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Laws. A, 2024, ‘The Beautiful Contours of Human Diversity’: On the intersection of gender diversity and neurodiversity, Reformulation 57, p. 31-33
In workshops about working in therapy with gender diversity, it used to be that people wanted to ask me about their work with their first gender diverse client. It’s pleasing to see that that is not often the case now, as people are more confident and have more experience of themselves as therapists alongside gender diverse clients. That question has been replaced instead with one about neurodiversity. People often dance tentatively around the idea that raising the question of neurodiversity, with me or their client, might in some way cause offence.
In fact this is a question that people in the fields of gender and neurodiversity have been asking for many years, so striking is the overlap at the intersection between them.
Some data on neurodiversity and gender diversity
Estimates of the number of autistic people in the UK population vary but could be between 0.8% diagnosed and 0.7-2.12% undiagnosed (O’Nions et al, 2023). Attention deficit hyperactivity disorder (ADHD) is estimated to affect up to 3-4% of people (NICE 2018a). Some studies estimate that between 30-80% of autistic people also have ADHD and 20-50% of people with ADHD are also autistic.
Much of the literature about the overlap between neurodiversity and gender diversity focusses on autism to the exclusion of ADHD, but their mutual overlap suggests that when we consider the data on autism, we should bear in mind the likely presence of co-occurring ADHD in a proportion of that population. Kallitsounaki and Williams (2023) carried out a systematic literature review and meta-analysis and found that there was a link between autism and gender diversity in the general population of autistic people. In the gender diverse population, the estimated ‘caseness’ of autism was between 14.5%-68% in children and young people and 1.2%-40.3% in adults, depending on methodology of the studies. Traits of autism were also higher than average, which would suggest that if the whole autistic phenotype was considered the number of individuals who might be included may rise further. The wide variety in estimated prevalence in this review suggests that this is not only a diverse group of people, but also that the detection and diagnosis of autism requires subtlety beyond a self-report screening questionnaire.
Why does it matter if people are neurodiverse and gender diverse?
Minority stress theory (Meyer, 2003) posits that people who are part of a minority group face additional stressors by virtue of their membership. These are both external stressors of living in a society, culture or family that is not promoting of their value as a member of that group and internalised factors, devaluing themselves for their group membership. In Cognitive Analytic Therapy terms these are the societal and cultural factors that influence the development of reciprocal role procedures which become internalised and then move from being ‘other to self’ and become ‘self to self’ procedures. If then, as a member of one minority group, I develop a set of internalised self-perceptions which are devaluing of myself, each time I become aware of a new minority group of which I am a member, I am at risk of further devaluing myself. This is the concept of a ‘double minority identity’ (Lewis et al, 2021) and with people who are sexually diverse, gender diverse and neurodiverse it has been found to convey vulnerabilities to higher perceived stress, lower quality of life and poorer mental health and higher risk of suicide completion (McQuaid et al 2023, McNeil et al 2012).
Whilst each of our intersecting parts offers us opportunities both for new strengths and new vulnerabilities, the literature suggests that people who are gender diverse and neurodiverse face significant challenges in navigating positive mental health and wellbeing.
What does this mean for us in the therapy room?
1, Think diversity first
As with most things that confront our clients, we need to consider ourselves as therapists and our own neurology before we can truly understand the needs of our clients. Our neurology mediates all our experiences and is so fundamental to our sense of self that we can be forgiven for overlooking it. One of the difficulties in estimating the prevalence of neurodiversity in all its forms is that neurodiverse people are so truly different one from another. We are mistaken if we think that neurodiversity exists only in people who are our clients or in people who struggle in the world.
Valuing neurodiversity, sexual and gender diversity, and celebrating it in ourselves and our clients, is the first and most important step in providing a therapy which can truly be considered to be safe for the client. Neurology is essential and fundamental. So fundamental that I have made a shift in my practice to starting all my therapies with a conversation about neurodiversity. Granted I work in a field where the prevalence of neurodiversity is exceptionally high, but if our neurology is the means by which we experience the world and regulate ourselves, surely understanding these mechanisms will underpin everything that follows.
2, Sensory second
When we can plot our neurodiversity on our map of ourselves, we are presented with a fantastic opportunity to explore the diverse ways in which we experience the world. Neurodiverse people are more likely to experience the world through hypo or hyperreactive sensory experiences. That is to say that for each sensory modality (add proprioception, interoception and vestibular sense to the 5 you usually think of) each of us is individually tuned to a different level of sensitivity, but this isn’t exclusive to people who are neurodiverse. We all regulate our sensory experiences all the time, but we don’t usually notice the differences between us until we find that we are tuned too low or high for comfort in one domain. We need to explore the sensory worlds of our clients in order to offer them meaningful understanding of their experiences of themselves and the world around them and to aid them in beginning to seek out better forms of self-regulation.
