Blackwell Science, LtdOxford, UKCCHDChild: Care, Health and Development0305-1862Blackwell Science Ltd, 2002200228Case ReportGender identity prob-
lems in autistic childrenN.M. Mukaddes
Keywords
autistic disorder, gender
identity disorder, cross-
gender behaviour
Correspondence:
N. M. Mukaddes, MD,
.
Istanbul Tip Fakultesı PTT’si
PK:53, Capa Istanbul, Turkey
34272
E-mail:
nmotavalli@yahoo.com
Case report
Case Report
Gender identity problems in
autistic children
N. M. Mukaddes
Medical Faculty of Istanbul, University of Istanbul, Istanbul, Turkey
Accepted for publication 1 July 2002
Abstract
Several psychiatric and behavioural problems have been described in children with autism. The aim
of this case report is to discuss the developmental pattern of cross-gender behaviour in children with
autistic disorder. Two boys are described with high functioning autism, followed for about 4 years,
who showed persistent gender identity problems.
Introduction
Autism is a type of pervasive developmental disor-
der characterized by deficits in the areas of social
interaction, communication and the existence of
repetitive, unusual behaviours (APA 1994). It
affects multiple areas of functioning, which makes
the disorder difficult to diagnose and treat. Despite
the existence of several reports on the pattern of
psychiatric and behavioural problems that compli-
cate the treatment of autism (Klinger & Dawson
1996), few studies have addressed the issue of
gender identity problems in this population. This
omission may reflect both the common conception
that autism is a childhood syndrome and our soci-
ety’s reluctance to confront sexual issues (Ousley &
Mesibov 1991).
Studies suggest that, between 6 and 9 months of
age, infants are able to distinguish between the two
sexes. A sense of gender identity develops around
the second year of life, and sex role behaviours begin
to emerge as early as preschool. By the beginning
of the school years, most children have not only
achieved gender identity, but a certain degree of
gender constancy as well, by which children begin
to believe that gender is a permanent state that
cannot be altered by a change of clothing or activity
(Paikoff & Brooks-Gunn 1994). The establishment
© 2002 Blackwell Publishing Ltd
of gender identity results from a combination of
biological and environmental factors that have not
been clearly identified (Bradley & Zucker 1997).
According to DSM IV (APA 1994), gender iden-
tity disorder (GID) is manifested by a repeated
desire to be a member of the opposite sex, a pref-
erence for cross-dressing in boys, a persistent pref-
erence for cross-sex roles in make-believe play, and
a strong preference for playmates of the opposite
sex. In child clinic samples, more boys are referred
with this disorder than girls in the ratio of 7 : 1
(Bradley & Zucker 1997). Children with GID
manifest more traits of separation anxiety (Zucker
1999) and more internalizing psychopathology
(Menvielle 1998). Some 20% of GID children are
described as being gender dysphoric in adolescence
(Zucker et al. 1997). Adolescents with GID are also
at high risk of suicide (Menvielle 1998).
Despite the increase in research on GID in chil-
dren in recent decades, publications on gender
identity development and gender-related problems
in autistic children are very limited. To my knowl-
edge, Abelson’s (1981) study is the first study that
evaluates the development of gender identity in
children with autism. He reported a significant
relationship between gender identity and mental
age, chronological age, communication skills,
physical skills, self-help skills and academic skills.
529
530 N.M. Mukaddes
An extended literature search reveals only two
studies that report gender cross-behaviour (Will-
iams et al. 1996) and GID (Landen & Rasmussen
1997) in autistic children. Williams et al. (1996)
reported two young boys with autism, who had
clear primary interests in feminine gender-
stereotyped activities and objects. These interests
were not limited to one or two objects, but
included a broad spectrum of typically feminine
concerns (dressing in feminine clothing, manipu-
lating dolls, imitating female cartoon characters).
Although this report indicated that treatment
resulted in marked improvement in communica-
tion skills and broadened interests, the cases still
had a fascination with feminine objects. The
authors hypothesized that the feminine preoccupa-
tions of these children with autism may have
resulted from an inherent predisposition towards
unusual interests combined with the boys’ social
environment. Landen and Rasmussen (1997)
reported transexualism in a girl with high func-
tioning autism and tried to speculate on a possible
relationship between autism and transexuality.
