I try to keep an eye on the world of transphobia, and, as an autistic person, I was particularly drawn to a Daily Wire (a right wing, transphobic website with dubious connections to truth created by Ben Shapiro) article on how autistic adolescents were helped with psychotherapy and no medical intervention, based on a recent study. Even writing this sentence, an astute reader will notice problems. But, I went beyond that and actually read the study.
Needless to say, I’ll be talking about transphobia and ableism. This is your content warning, if you’re not in a place where you want to deal with this stuff. You honestly don’t need to — there are enough of us who do, and your health is important.
So, the article…
Let’s start with the first sentence of the Daily Wire article:
A new pilot study found that psychotherapy — without medical intervention — improved the mental health of autistic adolescents with gender dysphoria.
The article makes a bunch of other dubious claims (for instance, it trots out the idea that most youth with gender dysphoria live happily as their assigned sex at birth once they grow out of it, which is a surprisingly robust, but also very wrong, belief), but I want to focus on the main point: psychotherapy without medical intervention helps autistic adolescents with gender dysphoria, and, further, that medical intervention is unnecessary. For the second part of that, that medical intervention is unnecessary, “[the study] challenges the ‘affirm-or-suicide’ narrative, which implies that medically transitioning adolescents will prevent them from committing suicide.”
Again, we could pick apart a lot of the rest of the article, like supposed links to rapid-onset gender dysphoria (an unscientific bogus theory that says you can catch g̶a̶y̶ transness from other trans people, and also ironic in an article that continues with ableist misunderstandings of autism, as a stereotype of autism is that autistics don’t follow peer-pressure). Or we could talk about citing Dr. Cantor (a gay man who advocated that pedophiles should be included in the LGBT umbrella) and Dr. Zucker.
That’s a bold claim! So let’s look at the study!
Unpacking the Claim
Let’s start with the claim. Recall, from the article:
A new pilot study found that psychotherapy — without medical intervention — improved the mental health of autistic adolescents with gender dysphoria.
Psychotherapy
This Daily Wire article does, correctly, identify the study as a pilot study (it probably helps that the journal article is entitled, “A Pilot Study on the Effect of Peer Support on Quality of Life of Adolescents with Autism Spectrum Disorder and Gender Dysphoria”). But moving past that, it claims that the study was about psychotherapy. The Daily Wire later article mentions “gender exploratory therapy” (a practice similar to conversion therapy with similar ethical concerns), in a way that expects the reader to link psychotherapy and gender exploratory therapy.
But what is pyshcotherapy? What do you think of when you hear the word “psychotherapy?” You probably think of someone talking to a doctor, probably while the patient is reclining on a couch and the doctor takes notes. But that’s not what this study did. This study examined peer support, which has a different authority model than laying on a couch while an authority takes notes. In essence, the model used in the study was a group of autistic trans people (I won’t say adolescent as that word is too murky, as we’ll see later) that, with facilitation and direction of a therapist, discussed verious aspects relating to autism and gender dysphoria. In addition, the study also provided a peer support group for parents of some of the people in the study (more on this later). The study found that, yes, that did improve one measure of psychological health. But it’s probably not the psychotherapy the average reader would think of!
As someone who co-founded a trans+autistic peer support group, I absolutely believe trans+autistic people are the experts on our own lives, and that we have a lot to learn from each other. I believe being in community, and finding out you’re not alone, is a big deal. And definitely helpful! But the article isn’t saying groups like the one I helped create are good, the article is trying to argue against medical transition of youth, replacing that peer support with, essentially, getting talked out of being trans.
But moving on…let’s go back to the Daily Wire article’s opening statement:
A new pilot study found that psychotherapy — without medical intervention — improved the mental health of autistic adolescents with gender dysphoria.
Without Medical Intervention
The Daily Wire article claims that the psychotherapy was done without medical intervention. In other words, the study says there is no need for puberty blockers, surgery, or hormones here! Instead, they helped kids without that, showing that people who claim to be trying to protect kids from unnecessary medical procedures are, in fact, correct! There is a better way! Talk therapy!
