Autism alarm

A Danish autism association breaks the taboo on talking about the extra risks of gender medicalisation for neurodiverse young people

Photo by Ange Loron on Unsplash

Time warp

Young people with autism may be at risk from an unethical form of “medical conversion therapy”, according to Denmark’s Autism and Asperger’s Association.

In a sharp critique of the Danish Health Authority’s draft guidance for handling cases of “gender incongruence”, the autism association notes the approved “use of potent hormone preparations that were originally developed for the treatment of hormone-sensitive prostate cancer and are in some cases used for the chemical castration of paedophiles.”

“This raises a serious question: Are we witnessing a new form of medical conversion therapy aimed at autistic children and young people?

“Less than 20 years ago, attempts were made to ‘normalise’ autism and cure homosexuality using the same types of hormone preparations that are currently used for gender-modifying treatment, including cyproterone acetate (Androcur), spironolactone, GnRH analogues (puberty blockers) such as Leuprorelin, and similar drugs.

“History has shown that medical experiments on autistic children have had serious consequences—and yet we are on the verge of repeating the mistakes of the past.”

The strong pushback to the health authority’s draft “Professional framework for healthcare assistance in cases of gender incongruence”—issued in December last year and yet to be finalised—is noteworthy because many autism organisations elsewhere have been silent on the heightened risk of medical harm to autistic people misled and disoriented by the “gender-affirming” treatment approach and social promotion of self-declared “gender identity”.

By contrast, the affirmative talking point—picked up by some neurodiversity activists internationally—is that autism and gender identity are entirely independent and that autistic people cannot be denied the “human right” to medical transition.

The Danish Paediatric Society—also strongly critical of the draft guidance, which was supposed to emulate the shift to caution seen in other Nordic countries—has urged “a more restrictive treatment practice for children and young people with mental illness and developmental disorders,” given the danger of misdiagnosing their difficulties as a gender issue.

“Particularly in cases of (possibly undiagnosed) autism spectrum disorders, children may experience uncertainty, unhappiness, and identity issues, including a potential feeling of gender incongruence, when they start school, where there are significantly increased demands on social skills,” the society says in its commentary.

Dina Raabjerg, a Conservative Party member of the Danish parliament and longtime critic of the poorly evidenced hormonal treatment of children, feels vindicated by the expert concerns of the organisations representing paediatricians as well as child and adolescent psychiatrists, Kristeligt Dagblad reported in March.

“I think we should stop completely until we find out what the right treatment is,” she told the newspaper.

“The paediatricians state very clearly in their consultation response that this is experimental treatment and that the long-term effects are unknown. It should stop now.”

However, Helge Sune Nymand of the Association for Support for Transgender Children, argues that “a precautionary principle” already exists in the draft framework.

“If you’re afraid that you can walk in off the street and get hormone therapy, you’re sorely mistaken. It requires a long investigation in collaboration with many medical professionals who weigh the indication for treatment against possible side effects,” he told Kristeligt Dagblad.

“It’s naive to believe that you can create a treatment without any risks or side effects. And it’s naive to think that there are no side effects from not treating. There are risks whether you do something or not, so it’s always a trade-off.”

At risk and overlooked

In its comment on the draft guidance issued by the Danish Health Authority’s working group, the Autism and Asperger’s Association says that young people with autism are over-represented among those who identify as transgender—and also among those who come to regret gender medicalisation.¹

“Despite this, there is no guarantee that autism will be thoroughly assessed during the assessment process [under the draft framework],” the association says.

“Autism can affect body perception, self-understanding, and identity, and can affect the ability to assess the long-term consequences of medical treatment. Therefore, thorough screening for autism should be an absolute minimum requirement before gender-affirming treatment.”

The association sets out particular risks facing autistic young people—

“Autism can affect identity understanding: Many autistic people experience challenges with social adaptation, sensory disturbances, and a black-and-white approach to self-understanding, which can make them particularly vulnerable to perceiving gender identity as a fixed truth.

“Risk of misdiagnosis: Autistic young people may misunderstand their own feelings and confuse gender dysphoria with other sensory or bodily challenges. They may also be more susceptible to social influence and identity-seeking communities.”

In 2022, following the shift away from routine hormonal treatment of gender-distressed young people in Sweden and Finland, Denmark’s specialised national gender service for minors, the Sexology Clinic at Rigshospitalet University Hospital in Copenhagen, reported a sharp decline in the number of patients put on the medical path.

The following year, Danish Health Minister Sophie Løhde acknowledged adoption of a more cautious clinical policy, with the suggested effect that patients presenting with teenage-onset gender distress would be likely to be denied the hormonal interventions reserved for those with distress dating back to early childhood.²

This represents the divide between the classic early-onset, chiefly male patients for whom there is some research supporting treatment, and the more recent atypical profile of predominantly female teenage-onset patients, for whom data is lacking.