3, Rewriting the story with new information
With the new information that we have gained about how a person experiences the world we can begin the process of telling a new story about their life where relationships, and particularly stigma, can be unpicked through a new more compassionate understanding of how they have been moving through the world. This has relevance to how we formulate family relationships in the context of neurodiversity and gender diversity and awareness of ‘neurodiversity family trees’ in which we understand the similarities and differences of family member’s neurologies and how those might have influenced interactions throughout the client’s life.
4, Setting affirming goals
With a deeper understanding of our client as a unique individual we are more able to support them to set the goals which they will find affirming and manageable. These are often the parts of the therapy where neurotypical and cisheteronormative (the expectation that everyone will be heterosexual and not gender diverse), expectations (in both therapist and client) of fulfilling and rewarding lives can interfere with the therapeutic work. Seeking out meaningful joy for our clients without imposing ourselves on the goals is a more subtle art than many people realise and therapists who have cisgender or neurotypical privileges often miss the moment when their client bows to their suggestion of a goal which is not really within the scope of the client’s desire or ability. These moments can appear superficially to be collaborative but if they’re being led by the therapist they are often not. Handing over control to clients who struggle to manage open forms of question or produce answers without guidance can be a tricky skill. As therapists we need to be patient and allow neurodiverse clients time to respond and reflect and offer guidance that structures their reflections without imposing our ideas of what an outcome should be. The finesse and elegance of my client’s goals, compared to my lumbering suggestions, frequently reminds me that giving them enough space and time in therapy to do the work at their own pace is worth its weight in rainbow gold.
Summary
Many of the gender diverse people with whom I work come to therapy burdened with experiences through their life of having been at odds with people and systems around them. Too often this is attributed to them being gender diverse in a cisgender dominant world. We stop and ask questions about neurodiversity, unpicking previous diagnoses like social anxiety, ‘personality disorder’, chronic fatigue and fibromyalgia and make new sense out of their experiences in the light of autism and ADHD. We map their sensory world and use this to understand how this has made them more susceptible to experiencing the world as traumatic and overwhelming. We work together to manage alexithymia and develop new insights into emotions and how they affect the body and mind. With our new compassion about the struggles that dysregulation has brought, we tell a new story about their family and how neurodiversity has shaped those relationships over time. Then we start to celebrate the beginnings of their newfound freedom to be themselves.
‘But when we see that this common co-occurrence exists across ages and into adulthood, I think we are called upon to step back and consider that this may very well be one of the beautiful contours of human diversity: that autism and gender diversity often intersect and that there is an authenticity to this pattern which is observed across ages as well as across countries and cultures.’ Dr John Strang in Gratton et al 2023.
A note on language: The terms ‘gender diverse’ and ‘autistic people’ are the current best practice but I acknowledge that not everyone will prefer these terms to refer to themselves.
Resources
If you or your service want to start thinking about neurodiversity here are some resources to start the conversation.
www.neurodivergentinsights.com Misdiagnosis Monday
www.authentistic.uk Psychological therapy for autistic adults by experts with lived experience
www.sensorystreet.uk sensory processing differences
Dr Anna Laws
Consultant Clinical Psychologist
Anna.Laws@cntw.nhs.uk
References
Gratton, F., Strang, J., Song, M., Cooper, K., Kallitsounaki, A., Lai, M-C., Lawson, W., van der Miesen, A. and Wimms, H. (2023). The Intersection of Autism and Transgender and Nonbinary Identities: Community and Academic Dialogue on Research and Advocacy, Autism in Adulthood, 5, 2, 112-124.
Kallitsounaki, A. and Williams, D. (2023). Autism Spectrum Disorder and Gender Dysphoria/Incongruence. A systematic literature review and meta-analysis, Journal of autism and developmental disorders, 53, 3103-3117.
Lewis, L., Ward, C., Jarvis, N., Cawley, E. (2021). "Straight Sex is Complicated Enough!": The Lived Experiences of Autistics Who are Gay, Lesbian, Bisexual, Asexual, or Other Sexual Orientations, Journal of Autism and Developmental Disorders, 51,7, 2324-2337.
McNeil, J, Bailey, L, Ellis, S, Morton, J. and Reagan, M. (2012). Trans mental health study, The Scottish Trans Alliance, www.scottishtrans.org.
McQuaid, G., Gendy, J., Raitano Lee, N. and Wallace, G. (2021). Sexual minority identities in autistic adults: Diversity and associations with mental health symptoms and subjective quality of life, Autism in adulthood, 5,2,139-153.
Meyer, I. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence, Psychological Bulletin, 129, 5, 674.
NICE (2018). NICE Guideline (NG87):Attention Deficit Hyperactivity Disorder: diagnosis and management, Updated December 2021. www.nice.org.uk/guidance/ng87
O'Nions, E., Petersen, I., Buckman, J., Charlton, R., Cooper, C., Corbett, A., Happé, F., Manthorpe, J., Richards, M., Saunders, R., Zanker, C., Mandy, W., Stott, J. (2023). Autism in England: assessing underdiagnosis in a population-based cohort study of prospectively collected primary care data, The Lancet Regional Health - Europe, 29.