In this report, two cases are described with
cross-gender behaviour in autism. The manifesta-
tion of cross-gender behaviour in different phases
of development in autistic children and its simi-
larity to non-autistic individuals with GID are
discussed.
Case histories
Case 1
S.A., a 10-year-old boy, was referred to the Child
Psychiatry Department of the Medical Faculty of
Istanbul, when he was aged 5 years. He was
referred by his parents because of his atypical
social relationship patterns, problems in language
and some repetitive–unusual behaviour. S.A. was
the product of a full-term pregnancy and vaginal
delivery and the second child of his 33-year-old
mother and 50-year-old father. Prenatal, perinatal
and post-natal medical histories were unremark-
able. His psychomotor development was within
the normal range except for his language. His
mother had taken care of him until he attended
school.
© 2002 Blackwell Publishing Ltd, Child: Care, Health & Development, 28, 6, 529–532
At the time of referral, he had restrictions in eye
contact, was unresponsive to verbal stimuli and
showed no interest in others. He spoke in short
sentences, spontaneous speech was rare, and
echolali, persevaration and neologism were also
observed. According to his parents, he had difficul-
ties in responding to smile and had not made eye
contact or shown interest in his peers since the
second year of life. His language development was
delayed; he started single words at age 3 years and
short sentences after age 4 years. His repetitive
behaviours, such as rocking and turning around,
were observed after age 3 years. Also, he developed
attachments to some feminine objects (such as cos-
metics) at age 3 years. Psychiatric evaluation and
organic investigation including EEG, MRI meta-
bolic screening, auditory evaluation and chromo-
somal analysis were done. There was a chiari I
malformation in his MRI. His IQ was 75 in
Stanford–Binet. After all the evaluations were com-
pleted, he was diagnosed with autistic disorder and
referred to a psychoeducational treatment pro-
gramme. One year after the referral, when he was
aged 6 years, he started to show improvements in
spontaneous speech and imitative play, and dis-
played more interest in his peers and other people.
At the same time, his mother reported some cross-
gender behaviours such as wearing his mother’s
dresses, putting lego bricks in his socks under
his heels and pretending to have high-heel shoes.
Along with the improvement in spontaneous
speech and imitative behaviour, he started to state
his disappointment about his gender. Sometimes,
he prayed and begged God to make his penis dis-
appear. After these verbal expressions, he shared his
fantasy about his wish to become a bride, married
to a man from the age of 8 years. He never shows
interest in male activities, he always avoids rough-
and-tumble play and prefers to play with girls.
Although he has shown some improvement in his
social relatedness and language, his social difficul-
ties in terms of reciprocal relationships with peers
and sustaining a conversation with others still
remain. Despite the eclectic treatment approaches
(behavioural modification, encouraging separa-
tion from his mother and establishing a bond
between him and his father), his cross-gender
behaviours show a persistent pattern.

Case 2
A.A., a 7-year-old boy, was referred to the Child
Psychiatry Department of the Medical Faculty of
Istanbul at the age of 3 years. He was referred by
his parents because of language delay as well as
problems with social interaction. A.A. was the first
child of his 40-year-old mother and 41-year-old
father. Prenatal, perinatal and post-natal medical
histories were unremarkable.
