The Cass Review, autism, and reinventing Blanchard

In the recently published Cass Review (2024), there is consistent mention of the prevalence of autism in the ‘trans and gender-diverse’ population, which is ‘three to six times higher’ than in the cis population ‘according to some studies’, such as Warrier et al., 2020 (Cass 5.41). The report cites concern in de Vries et al. (2011b) about whether autistic trans adolescents are experiencing “a general feeling of being just “different”” or a ““core” cross-gender identity”. A parent is quoted saying that their child, formerly bullied due to ‘ASD’, became a ‘celebrity’ and received ‘social kudos’ upon coming out (Cass p. 160); autistic children, including underdiagnosed “teenage girls”, are noted to have trouble “fitt[ing] in” (Cass 5.43) and “express[ing] how they are feeling about […] their gender identity” (Cass 5.44). There is also a note that a higher % of adolescents who discontinued puberty suppression were autistic (Cass 14.23). (I cannot examine the relevant commissioned study yet, but would note that the raw number here is likely to be very low.)

The obvious subtext here is that autistic trans children are less trustworthy about their articulation of transness than neurotypical trans children, and should therefore face more gatekeeping and vetting. In the report, it is noted that children, who know about this preconception, are routinely refusing to disclose neurodiversity to clinicians for fear of discreditation (Cass 11.11); the report’s response to this is to advocate for mandatory clinical screening for “neurodevelopmental conditions, including autism spectrum disorder” at point of entry for adolescent patients (Recommendation 2). I’m not going to get into the full scope of problems with this; there is no evidence that autistic people are impaired in identifying their own gender, or that the higher incidence of transness/gender diversity in the autistic population is symptomatic of misidentification. But I am going to talk about one study cited in Cass:

“In contrast [to the patients in the original Dutch study of puberty blockers], in a detailed study of young people with ASD and gender dysphoria (de Vries et al., 2010), it was noted that “‘while almost all adolescents with GID [gender identity dysphoria] are sexually attracted to individuals of their birth sex, the majority of the gender dysphoric adolescents with ASD were sexually attracted to partners of the other sex” (Cass 8.29). [highlights my own]

Anyone who is familiar with Blanchardian typology will recognise what is going on here: baseline expected attraction to individuals of one’s ‘birth sex’ (i.e. trans straight attraction) is contrasted with a suspect population who experience attraction to ‘other sex’ individuals (i.e. trans gay attraction). ‘Other sex’ attraction is used to devalue claims to transness in all trans populations, especially trans women, as it marks them both as desirably recuperable to cisheterosexuality and as unable to perform either legible homosexual gender variance or sufficiently authentic — i.e. straight — future transness, rendering them an ideal plausibly deniable target of gendered abuse. Transphobic fantasy fixates on the trans woman who pursues/‘predates on’ women, and trans men who pursue men are also a disproportionate target of anti-effeminate mockery. (This model also obviously erases bisexuality, which Cass itself notes is a high incidence sexuality among all trans groups (Cass 8.3), and uses bioessentialist sex terminology — it’s unclear what group I would be allocated to if I dated a trans man, for instance).

It shouldn’t matter regardless; autism and sexual orientation both shouldn’t impede someone’s right to medical autonomy. However, given this claim is clearly being used to delegitimise autistic trans people — including in the original study, where they claim that ‘adult transsexuals not sexually attracted to their natal sex show in some studies less satisfactory postoperative functioning compared with birth-sex attracted transsexuals’ — it is notable that the claim is false. It is obviously false the second you look at their data. They have a sample of nine adolescents (which would prove nothing even if the majority were ‘non-birth-sex attracted’) and the claim is still wrong about their own data.

De Vries et al (2010) is a nightmare of a study. It’s an analysis of 16 children with ASD who attended a Dutch gender clinic between 2004 and 2007 — specifically 7 children (ages 7–10) and 9 adolescents (ages 12–18). All the patients are misgendered throughout. There are also deeply disturbing comments about the sexual arousal and genital discomfort of children as young as 7, suggesting that the children seen at the clinic were asked deeply inappropriate and traumatising questions from admission. Various aspects of the under-11s’ profiles are immediately provoking, such as what the ‘behavioral program’ that reduced an 8-year-old’s ‘dressing up’ consisted of, or why certain children were referred to the clinic at all (some seem to have presented primarily with cross-gender behaviour rather than cross-gender identification). In any case, the sexual orientation of the under-11s clearly isn’t known, and the Cass Review’s claim is specific to adolescents anyway.

Of the adolescents, all of whom have a stated sexual orientation, we have:
-AFAB 12-year-old, attracted to boys
-AFAB 16-year-old, attracted to girls
-AFAB 18-year-old, attracted to girls
-AMAB 13-year-old, attracted to ‘neither boys nor girls’
-AMAB 14-year-old, attracted to boys
-AMAB 15-year-old, attracted to both girls and boys
-AMAB 16-year-old, attracted to boys (specifically ‘homosexual’ boys)
-AMAB 16-year-old, attracted to girls
-AMAB 17-year-old, attracted to girls

By my count, to use their terminology that’s 3 adolescents with solely ‘other sex’ attraction (and I would note that one of those is 12 years old), 4 with ‘birth sex’, 1 bisexual and 1 with no stated attraction. THAT IS NOT A MAJORITY. EVEN IF YOU INCLUDE THE BISEXUAL IT’S NOT A MAJORITY.

There’s a more salient aspect of this whole thing, though: the outcomes of the adolescents. The only adolescents approved for ‘SR’ — sexual reassignment, i.e. surgery — at this gender clinic were the ones who are ‘birth sex attracted’. The AFAB kid attracted to boys was ‘not eligible for SR’ and ‘happy being a ‘tomboy’ after counselling’; the bisexual AMAB kid was rendered ineligible and ‘referred for cognitive behavioral therapy around disturbing sexual arousal’; of the two AMAB kids attracted solely to girls, one was rendered ineligible but still had a ‘strong wish for SR’ at followup, while the other dropped out of the clinic, was ‘unwilling to assent to a treatment plan’, and got surgery abroad (good for her). ‘Non-birth-sex attracted’ trans adolescents here are obviously systematically gatekept from surgical interventions, and there are murky suggestions of conversion therapy, while most of the ‘birth-sex-attracted’ trans adolescents were awaiting surgery or hormones at followup.

But wait, there’s more. The study itself argues for lower ‘postoperative functioning’ of ‘non-birth-attracted transsexuals’, citing Smith et al. (2005) on ‘Transsexual subtypes: Clinical and theoretical significance’. (This study is straight up Blanchardian; it literally says that trans women attracted to men have a ‘more convincing cross-gender appearance.’) What does ‘postoperative functioning’ mean? It means that gay and bisexual trans people have ‘significantly more psychological problems’ than straight trans people — which would seem evidently explainable by a) less understood etiology of transness in non-homosexual-presenting trans youth, which means later treatment & more gatekept treatment, and b) worse cultural treatment of gay trans people.

So, the Cass Review took a study full of glaring markers of sexual misconduct & conversion therapy being enacted on trans children, quoted a statement about the data that is obviously incorrect if you look at the data for five seconds, used it to make a point intended to discredit autistic youth / paint them as delusional heterosexuals, and ignored blatant evidence of a long and documented history of gay and bi trans people being blocked from necessary healthcare interventions.