Working With Autistic Transgender And Non Binary People

Working with Autistic Transgender and Non-Binary People: Summary

Executive Summary

This foundational text challenges the medical and psychiatric models that frame both autism and transgender identities as deficits requiring correction. Instead, it positions these as forms of neurodiversity and gender divergence deserving validation and support. The book provides a comprehensive framework for professionals working with autistic transgender and non-binary people, centering the voices and lived experiences of those navigating these intersecting identities. Its distinctive contribution lies in explaining why autism and gender variance frequently co-occur—not as pathological outcomes but as expressions of autistic cognition that allow clearer recognition of imperfect social systems like gender norms. The text emphasizes autonomy, presume competence, and the right to self-determination while providing practical guidance for assessment, communication, and support.

Overview

The book establishes three core theoretical frameworks that distinguish it from other works on this topic. First, it presents autism through the neurodiversity model—recognizing it as a variance in perception, specifically monotropic attention patterns, with distinct sensory processing differences. Second, it introduces the double empathy problem, which frames communication difficulties as mutual rather than solely an autistic deficit. Third, it applies these frameworks to understanding gender identity development in autistic people, arguing that autistic cognition—systematizing, bottom-up processing, and flattened priors—enables recognition that gender norms are inconsistent systems that don’t fit everyone’s actual experience.

Throughout the text, the authors challenge deficit-based theories suggesting autistic people transition because of “rigid thinking,” “restricted interests,” or “confusion.” Instead, they propose that autistic people may have greater clarity about gender identity precisely because they’re less susceptible to social pressure and more likely to recognize contradictions in gender role systems. The book prioritizes identity-first language (“autistic people” rather than “people with autism”) and emphasizes that even autistic individuals with intellectual or psychosocial disabilities can understand and consent to transition-related treatment.

Autism and Neurodiversity Framework

Autism is presented not as a disorder but as a fundamental difference in how people perceive and process information. The neurodiversity framework recognizes autism as a variance with distinct strengths and challenges rather than a pathology to be cured. Key concepts include:

• Monotropic attention: Autistic people tend toward intense, focused attention rather than diffuse attention to multiple stimuli
• Sensory processing differences: Distinct experiences of sensory input that can include hypersensitivity, hyposensitivity, or both
• The double empathy problem: Mutual difficulty in understanding between autistic and non-autistic people, not solely an autistic communication deficit

The book emphasizes that understanding autism through this lens is foundational to supporting autistic transgender and non-binary people because it shifts the professional’s role from “fixing” to supporting. When autism is viewed as difference rather than deficit, gender diversity in autistic people becomes evidence of insight rather than symptom.

Sex, Gender, and Gender Variance: Core Definitions

The text carefully distinguishes between sex (biologically determined reproductive function and visible genitalia) and gender (culturally constructed social classification into masculine/feminine categories). However, it emphasizes that these interact continuously from conception through adulthood—biological and societal factors cannot be cleanly separated in practice. Key distinctions include:

• Transgender: People whose gender identity differs from their assigned birth gender
• Non-binary: People who identify outside the male/female binary (both terms are umbrella categories with overlap)
• Cisgender: People whose gender matches their assignment at birth
• Gender transition: Can occur through social means (name change, pronoun use, clothing, legal documents), medical means (hormone replacement therapy, gender-confirmation surgeries), or both depending on individual needs
• Gender dysphoria: Distress from incongruence between gender identity and bodily characteristics that often motivates transition to improve mental health

Importantly, the text emphasizes that gender identity is independent from sexual orientation—these are distinct aspects of identity that should not be conflated in assessment or support.

Diagnostic Bias and the Historical Autism-Gender Ratio

Historically, autism diagnosis showed a 3:1 to 5:1 male-to-female ratio, accompanied by theories like the “Extreme Male Brain hypothesis” claiming autistic traits are extreme versions of typical male neurology. This research centered how autism presents in boys, missing presentations more common in girls and gender-diverse people.

Recent “female autism phenotype” research notes autistic girls present more internalized profiles with subtle presentations, masking, and typically feminine interests. However, this neurotypical-centered research ignores autistic people’s own diverse gender perspectives. Autistic research prioritizing autistic voices finds autistic people view gender identity as far more diverse, centering interests rather than gender in identity perception.

