Gender Identity Issues Linked to Autism, ADHD

Kathleen Louden

March 17, 2014

Children and teens with autism spectrum disorder (ASD) or attention-deficit/hyperactivity disorder (ADHD) are much more likely to express a wish to be the opposite sex compared with their typically developing peers, new research shows. But at least 1 expert is sceptical.

The single-center study showed that compared with normally developing children, young people with ASD were nearly 8 times more likely to express a desire to be other than their biological sex — a phenomenon the authors describe as "gender variance." Those with a diagnosis of ADHD had more than 6 times the odds of communicating gender variance, according to parent-reported data.

"Doctors, whether general care or specialists in autism or gender identity, should be aware that a co-occurrence of these conditions is not uncommon," John Strang, PsyD, the study's lead author and a pediatric neuropsychologist at Children's National Medical Center in Washington, DC, told Medscape Medical News.

These findings, said Dr. Strang, confirm previous research suggesting that autism is overrepresented among children referred for management of gender identity disorder and gender dysphoria.

According to the investigators, the study is the first to compare the occurrence of gender identity issues in children with neurodevelopmental disorders against typically developing children and is the first report of a possible connection between ADHD and gender variance.

The research was published online March 12 in Archives of Sexual Behavior.

No Prevalence Difference in Males and Females

Through a chart review of patients in a hospital's pediatric neuropsychology program, the researchers tracked the parents' responses to the Child Behavior Checklist (CBCL) item "wishes to be the opposite sex."

Responses of "sometimes" or "often" were compared with responses of "never." The investigators excluded participants from the study if the hospital's gender identity clinic had referred the child.

Included in the study were 389 patients aged 6 to 18 years who had 1 of 4 neurodevelopmental disorders: ASD (n = 147), ADHD (n = 126), epilepsy (n = 62), or neurofibromatosis 1 (n = 54). The latter 2 conditions made up the medical neurodevelopmental disorder group. Each of these groups was compared with 165 control individuals from the local community who had no identified neurodevelopmental disorders and with normative data of 1605 nonreferred participants in the CBCL standardization sample.

Approximately 5% of the children with either an autism disorder or ADHD expressed gender variance to their parents. Significantly more patients with ASD (P = .003) or ADHD (P = .005) had parent-reported gender variance than local control individuals, whose parents reported no gender variance. Both groups also showed significant differences compared with the CBCL comparison group (0.7% gender variance).

Table. Child's Wish to Be the Opposite Sex as Reported by Parent

Group Percent Endorsement Odds Ratioa 95% Confidence Interval P -value
Epilepsy or neurofibromatosis 1.7 0.52 0.10 - 10.53 Not significant
Attention-deficit/hyperactivity disorder 4.8 6.64 2.45 - 17.99 < .001
Autism spectrum disorder 5.4 7.59 3.05 - 18.87 < .001

aPeto odds ratio compared with the standardization sample of the Child Behavior Checklist.


Gender variance reportedly occurred equally in male and female patients after the investigators controlled for the high male-to-female ratios in the ASD and ADHD groups.

Dr. Strang said they were initially surprised to find an overrepresentation of gender variance among children with ADHD. However, they later realized that prior studies have shown increased levels of disruptive behavior and other behavioral problems among young people with gender variance.

Despite the overlap the investigators found with regard to gender variance and ADHD or autism, Dr. Strang cautioned that a child's expressing a desire to be the opposite sex does not imply a diagnosis of persistent gender dysphoria or gender identity disorder.

He did recommend, however, that healthcare professionals who treat children and adolescents with ASD or ADHD ask parents whether their child has expressed a wish to be the other sex, as part of the CPCL or another questionnaire.

"We want to help kids who struggle with both [gender variance and a neurodevelopmental disorder] get the help and support they need," Dr. Strang said.

The study findings underscore the need for more research into gender variance in neurodevelopmental disorders, including obtaining self-reports from children and adolescents, he added.

High Prevalence Disputed

Commenting on the study for Medscape Medical News, Eric Butter, PhD, a psychologist and associate director of the Child Development Center at Nationwide Children's Hospital in Columbus, Ohio, said, "I'm not ready to say that kids with autism spectrum disorder have a higher prevalence of gender variance. We don't know that from this research."

A study limitation was the use of parent-reported data, according to Dr. Butter, who was not involved with the research.

"Parents will respond to that question ["wishes to be the opposite sex"] from their own experience and their own cultural expectations of gender," he said. "Does a response of 'wishes to be the opposite sex' mean a little girl likes to play with trucks and a boy likes playing with dolls, or does it mean a child is uncomfortable with his or her gender and wants to be the opposite sex?"

That ambiguity may account for the high prevalence — 5.4% — of combined gender variance and ASD found in the study, Dr. Butter suggested.

"At our large regional clinic," he said, "some children presenting with ASD also present with gender variance, but it's a very small percentage, not anywhere near what the authors found."

On the basis of this single-center, chart-review study, Dr. Butter said he could not recommend acting clinically or changing practice at this time.

"This research is interesting and important because it opens a conversation about gender identity. We should make sure we are treating the whole child, no matter what the neurodevelopmental disorder is."

Dr. Strang and Dr. Butter have reported no relevant financial relationships.

Arch Sex Behav. Published online March 12, 2014. Abstract


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