The family history was significant with father’s
obsessive–compulsive behaviour. His psychomotor
development was in the normal range, except for
language development. He had difficulties in
social–affective development in terms of eye con-
tact, imitative play, sharing interests with others,
and he also used some meaningless single words
and had some stereotypical behaviours such as
rocking, intermittent toe walking and a low
frustration tolerance. The organic investigations
including auditory evaluation, EEG, MRI, meta-
bolic screening and chromosomal analysis for
fragile-X showed no pathology. His full IQ in
WISC-R was 85. He was diagnosed with autistic
disorder and referred to a psychoeducational pro-
gramme. He started to use phrases at age 4 years,
showed improvement in social relationships and
sharing interests with peers at nursery school. He
also started some make-believe play. At the same
time, he had shown persistent attachment to his
mother’s and some significant female relative’s
clothes and especially liked to make skirts out of
their scarves. After age 5 years, he started to ‘play
house’ and ‘play mother roles’. This was the most
persistent and most pervasive pattern of his play,
and he pushed his therapist as well as his peers and
family members to ‘play house’ with him. He
avoids rough-and-tumble play and likes to share
his interests with one or two of his female class-
mates. His parents were worried about his behav-
iour and tried to prevent it, but he reacted
aggressively. He started to state his desire to grow
up as a woman (like his mother). He gave up his
attachment to some feminine objects, but still
shows persistence in playing the ‘mother roles’ and
expresses his desire to be a woman. Although there
are some improvements in terms of social related-
ness, language and the disappearance of stereotyp-
© 2002 Blackwell Publishing Ltd, Child: Care, Health & Development, 28, 6, 529–532
Gender identity problems in autistic children 531
ical behaviours, his social interaction pattern is still
inappropriate for his age. His parents have tried
to establish good bonding between him with his
father as a identification object. Despite this, his
cross-gender behaviours are persistent.
Discussion
An extended literature search revealed only two
earlier case reports about the existence of cross-
gender behaviour in autistic individuals. The cases
reported here show similarities to the cases
reported by Williams et al. (1996) in terms of
cross-dressing, ‘playing house’ and some other
cross-gender behaviours. However, there are some
differences between our cases and the cases
reported by Williams et al. (1996). The most
important difference is the existence of verbal
expression in our cases, who expressed their disap-
pointment about their genders and also their per-
sistent desires to become a woman. Williams et al.
(1996) showed caution in diagnosing their cases as
GID and preferred to evaluate them in the context
of autism. This concern may be related to the
short-term follow-up and the lack of verbal expres-
sion in their cases. As our first case has been fol-
lowed for 5 years, and the second for 4 years, it is
possible to assess the developmental patterns of
cross-gender behaviour in detail and to compare
them with those of non-autistic GID children.
Attachment to feminine objects (which at first
glance seem like transitional objects) is the first
symptom of cross-gender behaviour in both
cases. As language development and imitative play
improved, cross-gender behaviour started to man-
ifest itself in more complex forms. Both our cases
are high functioning autistic children, who have
shown improvement in their language develop-
ment as well as in the social affective area. They
both have the ability to express their disappoint-
ment about their gender and to state their wishes
to become a woman (a mother or a bride). Both
these cases have repeatedly reported their discom-
fort with their own sex and desire to be the oppo-
site sex and meet the criteria for GID (according to
DSMIV). In studies with non autistic children with
GID, identity statement and cross-dressing are
two of the more commonly noticed behaviours
532 N.M. Mukaddes
reported by parents (Zucker & Bradley 2000). One
needs to bear in mind that the cases reported here
had acquired sufficient linguistic ability, which is
an important factor in developing self-concept, to
express themselves. Lee and Hobson (1998) stated
that verbally able individuals with autism seem to
think about their physical attributes and their
activities in much the same way as non-autistic
people of the same ages and mental abilities. Ver-
bally able autistic individuals can state their pref-
erences, but they express a more restricted range of
emotions than non-autistic individuals and, more
strikingly, they do not anchor their self-attributes
in social activities and relations. It seems that, in
verbally able autistic individuals, their expressions
of disappointment of their gender can be helpful
in diagnosis.
The rare report of cross-gender behaviour in
autistic cases may be related to: (1) under-report-
ing by parents to avoid the stigmatization of their
children; (2) interpretation of cross-gender behav-
iour as a ‘usual’ part of ‘unusual’ interests of autistic
individuals by clinicians. This case study, which is
a preliminary attempt to report the developmental
pattern of cross-gender behaviour in autistic chil-
dren, tries to underline that (1) diagnosis of GID
in autistic individuals with a long follow-up seems
possible; and (2) high functioning verbally able
autistic individuals can express their gender
preferences as well as other personal preferences.
Finally, this report points to the need for further
study of gender identity development as well as
other identity problems in individuals with high
functioning autism.
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