Critically, autistic people repeatedly describe “doing gender”—performing expected gendered behaviors—as confusing, exhausting, and emotionally taxing. This explains why many explicitly reject binary gender norms. The text argues that higher rates of gender diversity among autistic people may reflect either reduced susceptibility to social pressure or greater clarity about gender identity rather than confusion.

The Autism-Gender Variance Overlap: Competing Explanations

Research shows 3–10 times more autistic individuals present at gender identity clinics compared to the general population, and approximately 30–40% of autistic individuals without learning difficulties identify as having gender fluidity or gender neutrality. The book critically examines theories explaining this overlap.

Flawed deficit-based theories suggest autistic people transition because: restricted interests in “feminine” things cause gender confusion; rigid autistic thinking causes misinterpretation of interests as proof of wrong gender; autistic “empathy deficits” allow easier coming out without social constraint; or bullying causes gender identity confusion. These theories position transition as pathological outcome of autism rather than legitimate identity expression.

Better explanatory frameworks grounded in autistic cognition include:

• Imperfect systems theory: Autistic people use systematizing (rule-based, logical) approaches to understanding social constructs. When applied to gender roles defined by cisgenderism, autistic people recognize these as “imperfect systems” failing their own rules, leading them to reject cisgender constraints. If gender rules state “boys do X, girls do Y,” an autistic person observing themselves doing both may recognize the system as inconsistent and reject it entirely.

• Bottom-up processing advantage: Autistic people rely less on top-down category rules (like “only two genders with fixed criteria”) and more on bottom-up evaluation of actual experience. This allows them to categorize gender outside rigid pre-existing frameworks, recognizing when binary categories don’t fit their actual experience.

• Flattened priors theory: Autistic people rely less on predictions based on past experience, maintaining greater uncertainty about what future experiences mean. Social conditioning creates steep priors (expectations) that gender is fixed, binary, and tied to anatomy. Flattened priors make it easier to overcome this conditioning and recognize gender incongruence. Additionally, autistic people are often less motivated by others’ approval and may not invest heavily in fitting assigned gender roles, prioritizing factors more immediately affecting well-being (sensory processing comfort, interests, safety).

Youth Liberation and Disability Justice Approaches

The text presents a radical challenge to paternalistic approaches: children and disabled people are full people with equally valid rights and interests distinct from caregivers’. The need for support doesn’t diminish autonomy rights or capabilities. Paternalism—the belief that neurotypical, cisgender adults know what’s best for children and disabled people—causes harm equivalent to or exceeding intentional malice.

Historical context demonstrates this harm: Both Applied Behavior Analysis (ABA) and conversion therapy trace to Ole Ivar Lovaas’s 1960s-70s work. ABA aimed at making autistic children indistinguishable from peers through operant conditioning, historically using extreme punishment like cattle prods; modern “positive” ABA still functionally restricts access to preferred communication and comfort. Lovaas’s work explicitly stated goals of “forcing [children] to act normal” and included experiments punishing gender-variant children for feminine behavior, with documented suicides among subjects. Conversion therapy aimed at forcing LGBTQ+ youth toward heterosexuality and cisgenderism, using aversive interventions including electric shock. These historical practices demonstrate how “for their own good” justifications enable systematic abuse.

Alternatives to paternalism include: support without coercion or pain; teaching skills enabling safe autonomy; providing maximum control possible even in constrained situations (e.g., choice of which arm for injection); recognizing children as full people experiencing pain and remembering trauma; and distinguishing between who someone is versus what adults want them to become.

Supporting autistic transgender children requires: (1) Focusing on the individual child, not talking points—set aside biases to learn their actual needs; (2) Providing language and knowledge for understanding identity, as labels are crucial for self-understanding; (3) Connecting them with autistic transgender adults as mentors and resources; (4) Advocating on their behalf while respecting privacy decisions; (5) Identifying and providing accommodations (plain-language explanations, communication devices, sensory processing accommodations around medical care, attention to comorbid conditions); (6) Validating identity while allowing for future changes—puberty is as hard to reverse as medical transition, and validation builds trust; (7) Always having the child’s back—they need to know adults can choose kindness.