We already looked at what the psychotherapy was, but let’s move on a bit and look at what the study itself said about medical intervention. From the study:
The adolescents who participated in the study were in different phases of their gender journey. Those who were starting their gender journey had their focus on how to verbalize or express their gender identity, while others were already receiving or started using cross-gender hormones prescribed by a medical specialist.
So, some were using hormones (not puberty-blockers, but actual estrogen or testosterone). If the claims of trans people are true, that hormone therapy can help with mental health, we would expect someone on hormones to see increasingly better mental health, at least for some initial period after starting (few medications provide full effect instantly, and hormones certainly don’t, as they mold the body over a period of time).
Of course not every trans or non-binary person diagnosed with gender dysphoria chooses to use hormones. Indeed, some of the most frightening trans people, at least in the eyes of transphobic people, are trans people who don’t change their bodies. These people exist, and could also have been in the group, as might people who were just starting to explore their gender at a very early stage (contrary to transphobic belief, the normal progression for someone who does use hormone therapy is to spend time exploring gender prior to starting hormone therapy).
There was no analysis done of whether people not doing hormone therapy saw different outcomes than those not on hormone therapy — the study is silent on that.
But beyond that, I’d also remind readers that psychotherapy is a medical intervention! Mental health intervention is often medical intervention. In this case, the study includes plenty of guideposts to this fact, talking about interventions, clinical practice, medical ethics, among other terms you would find in many overtly medical studies.
So, again moving on, and reminding ourselves if the opening statement of the Daily Wire article:
A new pilot study found that psychotherapy — without medical intervention — improved the mental health of autistic adolescents with gender dysphoria.
Improved Mental Health
The Daily Wire article seems to claim that the psychotherapy these kids got, while not getting puberty blockers or hormones, improved their mental health. So, what does the study say?
It turns out “mental health” is complicated, because it isn’t a single thing. Indeed, this study focused on “Quality of Life” which is a specific mental-health measure, and while interlocking with other aspects of mental health, is distinct from something like anxiety, depression, gender dysphoria, and psychological conditions. Indeed, the study looked at several aspects of mental health, most of which didn’t yield particularly strong changes over the course of the study (these were measured at the start and end of the study, to see if it is plausible that the peer support might have impacted them). The following were measured in the study:
- Quality of Life (both “well-being” and “psychological complaints”, which have particular meanings in this type of research, and are not synonyms with “mental health”)
- Self-esteem
- Gender dysphoria
- Social responsiveness (characterized, wrongly, by the study authors as “ASD characteristics”)
All of these, arguably, are part of the thing we call “mental health.”
That said, did the study find these improved?
Not quite. It found that the autistic people in the study did show less psychological complaints (based on, as are the rest of these, an instrument — basically a survey — they completed themselves). The differences were not statistically significant for well-being, self-esteem, or social responsiveness, and the measure of gender dyshporia increased! I wouldn’t say these results make it clear that “mental health” was improved, although I do suspect it is for reasons I’ll mention below, but that’s not something that you can gather directly from the study.
What you can gather from the study is that psychological complaints (as reported through the study instrument by the participants) were reduced during the study. That’s probably a good thing, and hence why the title of the study says that this peer support improved quality of life. So at least one aspect of mental health was better, but the authors of the study were careful to limit their conclusion to just quality of life, as measured by the well-being measure.
Concern about the Study Instruments
Diverting a bit from our analysis of the Daily Wire claim, I will say that I am disappointed with the methods used in this study. The study tried to use instruments that were, primarily, developed for non-autistic populations. The study itself noted the problem of this:
The inconsistencies in completed questionnaires, although it can be explained by the deficits of ASD, are the first limitation of the current study. It was strenuous for the participants to complete the questionnaires. For some of them, it took a lot of time and they had trouble interpreting the questions.
