit rations tend to become more feminized with age and inconsistent results are been found, some indicating that most autistic people have masculine digit ratios, and some suggesting that AFAB autistics have masculine and AMAB autistics have feminine digit ratios (McKenna, et. all, 2021).  Another concern is that much research on autistic populations was sampled from group homes, which may skew results, as group home residents are more reliant on their caregivers and may internalize the viewpoints of those in authoritative positions (Gilmour, et. all, 2012).

An area that research does not well cover is why AFAB autistic people have higher rates of gender and sexuality divergence.  An area of need is in researching non-binary identities and autism, much research is still presented using gender binaries and may include transgender men and transgender women,.  As autistic people lean more towards the gender spectrum instead of binary gender identities, and may not identify with any gender at all, there is not a strong body of work researching non-binary identities (Ehrensaft, 2018) even though up to 3.9% of the adult population identify as non-binary (Walsh, et. all, 2018).  Another area of need in research is in AFAB autistics in general, as most research has relied on the autism diagnosis rates of four males to one female (although rates are estimated to be more accurate at three to one), most research is centered on the male autistic profile and female autistic profiles are underdiagnosed and less understood (Milner, et. all, 2019; Walsh, et. all, 2021).   

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