Gender Performance, Masking, and Intelligibility

Judith Butler’s theory of gender performativity argues gender exists only through stylized, repetitive performance of gendered acts—it’s not an expression of an inner self but construction through imitation of dominant conventions. Applied to autism: autistic ways of being naturally subvert gendered expectations because autistic people struggle to mimic others and identify gender norms to perform them.

Masking, scripting, and passing are survival tools used by marginalized people. Masking involves suppressing identity to go unnoticed (e.g., not stimming publicly, conforming to gender expectations). Scripting is performative—adopting behaviors from peers, media, or constructed personas to blend into society. Precognition means mentally mapping possible outcomes of social interactions in advance, scripting reactions to each scenario to steer toward “win states” and avoid harm.

One author spent 30 years passing as a cisgender neurotypical man, earning labels like “talented” and “intelligent,” while internally feeling confused, drained, and unsafe. After autism diagnosis and realizing her non-binary identity at 32, she faced immediate rejection—within hours of disclosure, friends and professional contacts abandoned her. Precognition becomes obsessive and dissociative when used constantly; it disconnects people from present moments and makes them extremely reactive to schedule changes or unexpected outcomes. Long-term costs include cynicism toward praise, difficulty trusting others, self-loathing, and deep isolation.

However, autistic people demonstrate willingness and ability to mask for social harmony, contradicting theories that autism prevents gender identity concealment. The tension between authenticity and safety is acute for autistic trans/non-binary people navigating overlapping intelligibility challenges—their gender identities don’t fit dominant cultural frameworks, and their autistic communication styles compound this incomprehensibility.

Double Empathy Problem and Gender Communication

The double empathy problem states communication difficulties are mutual, not solely the autistic person’s deficit. Applied to autistic transgender/non-binary people: they face two-fold intelligibility challenges—different communication frameworks from allistic people AND different gender frameworks. Most of their environment uses both frameworks differently.

Autistic people often already bridge communication gaps; allistic people may see their role as merely tolerating rather than actively participating in bridge-building. This compounds anxiety and may pressure autistic trans/non-binary people toward excessive compromise, prioritizing others’ comfort over themselves. Clarity in communication prevents both autistic people detecting hints wrongly and trans/non-binary people detecting unintended hostility. Professionals must actively bridge communication gaps, not merely tolerate them, by using clarity, directness, explicit communication, and active education of people in the person’s environment.

Interoception, Alexithymia, and Gender Identity

Interoception—sensing internal bodily states like hunger, heartbeat, arousal, and emotional states—differs significantly in autistic people and relates to alexithymia (difficulty identifying and describing emotions and bodily sensations). About 50% of autistic people experience alexithymia, compared to 5-8% in the general population. For autistic transgender/non-binary people, these differences profoundly affect gender identity development and dysphoria experience.

Poor interoception may delay gender identity recognition for years or decades—people may not recognize physical dysphoria signals until later life. Without interoceptive connection to bodily signals, gender identity formation is compromised. One author describes knowing her breasts “were not supposed to be there” from age 11 but not understanding why until age 22—an 11-year gap between action (binding) and understanding (gender identity recognition).

Additionally, dysphoria itself increases dissociation, making interoceptive signals harder to access, creating a feedback loop. After gender-affirming surgery, she experienced improved bandwidth for noticing other bodily signals and decreased dissociation, though interoception itself didn’t fundamentally improve. Sensory processing differences also intersect with gender—genital discomfort, sensory aversions to clothing textures, or difficulty with typical medical care—requiring specific accommodations that distinguish sensory from gender issues.

Professional Practice Guidelines: Three Core Principles

Be Open: Set aside pathological frameworks denying individual experience. Trust the service user. Don’t assume language preferences about gender or body parts. Listen to what’s being said rather than relying on societal assumptions. Presume competence regarding individuals’ understanding of their own lives, bodies, and identities—even autistic individuals with intellectual or psychosocial disabilities can understand and consent to transition-related treatment.

