**1. Introduction**

The empirical and research interest in the topic of gender identity and gender diversity in children and adolescents has increased exponentially over the last two decades. Such trend has been evident from inspired research activity in the field of transgender youth, as illustrated by **Figure 1** depicting the steady increase in the volume of relevant publications from 1997 to 2016 [1]. Since the turn of the century, we are witnessing a dramatic surge in the numbers of children and adolescents referred to gender clinics, this is happening in the context of general increase in numbers of individuals identifying as transgender. Internationally, this trend is well documented in the Western countries, for example in Canada between the periods 2000–2003 and 2008–2011 [2], in United States [3], the Netherlands [4], in the United Kingdom [5] and in Australia [6]. To address this gap of unmet clinical needs, the dedicated gender identity clinical services have been set up out of existing child and adolescent mental health services in collaboration with paediatric endocrinology services in order to deliver specialised gender affirming care.

**Figure 1.** *PubMed indexed publications from 1997 to 2016 using the search term "transgender youth". Turban and van Schalkwyk [1]. Copyright © 2021 Elsevier Inc. except certain content provided by third parties.*

In the public arena, a well-publicised UK High Court's case that is commonly referred to as Bell v Tavistock [7] highlighted the growing concerns regarding the unexplained surge in the number of adolescents identifying as having gender dysphoria, as well as pointed to the lack of evidence that hormones and surgery improve long-term health outcomes, including suicidal risk. This well-publicised court decision caused ripple effect across community of trans activists, gender and legal scholars, advocacy groups and service users who are still reeling from the ruling. There are loud voices on both sides of the argument with popular opinion that this landmark judgement will result in a fundamental transgression of trans and adolescent rights. On the other hand, the ruling was welcomed by traditionalists and more conservatively inclined "as a victory for common sense and safeguarding" [8].

#### **2. Gender identity**

Gender dysphoria (GD) has been defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), as a characteristic of the individuals presenting with incongruence between their natal sex (sex at birth) and their experienced gender [9]. The diagnosis is characterised by intense and persistent cross-gender identification, which is often associated with significant distress of one's own assigned biological and social characteristics. The key elements of GD' diagnostic construct evolved from DSM-IV-TR diagnostic criteria for Gender Identity Disorder [10] by shifting the focus towards the dysphoria associated with the incongruence and moving away from the notion of identity disturbance.

The International Classification of Diseases, 10th Edition [11] describes the desire to live and be accepted as a member of the opposite sex as transsexualism, under the "disorders of adult personality and behaviour" which limits the use of this diagnostic category for children and adolescents. We are looking forward to the rolling out of ICD-11 [12] that will come into effect on January 1, 2022, as it contains new taxonomies of Gender Incongruence of Childhood (2- year duration) and Gender Incongruence of Adolescents and Adults ("at least several months" duration, criteria otherwise similar to Gender Dysphoria.) These new diagnostic categories moved out of Chapter V and no longer under the "Mental and

**41**

**Figure 2.**

*pieces (author Sam Killermann, [16]).*

*Autism and Gender Identity*

*DOI: http://dx.doi.org/10.5772/intechopen.97517*

behavioural disorders" section, instead they can be found under the "Conditions related to sexual health", chapter 17. Such move is justified based on the notion that the broader spectrum of gender identity issues is increasingly recognised as part of normal human diversity and should not be classified as a mental illness [13].

Gender diversity is an umbrella term that reflects the growing recognition that being transgender is part of the continuum of gender spectrum. It is used to describe different gender identities in a non-stigmatising way, similar to the way researchers use 'neuro-diverse' to describe variations in cognitive style that are characteristic of autism and attention deficit hyperactivity disorder (ADHD). The diversity in

*Genderbread Person v4.0. A teaching tool for breaking the big concept of gender down into bite-sized, digestible* 

#### *Autism and Gender Identity DOI: http://dx.doi.org/10.5772/intechopen.97517*

*Autism Spectrum Disorder - Profile, Heterogeneity, Neurobiology and Intervention*