While I object to framing this as a “deficit” of autism spectrum disorder (ASD), as I find that framing ableist and assumes that the problem is with the individual and not the measure used (that was hardly the only example of anti-autistic stigma in the study), it’s clear the instruments (surveys) were being seen very differently by the autistic people in this study than with other people. Other parts of the study indicated that some participants couldn’t even complete some of the instruments, further indicating their unsuitableness for the group using them. This raises some questions about the conclusions.
Back to Mental Health
Getting back to the Daily Wire article’s suggestion of improved mental health, what should we make of increased gender dysphoria, according to a measure called the UGDS (“Utrecht Gender Dysphoria Scale,” two instruments developed by Dutch researchers for measuring gender dysphoria)?
My own personal experience with gender dysphoria is that sometimes things get worse before they get better. A transphobic reading would be that health care is supposed to improve my health, and the “getting worse” part shows how bad dysphoria treatment can be. I’d counter with my experience, as while my gender dysphoria was worse, I had hope that I didn’t have before I started the path to living as my gender. But, that hope meant that now I could see possibilities, not bleakness, and see the distance between the possibilities and my present state. In other words, I wasn’t disassociating. I was living, with hope.
The researchers for their part, stated “In line with Routine Outcome Monitoring (ROM) research that stats that sometimes treatment can lead to an increase in complaints or symptoms, this result underscores the importance of discussing and interpreting the outcomes with the patients themselves” (referencing van Os, et al., 2012). They also noted that “this outcome may also be related to the binary structure of the UGDS survey.” What they did not do was to link this to peer contagion or “rapid-onset” gender dysphoria, unlike the Daily Wire article.
Regardless, however, it is clear that this study isn’t able to make a claim about holistic “mental health,” and thus limits itself to well-being.
So, back to unpacking the Daily Wire article, and the opening statement:
A new pilot study found that psychotherapy — without medical intervention — improved the mental health of autistic adolescents with gender dysphoria.
Autistics
I’ll give credit here to the Daily Wire, for using the term “autistic adolescents” rather than the person-first term “adolescents with autism” — autistic people tend to prefer identity-first rather than person-first language. And, yes, the study was about autsitic people! So they got this right!
That said, both the Daily Wire and the study report both stigmatized autistic identity, but that’ll take us on yet another diversion, and we’ve had enough of those already here, so we’ll just skip past that and go back to the Daily Wire:
A new pilot study found that psychotherapy — without medical intervention — improved the mental health of autistic adolescents with gender dysphoria.
Adolescents?
Like we did with psychotherapy, think about the word “adolescents?” Does it remind you of your mother (sorry, I couldn’t help but slip a psychoanalytic joke in here)?
In seriousness, what do you think about? You’re probably thinking kids, maybe puberty age through 18-years-old. That’s certainly what the Daily Wire article wants you to think (basically that we’ve found an alternative that doesn’t require “medicalizing” kids), although they can be forgiven somewhat because that’s also the term the study itself uses, as the study uses a different definition of adolescent that includes many adults. There is no one definition of adolescent (the WHO uses ages 10–19), but not all of the study participants are kids. For the study, the ages were 13–24, with the median age of 17.8 years old (I.E. around half the participants were adults, well past puberty age). The majority of participants were within a couple years of that 18-years-old (standard deviation was 2.32). I.E. we can infer that this was mostly a study of 16–20 year old people.
So, while it included some kids (roughly half), most (perhaps all) were past the age you would initiate puberty blockers. I mention this because the Daily Wire article claims the study “deprioritized medical interventions like puberty blocking drugs,” when puberty blockers would simply not be an option for most participants (hence, also, the mention of hormone therapy that some participants were taking). I’ll add that the study did not deprioritize medical intervention, but simply added peer support to whatever else the autistic person was doing.
Regardless, while the Daily Wire article wants you to think of kids, you might be better off thinking military-enlistment-age persons.
Back to the Daily Wire’s opening statement, to continue unpacking it:
A new pilot study found that psychotherapy — without medical intervention — improved the mental health of autistic adolescents with gender dysphoria.