Be Clear: Autistic people understand communication only if explicitly communicated—say things directly, literally, and kindly (directness without kindness is missed). Clarity prevents both autistic people detecting hints wrongly and trans/non-binary people detecting unintended hostility (trust erosion from negative professional experiences makes them hypervigilant). Clarity builds trust, particularly when professionals work within systems that don’t readily facilitate trans/non-binary realities. Provide clear, explicit parameters; manage expectations within systemic constraints while pushing for best outcomes.

Be Patient: Both being trans/non-binary and being autistic are exhausting experiences. Trans/non-binary people struggle against widespread hatred and incomprehension; autistic people struggle against ableist social worlds that overstimulate and blame them for miscommunication. Both groups show elevated rates of stress-related health problems. Gender identity exploration in autistic individuals often extends longer than in neurotypical peers, sometimes into adulthood rather than resolving during typical adolescence. This delayed exploration should not exclude the possibility of genuine gender diversity. Apparently “unreasonable” behavior often stems from systemic cruelties beyond individual control.

Intersectionality: Race, Culture, and Gender

Autistic transgender/non-binary people of color (BIPOC) face compounded discrimination from racism, ableism, transphobia, and cisgenderism. Western binary gender concepts are not universal; they represent colonization and erasure of historical gender diversity worldwide. Non-Western cultures historically recognized multiple genders, including hijras (India), kathoey and phuying praphet song (Thailand), baklâ, bayot, and agî people (Philippines), māhū (Hawaii), and muxes (Juchitán, Mexico). Many Native/Indigenous people use “two spirit” to describe gender and sexual identities beyond the white, colonizing gender binary.

Trans women of color—particularly Black, Brown, and Native trans women—face extraordinarily high risk for violence, criminalization, and abuse. Legal defenses like “trans panic defence” in several U.S. States allow violent crime perpetrators to claim a victim’s trans identity justified their violence. Autistic trans people of colour face systematic underrepresentation in research, with fewer publishing than white autistic trans people. Community-based participatory research models align research with directly impacted communities’ goals and require autistic trans people of colour as compensated co-investigators, not subjects.

Ableist arguments claiming autistic youth are “brainwashed” into trans identities rely on harmful presumptions of incompetence with real, devastating consequences. Some trans youth have been pressured to leave support groups due to lack of inclusion for members with intellectual disabilities. Others face pressure to “cure” autism before accessing gender-affirming care—a discriminatory practice. These barriers contribute to alarming mental health outcomes: 41% of transgender people have attempted suicide compared to 5% of the general population, with additional elevated suicide risk in autistic populations.

Older Autistic Transgender/non-Binary Adults

Many older autistic trans/non-binary people recognized gender identity later in life due to: poor interoception preventing dysphoria recognition; lack of autism and gender diversity awareness; multiple misdiagnoses and mental health issues; professional reluctance to diagnose gender dysphoria in autistic people. Gender dysphoria appears in 6-7% of autistic adults versus 1% of non-autistic populations, yet little research examines why or how these experiences intersect.

Later transition has distinct implications for families, professional relationships, and accumulated trauma from decades of inauthenticity. Decades of living in one gender create entrenched patterns; family relationships may depend on that presentation; institutional gatekeeping intensifies. Older autistic adults face additional barriers around employment, making it harder to meet criteria for gender-affirming care that require “living your gender in the world.”

One 62-year-old author describes growing up undiagnosed autistic in the 1950s-60s without modern resources, identifying with fictional characters and adopting “butch lesbian” as the only available label—though it never felt right. After transition in later life, with improved interoceptive connection and alignment with true gender, the author became less ambivalent about daily decisions, more willing to attempt things independently, and required less external validation. This suggests that for some autistic transgender people, being in the “right” gender removes a major source of dissociation that was masking or worsening autistic traits.

Practical Strategies & Techniques

Understanding Your Own Beliefs and Biases

Professionals must first examine their own beliefs about gender, gender binaries, and the connections between sex and gender. This includes reflecting on how their profession perpetuates gender stereotypes and recognizing their own biases. Examine views on the “gendering of autism”—the assumption that autism affects boys/men differently or more than others—which directly impacts how you support transgender autistic individuals. Resources like Gendered Intelligence (a UK transgender-led charity) and Mermaids provide free training and guidance on supporting trans youth and understanding gender diversity.