In the public arena, a well-publicised UK High Court's case that is commonly referred to as Bell v Tavistock [7] highlighted the growing concerns regarding the unexplained surge in the number of adolescents identifying as having gender dysphoria, as well as pointed to the lack of evidence that hormones and surgery improve long-term health outcomes, including suicidal risk. This well-publicised court decision caused ripple effect across community of trans activists, gender and legal scholars, advocacy groups and service users who are still reeling from the ruling. There are loud voices on both sides of the argument with popular opinion that this landmark judgement will result in a fundamental transgression of trans and adolescent rights. On the other hand, the ruling was welcomed by traditionalists and more conservatively inclined "as a victory for common sense

*PubMed indexed publications from 1997 to 2016 using the search term "transgender youth". Turban and van* 

*Schalkwyk [1]. Copyright © 2021 Elsevier Inc. except certain content provided by third parties.*

Gender dysphoria (GD) has been defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), as a characteristic of the individuals presenting with incongruence between their natal sex (sex at birth) and their experienced gender [9]. The diagnosis is characterised by intense and persistent cross-gender identification, which is often associated with significant distress of one's own assigned biological and social characteristics. The key elements of GD' diagnostic construct evolved from DSM-IV-TR diagnostic criteria for Gender Identity Disorder [10] by shifting the focus towards the dysphoria associated with the incongruence and moving away from the notion of identity disturbance. The International Classification of Diseases, 10th Edition [11] describes the desire to live and be accepted as a member of the opposite sex as transsexualism, under the "disorders of adult personality and behaviour" which limits the use of this diagnostic category for children and adolescents. We are looking forward to the rolling out of ICD-11 [12] that will come into effect on January 1, 2022, as it contains new taxonomies of Gender Incongruence of Childhood (2- year duration) and Gender Incongruence of Adolescents and Adults ("at least several months" duration, criteria otherwise similar to Gender Dysphoria.) These new diagnostic categories moved out of Chapter V and no longer under the "Mental and

**40**

and safeguarding" [8].

**Figure 1.**

**2. Gender identity**

behavioural disorders" section, instead they can be found under the "Conditions related to sexual health", chapter 17. Such move is justified based on the notion that the broader spectrum of gender identity issues is increasingly recognised as part of normal human diversity and should not be classified as a mental illness [13].

Gender diversity is an umbrella term that reflects the growing recognition that being transgender is part of the continuum of gender spectrum. It is used to describe different gender identities in a non-stigmatising way, similar to the way researchers use 'neuro-diverse' to describe variations in cognitive style that are characteristic of autism and attention deficit hyperactivity disorder (ADHD). The diversity in

#### **Figure 2.**

*Genderbread Person v4.0. A teaching tool for breaking the big concept of gender down into bite-sized, digestible pieces (author Sam Killermann, [16]).*

gender expression encompasses a range of descriptions, including 'non-binary', 'transgender', 'gender nonconforming' - that individuals may adopt when their gender identity, expression or behaviours do not conform to the expected norms and stereotypes of their natal sex [14]. There is a renewed freeing sense that gender is more fluid than it was ever thought to be before, and either that gender of self and others are less deterministic of who we are or that it is seen as natural that a person's sense of their gender fluctuates. The narrative of suffering and gender dysphoria are not universal to Trans' population and not every gender diverse person hates their body, hence it's important to avoid misleading assumptions. Views about gender and sexuality are influenced by multitude of factors, including one's own orientation and identity, personal experiences and upbringing, religious and moral beliefs, as well as popular cultural stereotypes. At any given time, gender identity belongs to the intersubjective field where possibilities for evolving gendered roles may be created, for example, in a situation where women and men may experience the impact of hierarchical structures in a workplace that can trigger the identity of dominance to emerge as a way of healthy adaptation process.

Two-spirit is a contemporary term adopted by some Native American Nations, and Aboriginal peoples to signify their spiritual, sexual, gender, cultural, and community identities, and the use of this term has been known to facilitate an individual's reconnection with the tribal understandings of non-binary sexual and gender identities [15]. Some traditional Diné Native Americans acknowledge a spectrum of four genders: feminine woman, masculine woman, feminine man, and masculine man. The term "third gender" has been used to describe the hijras of India (male at birth choosing a female identity) who have gained legal identity in 2014. Third gender also applies to fa'afafine of Polynesian Samoa's population and to 'sworn virgins' of Albanian Alps. In Thailand one can find up to 18 different gender roles, identities and diverse visual markers of masculinity and femininity.