With Gender Dysphoria
Again, one of the few things this opening Daily Wire sentence gets correct: yes, the study dealt with people labeled as having gender dysphoria! A lot could be said about the concept of gender dysphoria, and there are valid criticisms (I honestly believe trans liberation that requires dysphoria for access to medical technology is no trans liberation), but we’ll also skip over those, as others are more adept at writing about that!
I will note that the study itself cites outdated and incorrect information about gender dysphoria, such as the idea that only 4.6 in 100,000 people have gender dysphora. Way back in 2002, one of the most fascinating studies on the size of trans people involved asking “kathoey” people in Thailand to observe people going into and out of major shopping centers (along with the researcher), counting how many are also “kathoey” to calibrate the researcher’s ability to spot kathoey, which was then used for counting how many “definite” kathoey existed (“possible” kathoey were excluded). While I want to be careful to not map kathoey identity onto western transgender identity, this identity is a person assigned male at birth who dresses and lives as a woman. This “kathoey-dar” (similar to gaydar) approach came up with 292 out of 100,000 people, which is nearly two orders of magnitude larger than the study writers claim in this study. Dr. Lynn Conway quoted that study when she found these low estimates were wrong, and found it also gave strength to her scientific estimates that there are a lot more of us than a few out of 100,000.
Indeed, bad estimates may be a cause of assuming we’re seeing a growth in number of trans people, just as it was for the supposed (but not real) growth in number of autistic people. Yet this fuels panic, and in this case the panic is compounded by “look at these autistic people who all have gender dysphoria! Something sinister must be happening!” It may also be why the study was proud of the 41 person sample size (of which 7 dropped out), if their estimates of trans and autistic identity are based on bad information.
So, where do we go from here?
The next time a publication, particularly one that is known to have a strong political bias, says something that sounds out-of-step with mainstream science, maybe approach it a bit cautiously.
In this case, the Daily Wire would often be read as saying a lot of things about the study that the study didn’t actually say (some of these not directly, as the Daily Wire writes carefully to imply without saying some of these incorrect statements — it is relying on the reader to make the obvious connections). For instance, the study didn’t study mostly kids, didn’t talk about puberty blockers, didn’t study 1-on-1 talk therapy, didn’t look at therapy as an alternative to drugs and surgery, didn’t suggest “gender exploration therapy,” didn’t find that mental health holistically improved, didn’t find links to rapid-onset gender dysphoria, didn’t challenge an “affirm-or-suicide” model, and didn’t find that participants desisted from their trans identity.
Sadly, the study itself also had problems, but the main conclusion is clear: it’s probably good for trans+autistic people to get together and talk — not as an alternative to other parts of transition, but as a part of transition. Indeed, the study itself stated: “In fact, joining such a group [like the peer group described by the study] can in itself be seen as a step in social transitioning.”
Some References
The study the Daily Wire article drew from
Brandsma, T., Visser, K., Volk, J. J. G., Rijn, A. B. van, & Dekker, L. P. (2022). A pilot study on the effect of peer support on quality of life of adolescents with autism spectrum disorder and gender dysphoria. Journal of Autism and Developmental Disorders. Advance Online Publication, https://doi.org/10.1007/s10803-022-05832-4
Ethical considerations with “gender exploratory therapy”
Ashley, F. (2022). Interrogating gender-exploratory therapy. Perspectives on Psychological Science, Advance Online Publication, 1 - 10. https://doi.org/10.1177/17456916221102325
How many trans people are there?
These are both somewhat outdated sources, but the Winter article in particular is fascinating for the culturally interesting method of counting kathoey people, while the Conway article was one of the first trans-informed estimates (from a very concrete, mathematical method that we would expect of a great Computer Scientist like Conway) of the number of trans people. Newer research puts the estimates as higher:
Conway, L. (2012, April 2). Estimating the prevalence of transsexualism. University of Michigan. https://ai.eecs.umich.edu/people/conway/TS/TSprevalence.html
Winter, S. (2002, August 27). Counting kathoey. Sam Winter. https://samwinter.org/transgenderasia/paper_counting_kathoey.htm
Gendered Thoughts 