A couple of years ago, it was impossible to be both transgender and mentally healthy—at least according to the International Classification of Diseases, an enormous guidebook doctors the world over used to diagnose their patients. For decades, “transsexualism” and “gender identity disorder of childhood” sat beside personality disorders and paraphilias, or atypical sexual interests, in the ICD’s mental illness section.
Finally, in the edition that took effect last year, gender-related diagnoses were reclassified as sexual health conditions, a major move toward destigmatizing transness. Around the same time, the World Professional Association of Transgender Health (WPATH) updated its guidance on the medical treatment of transgender people to no longer recommend a full psychological assessment before someone can obtain hormones or gender-affirming surgery. “There is a letting go of older models that saw trans identities as a mental illness to be questioned and potentially ‘cured,’” says Laura Erickson-Schroth, chief medical officer at the Jed Foundation, who contributed to that updated guidance.
But just as the medical establishment has moved in one direction, political forces have pushed the opposite way. In April, the attorney general of Missouri introduced an emergency rule that would have required all clinicians providing gender-affirming medical care to screen their patients for autism and ensure they have no current “psychiatric symptoms.” Patients would also have had to receive almost two years of therapy focused on their gender identity.
The emergency rule, which represented a direct attack on the medical autonomy of trans adults among a recent flood of anti-trans policy, was ultimately blocked by a judge. But in specifically targeting autistic trans people and trans people who may be experiencing mental health conditions, it reflects a powerful strand of rhetoric in the anti-trans movement. Some research has suggested that trans people may be statistically more likely than their cis peers to be autistic or to experience mental health conditions, an idea that anti-trans campaigners have leveraged to cast doubt on the validity of trans identities. They assert that some trans people are “really just autistic” or “really just mentally ill” and won’t respond well to gender-affirming care—medical interventions such as hormone therapy and surgery to support their gender identity.
While it is conceivable that autistic people or those with certain types of mental illness could fare worse than their neurotypical peers after receiving gender-affirming care—there’s little evidence on either side. But Florence Ashley, an assistant professor of law at the University of Alberta, says a lack of evidence can’t be used to deny people the care that they choose for themselves. “The burden is not on trans people to prove the importance of gender-affirming care,” they say. “It’s on those who want to force barriers to care, or remove access to gender-affirming care, to prove that that’s absolutely necessary.”
The Missouri emergency rule cites research drawing links between trans identity and the frequency of mental illness or autism—but no studies proving that mental illness or autism lead to poor outcomes in gender-affirming care. There’s a good reason for that: There are no such studies. One study found that neurodiverse people and those experiencing mental illness are less likely to complete their intended courses of gender-affirming care, but it did not evaluate why—and factors unrelated to poor medical outcomes, like socioeconomic difficulties, could play a role. Another study found that autistic youth were no more likely than non-autistic youth to change their requests for gender-affirming care, but the group was too small to demonstrate anything conclusive.
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In the absence of rigorous research, attacks on gender-affirming care that cite psychiatric conditions appear to rest on a presumption that autism or mental illness could somehow make a person believe, incorrectly, that they are trans. Broadly speaking, that idea holds little water. In very rare cases, someone with schizophrenia or a related illness may temporarily believe that they are a different gender while having a psychotic episode, but there’s little reason to think that mental health conditions could prompt someone to seek gender-affirming care.
On the other hand, there’s plenty of evidence that being trans in a hostile society can contribute to poor mental health. Trans people must endure daily discrimination, and for the past few years they have watched themselves become major political targets. Some are rejected by their families and have little social support. All of these burdens appear to worsen mental health. Importantly, gender-affirming care may actually improve mental health and quality of life, and it could even reduce the risk of suicide. According to a just-released study from Denmark, trans people are markedly more likely to die by suicide than cis people, which makes the potential benefits of gender-affirming care all the weightier.
Autism presents a slightly different case. Some researchers have speculated that autistic people may want to transition due to specific autistic traits: because they have a sensory aversion to the trappings of the sex they were assigned at birth, like body hair or stiff clothing, or are fixated on the idea of transition. But Anna van der Miesen, a physician and researcher at the Center for Expertise on Gender Dysphoria in Amsterdam, has found that transness is associated with all components of autism, not just obsessive behaviors or sensory difficulties. Based on her work with autistic clients, Van der Miesen says that autistic people might simply feel less pressure to conform to gender norms and so express their gender variance more openly.
That idea has yet to be rigorously tested, but that is also true of all the other theories about autistic people and trans identity. Without any definitive science available, Finn Gratton, a psychotherapist who specializes in working with trans and autistic clients and is autistic and genderqueer, says that such beliefs ultimately come down to bias. Parents and lawmakers are operating on the misguided assumption that “autism makes a person an unreliable witness of their own experience,” they say. “There is no more reliable witness than the person at the center of that experience.”
Gratton worries that rather than protecting autistic people and those with mental health concerns, policies like the Missouri rule could make life much more difficult for them. If trans people who are autistic or experiencing mental health conditions fear that a diagnosis could prevent them from accessing gender-affirming care, they might attempt to hide their neurodivergence from medical providers. For autistic people, this might prevent them from accessing support at work or school, and people struggling with mental illness might be afraid to seek appropriate care or support. Even without any current limitations on care, people might hesitate to get a diagnosis if they fear such limitations will be enacted in the future.
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Psychological care can be important for various reasons. Some people may need a degree of support to undergo medical treatments: A person with severe depression, for example, might struggle to keep up with post-surgical care. For others, psychotherapy could be an important step in the process of deciding to transition. Some people who have detransitioned—that is, resumed living as the sex they were assigned at birth—do attribute their decision to undertake gender-affirming medical care to mental illness, though research on that population is still extremely limited. But even if it were to turn out that having a history of mental health concerns makes detransition more likely, that would hardly imply that people should be prevented, or even dissuaded, from transitioning. Drivers experiencing mental illness may be more likely to get into an accident, but it would be absurd to propose that no person with a mental health condition be permitted to operate a vehicle.
Most experts agree that forcing trans people to seek counseling before they can access hormones or surgery isn’t appropriate—WPATH specifically states in its guidance that psychotherapy should never be a requirement for obtaining gender-affirming care. “Not everyone is in a place on their journey where therapy is necessary or a priority,” Erickson-Schroth says. Many trans people spend years working with their gender identity, with or without professional support, before deciding to medically transition. The far bigger problem, Erickson-Schroth says, is access: Some trans people who do want therapy will struggle to access it. Therapy can be expensive, and therapists with expertise in gender identity are hard to find in some regions.
Politicians who want to restrict gender-affirming care often claim that they are trying to prevent regret, and they frequently call on people who have detransitioned to substantiate their positions. But as important as those individual stories are for the people who lived them, they are only anecdotes: One autistic detransitioner does not prove that autistic people are likely to detransition. And even if scientists eventually find traits that predict detransition, that won’t be an adequate reason to prevent a whole demographic of adults from voluntarily accessing gender-affirming treatment, Ashley says.
“It’s impossible to live a human life without risking regret,” they say. “That’s part of the messiness of human existence. But it’s quite a jump from there to say that this somehow justifies cracking down on autonomy, and cracking down on gender-affirming care in particular.”