Gender, psychosexual development and identity formation are all intertwined. One way to integrate the many components of gender identity and gender expression is by utilising the so-called 'Genderbread Person' model [16], see **Figure 2** above.

#### **3. Psychodynamic underpinning of gender**

Psychoanalytic contribution to the study of gender issues first of all belongs to Sigmund Freud and his theory of psychosexual development and the recognition of Freud's understanding of the ego as body-ego, which is under the influence of the id [17]. Freud's theories are echoed by the contemporary gender theories that propose that the id, like genetic material, has male and female impulses [18]. Freud also speaks of "psychical hermaphroditism" and human ability to produce a different core gender identity under certain conditions, the notion debated by Myra J. Hird who argues that there is, at some level, a refusal to allow a person to transgress the boundaries of traditional gendered identities as represented in the visual 'cultural genitals' [19]. Freud saw nature as masculine and coined the phrase "anatomy is destiny" [20], that can be summed up as - one's gender determines one's main personality traits. Nevertheless, with the rise of the feminism, the Freudian father-centred theory rooted in the concepts of the 'penis envy' and the 'castration complex' had been gradually replaced by maternal or more gender neutral primary caregiver' determinants [21–23]. Anne Fausto-Sterling suggests that the critical aspects of pre-symbolic gender embodiment occur during infancy as part of the synchronous interplay of caregiver-infant dyads. Around the time children begin to speak, they recognise themselves as distinct entities in the mirror and commence their transition to symbolic representation and achieving accurate gender labelling

**43**

treatment.

**5.1 Co-occurrence rates**

*Autism and Gender Identity*

than about sexuality [25].

past year [30].

universities [32].

**4. Mental health comorbidities**

*DOI: http://dx.doi.org/10.5772/intechopen.97517*

of self and others by the age of three [24]. "Gender is about affinities"– does it feel "like me", or different from me? Gender may remain stable or evolve and change, the author urges that clinicians take a dynamic developmental view of gender identity formation after into account [24]. Finally, the Lacanian perspective on gender difference is rooted in the original concepts that situate in the space between life and death and propose that a gender transition is more about strategy of being

Review of the recent literature suggests that 0.17% to 1.3% of adolescents and young adults identify as transgender [26]. Transgender individuals experience disproportionately high rates of negative mental health outcomes, as compared with their cisgender heterosexual peers, as well as their gender-normative lesbian, gay and bisexual peers [27]. Recent studies have offered a deeper understanding of the prevalence of depression among trans- and gender-variant youth, providing evidence that rates of depression are 2.4 to 3.5 times higher than in their cisgender peers, 50.6% vs. 20.6% in a retrospective matched cohort (n = 360) of 12–29 years old patients at community health centre in Boston [28] and 41.3% vs. 11.8% in a high school-based sample (n = 8,166) from New Zealand [29]. A study by Veale et al. measured stigma-related experiences, social supports, and mental health (self-injury, suicide, depression, and anxiety) among a sample of 923 Canadian transgender adolescents and young adults aged 14 to 25; they reported that over two-thirds (68.3%) of the sample experienced a major depressive episode in the

The large scale 2015 U.S. Transgender Survey (USTS) with 27,715 respondents with a median age of 26 years, found that 40.4% of respondents reported attempted suicide in their lifetime, 81.7% of respondents had seriously thought about killing themselves in their lifetimes, and 48.3% had done so in the past year while 7.3% had attempted suicide in the past year; respondents who reported having a disability had higher prevalence on all suicide-related measures than those without disabilities [31]. Another large survey that was primarily capturing an eating-related pathology revealed that transgender students had increased rates of eating disorder diagnosis compared to cisgender heterosexual women (15.8% vs. 1.85%), this set of data was collected from 289,024 students via the American College Surveys from 233 U.S.