Drawing on public funds from a DKK 24.8 million LGBT+ action plan, the Danish Health Authority decided to replace its 2018 guidance, “Healthcare help with gender identity issues”, with the new framework, which was supposed to be finalised during this northern spring.

The shortcomings of the draft framework testify to the enduring influence of trans-affirmative experts and activists on health institutions, and the difficulty of bringing precision and safety to a gender-affirming treatment model with a vague and subjective gender identity at its core.

A spokesperson for the health authority told GCN that the finalised guidance was expected to be published “within the next few months”, and there would be “no new hearing before then.”

“The [2024 draft] guidelines appear even more ‘trans-ideological’ in their approach and language than the current [2018] guidelines.”—Consultation response, the Danish Rainbow Council, an “anti-woke” LGBT group which campaigns for a ban on medical transition of young people up until at least age 25

“The ideologically influenced definition of the framework surrounding the disorder that the [health authority] wishes to alleviate in children and young people is a major part of the problem—because it leaves no other treatment option than to medicate and perform surgery on patients—and diagnostic certainty is completely absent.”

Support, but only our way

Under the 2024 draft framework issued by the Danish Health Authority, the primary intervention for minors would be psychosocial support, but within “an environment that supports their gender identity.”

And for those with “persistent” gender incongruence—a sense of disconnect between birth sex and a feeling of gender identity whose diagnosis does not require any distress on the part of the patient—referral for specialised assessment and medical treatment would be options.

Such assessment would seek to distinguish “temporary identity exploration”—with no need for medical treatment—from persistent gender incongruence, defined as at least two years’ duration. There would be some kind of “special focus” on minors with developmental disorders, such as autism.

However, the framework insists that autism, like “well-treated” mental health conditions, should not be a necessary obstacle to hormonal intervention, although it might demand longer or more thorough assessment.

The document does concede that paediatric medical transition might not be a good idea if the minor suffers from a “severe psychotic disorder”, or mental and developmental conditions involving “an inability to participate in the assessment, understand and reflect on the consequences of treatment”.

“It is worth noting that the revised [draft] guidelines do not contain a single word about other help for gender-questioning children and young people than medical and surgical options.”—Consultation response, the Danish Rainbow Council

“For talk therapy and other cognitive-based treatment for children and young people who are refused treatment at the Sexology Clinic, we understand from the treatment guidelines that [the health authority] refers to private initiatives run by strongly trans-ideological interest groups such as the Association for the Support of Transgender Children or various municipally funded services.”

We don’t know

There is a frank admission of ignorance in the draft framework—“The long-term physical and psychosocial consequences of [gender] medical treatment of children and young people are not yet known.”

And although the health authority describes puberty blockers as “in principle reversible”, it admits that “the lifelong physical, psychological, cognitive and social consequences of postponing puberty beyond the age of 15 are not yet known.”

However, the health authority’s response to these unknowns is not to end routine treatment—early puberty blockers would still be available, and the age of 15 would be a negotiable threshold for cross-sex hormones—but to require follow-up research “to generate knowledge about the long-term effects of treatment for this target group.”

The autism association objects to the proposal that hormonal interventions based on such weak evidence should remain “part of the standard treatment”, as the framework puts it.

“In practice, this means that patients accept experimental treatment whose full risk profile is not known,” the association says. “How can a child or young person make an informed decision when even doctors do not know the long-term consequences and therefore cannot communicate them?

“Providing irreversible treatments without solid scientific evidence is not medicine—it is experimenting on vulnerable patients.

“Therefore, the guidelines should be revised so that they do not allow medical and surgical treatment of children and young people without a thorough, evidence-based risk assessment.

“Until reliable long-term studies are available, treatment options should be based on psychotherapeutic and supportive interventions rather than medical experiments with potentially life-destroying consequences.”

“This ideological approach to healthcare has come, on a global scale, at great cost to a growing number of children and young people who, with society’s trans-ideological stamp of approval, have been sucked uncritically into trans ideology and its distorted view of gender, gender identity, puberty and sexuality.”—Consultation response, the Danish Rainbow Council

“Today, there is talk of the concept of ‘transing the gay away’—the fact is that many of these children [would otherwise become] ordinary homosexuals or bisexuals whose unhappiness, for various reasons, has led them to believe that a change to the opposite sex was the solution.”

Words that bind

The pitfalls of preferred pronouns and misconceived “depathologisation” are also analysed by the Autism and Asperger’s Association in its commentary on the draft framework.