Pronoun Use and Written Documentation

Respecting pronouns is crucial for building trust but requires strategic implementation. In verbal communication, practice pronouns in personal notes or colleague meetings to become comfortable, especially with non-binary pronouns like they/them or neopronouns (xer, ze, etc.). When mistakes occur, apologize briefly and move on—do NOT offer preemptive apologies, as this signals you won’t try hard and places unfair burden on the person to forgive you in advance.

Written communication presents greater challenges: documents can be revisited repeatedly and cause deeper harm through misgendering. Always proofread using “find and replace” functions to ensure consistency. Critically, understand who has access to documents and whether the person has disclosed their identity to those individuals. Consider retroactive correction of records, particularly important for autistic people who access many services, creating numerous documents with potentially incorrect information. Non-binary identities present additional complications since they lack official recognition in many institutional systems; advocate for documentation systems that accommodate non-binary identities or find workarounds.

Supporting Gender Identity Exploration Without Directive Pressure

For professionals primarily working with autism, understanding how autism affects gender identity development is essential. Create space for exploration without pressure to settle on labels or take specific transition steps. When someone discloses their gender identity, respond with validation rather than questioning or challenging. Recognize that transitioning looks different for autistic people—some may have sensory sensitivities that prevent binding or packing, or they may prefer partial rather than complete physical transition. Discussing risks (e.g., binding complications) is important, but the ultimate goal is alleviating dysphoria and mental anguish in whatever way the person chooses.

Clinical Assessment: Distinguishing Sensory from Gender Issues

Professionals must distinguish between sensory processing discomfort, obsessive interests, underlying conflicts (denial of autism diagnosis, romantic rejection, lack of sexual experience), and genuine gender dysphoria. The Gender Identity Profile questionnaire (40 questions assessing imagination, behavior, gender expression, sexual behavior, transition desires, and mental health concerns) helps identify whether individuals seek social or medical transition versus gender neutrality/flexibility.

Additionally, assess sensory processing profiles to distinguish sensory aversion from gender dysphoria—sensory processing hypersensitivity (genital discomfort, tactile pain with penetration, clothing texture aversions) can masquerade as gender dysphoria. Proper differential assessment prevents unnecessary medical interventions while ensuring genuine gender dysphoria receives appropriate treatment. Executive dysfunction often goes unaddressed; the BRIEF assessment reveals specific organizational challenges requiring targeted coaching and visual supports.

Structural Support for Executive Dysfunction

Multiply marginalized autistic trans people face barriers in paperwork-heavy processes (name changes, benefits renewal, housing applications). Executive dysfunction means missed deadlines and abandoned tasks are predictable, requiring external accountability and support rather than blame. Provide structured coaching, visual organization tools, scheduled check-ins, and follow-through. Recognize that being autistic does not invalidate transness—support should improve mental health and alleviate dysphoria in whatever way the person chooses.

Planning for Transition out of Professional Support

Often overlooked but critical: planning for when professional support ends (due to parental leave, contract endings, organizational changes, etc.). For autistic transgender and non-binary people, this is particularly distressing because they must come out again and renegotiate boundaries with new providers. Clear communication among staff about what information is shared, and support for the transition itself, significantly reduces stress. Abrupt transitions without solid continuation plans create additional trauma for people already navigating complex identities.

Safeguarding and Violence Prevention

Autistic trans/non-binary people and autistic women experience disproportionately higher rates of sexual assault. Professionals and law enforcement have a duty of care to help this population recognize dangerous situations while maintaining presumption of honesty when crimes are reported. Social power dynamics create vulnerability; actively mitigate power imbalances in professional-client relationships.

Help people evaluate safety compromises: Is the compromise delivering the desired effect? Is the person comfortable with chosen pronouns/presentation? Compromises may need revision if identity evolves, dysphoria triggers shift, or circumstances change. Defend trans youth, clients, and co-workers from bullying and misgendering; coordinate name/pronoun usage appropriately across different settings. Support access to gender-affirming spaces matching individuals’ genders (sports teams, facilities, etc.). Advocate for employment protection when jobs are at risk due to trans/autistic identity.