Among the general population, the prevalence of autism spectrum disorder (ASD) in children is estimated at 1% with a ratio of 1:42 for boys and 1:189 for girls respectively [33]. The evidence that suggests an overrepresentation of ASD in gender diverse samples, particularly in children and adolescents [34, 35], is robust and largely accepted by scientific community. The association between GD and ASD has been of great clinical interest because it has implications for diagnosis and

Trans Pathways study conducted in Australian large sample of trans and genderdiverse young people (n = 859; mean age = 19.4), found that 22.5% of the sample

**5. Autism spectrum disorders and gender identity**

*Autism Spectrum Disorder - Profile, Heterogeneity, Neurobiology and Intervention*

to emerge as a way of healthy adaptation process.

**3. Psychodynamic underpinning of gender**

gender expression encompasses a range of descriptions, including 'non-binary', 'transgender', 'gender nonconforming' - that individuals may adopt when their gender identity, expression or behaviours do not conform to the expected norms and stereotypes of their natal sex [14]. There is a renewed freeing sense that gender is more fluid than it was ever thought to be before, and either that gender of self and others are less deterministic of who we are or that it is seen as natural that a person's sense of their gender fluctuates. The narrative of suffering and gender dysphoria are not universal to Trans' population and not every gender diverse person hates their body, hence it's important to avoid misleading assumptions. Views about gender and sexuality are influenced by multitude of factors, including one's own orientation and identity, personal experiences and upbringing, religious and moral beliefs, as well as popular cultural stereotypes. At any given time, gender identity belongs to the intersubjective field where possibilities for evolving gendered roles may be created, for example, in a situation where women and men may experience the impact of hierarchical structures in a workplace that can trigger the identity of dominance

Two-spirit is a contemporary term adopted by some Native American Nations,

and Aboriginal peoples to signify their spiritual, sexual, gender, cultural, and community identities, and the use of this term has been known to facilitate an individual's reconnection with the tribal understandings of non-binary sexual and gender identities [15]. Some traditional Diné Native Americans acknowledge a spectrum of four genders: feminine woman, masculine woman, feminine man, and masculine man. The term "third gender" has been used to describe the hijras of India (male at birth choosing a female identity) who have gained legal identity in 2014. Third gender also applies to fa'afafine of Polynesian Samoa's population and to 'sworn virgins' of Albanian Alps. In Thailand one can find up to 18 different gender

roles, identities and diverse visual markers of masculinity and femininity.

Gender, psychosexual development and identity formation are all intertwined. One way to integrate the many components of gender identity and gender expression is by utilising the so-called 'Genderbread Person' model [16], see **Figure 2** above.

Psychoanalytic contribution to the study of gender issues first of all belongs to Sigmund Freud and his theory of psychosexual development and the recognition of Freud's understanding of the ego as body-ego, which is under the influence of the id [17]. Freud's theories are echoed by the contemporary gender theories that propose that the id, like genetic material, has male and female impulses [18]. Freud also speaks of "psychical hermaphroditism" and human ability to produce a different core gender identity under certain conditions, the notion debated by Myra J. Hird who argues that there is, at some level, a refusal to allow a person to transgress the boundaries of traditional gendered identities as represented in the visual 'cultural genitals' [19]. Freud saw nature as masculine and coined the phrase "anatomy is destiny" [20], that can be summed up as - one's gender determines one's main personality traits. Nevertheless, with the rise of the feminism, the Freudian father-centred theory rooted in the concepts of the 'penis envy' and the 'castration complex' had been gradually replaced by maternal or more gender neutral primary caregiver' determinants [21–23]. Anne Fausto-Sterling suggests that the critical aspects of pre-symbolic gender embodiment occur during infancy as part of the synchronous interplay of caregiver-infant dyads. Around the time children begin to speak, they recognise themselves as distinct entities in the mirror and commence their transition to symbolic representation and achieving accurate gender labelling

**42**

of self and others by the age of three [24]. "Gender is about affinities"– does it feel "like me", or different from me? Gender may remain stable or evolve and change, the author urges that clinicians take a dynamic developmental view of gender identity formation after into account [24]. Finally, the Lacanian perspective on gender difference is rooted in the original concepts that situate in the space between life and death and propose that a gender transition is more about strategy of being than about sexuality [25].