“There are no other areas of healthcare where the patient’s linguistic choices dictate the healthcare approach,” the association says. “For example, a patient with an eating disorder would not have their distorted body image confirmed by healthcare professionals.

“Making the patient’s choice of pronouns an essential part of the process may indicate that subjective self-understanding should take precedence over a thorough and nuanced clarification of identity and well-being.

“This is particularly problematic when there may be other underlying factors, such as autism, trauma, or mental illness, that need to be explored and addressed.

“For autistic patients, who often have a concrete and literal approach to language and identity, an emphasis on pronouns can increase confusion and possibly lead them to maintain an identity that is not the correct one or that is influenced by other factors.”

In a similar way, the association targets the anti-psychiatry flavour of the draft framework.

“We recognise that many people feel uncomfortable with a psychiatric assessment. This also applies to the group we represent,” the association says. “Autism is assessed in psychiatry, but it is not a mental illness—it is a pervasive developmental disorder.

“Just as autistic people accept psychiatric assessment as a necessary part of getting the right support, people with gender dysphoria should recognise the need for a thorough psychiatric assessment to ensure the best possible treatment.

“There is no shame in having a psychiatric diagnosis or being assessed in psychiatry.

“On the contrary, the health authority should maintain that a correct assessment requires a psychiatric perspective, as gender incongruence often coexists with psychiatric disorders and developmental disorders—proper treatment is in everyone’s best interest.”

“[The Danish Health Authority] is now, strangely enough, doing the exact opposite [of England after the Cass review] and continuing undeterred with the heavily criticised, potentially irreversible treatment with puberty blockers for the youngest children, and the authority is even opening up the possibility for patients younger than 15 years of age to receive treatment with irreversible cross-sex hormones.”—Consultation response, the Danish Rainbow Council

Trouble in the ranks

Concern about the welfare of autistic people under the new framework led two of Denmark’s three adult gender clinics—in Copenhagen and Odense—to send a joint letter of concern to the health authority.

Copenhagen psychotherapist Lotte Ingerslev, who is a critical observer of gender ideology, has described this as “a bombshell”—and perhaps a sign of a staff revolt.³

In their letter, the gender clinicians suggest that at least a third of new referrals are diagnosed with autism, while even more have autistic traits, creating doubt and uncertainty about assessment and treatment, as shown by the different approaches of the country’s three clinics.⁴

“Patients with [autism] may find it difficult to understand how others think. They therefore develop their own private logic and understanding of what it means to have gender dysphoria. This can lead them to interpret a range of other social challenges as being related to gender dysphoria,” the letter says.

“Patients with [autism] may have unrealistic expectations of how, and with what understanding, those around them will treat them after any treatment.

“[These patients] are immature in some areas relative to their chronological age and, with further cognitive maturation and psychoeducation about the body, emotions, sexuality, etc, could potentially come to realise that hormone treatment and surgery are not the solution.

“Their reflection on gender discomfort is complicated by the fact that patients with [autism] may tend to become fixated on a certain way of thinking and therefore lack flexibility towards other perspectives.”

The clinicians give the example of a patient “who has not previously reflected on their gender identity and whose puberty was not particularly problematic. However, the patient comes across a description of transgenderism online and very quickly becomes convinced that they are in this situation.”

This patient, the clinicians say, identifies as non-binary but does not express this socially much at all, and offers only “vague or stereotypical descriptions of their discomfort” at being gender incongruent.

And yet this person “is convinced that hormones and possibly surgery are absolutely necessary to make their life significantly better,” the gender clinicians’ letter says.

“The patient may add that getting hormones will be the [clinical] team’s seal of approval that they are transgender, and that this will make it easier to come out. Patients with [autism] also often argue that they cannot move forward with their education or work until they receive treatment—they have put their lives on hold.

“Thus, their descriptions of the development of their gender identity may be characterised by a ‘special interest’ [an intense focus on a subject, characteristic of autism].”

The concern of the clinicians is also driven by their belief that patients with autism are particularly at risk of discontinuing or regretting treatment—one reason being the failure of these gender interventions to alleviate the social isolation and other problems bound up with autism.

---

Video: Jesper Rasmussen, chairman of the Danish Rainbow Council, explains the mission of his unusual organisation, an LGBT group which opposes gender ideology and whose founding chair was a transsexual man, Marcus Dib Jensen

What, no Cass?

In its contribution to the consultation on the draft framework, the Danish Paediatric Society argues that the health authority has failed its own test—to review the 2018 guidance in the light of “the latest knowledge.”

The society contends that the draft framework, which fails to mention England’s 2024 Cass report, has not adequately taken account of recent confirmation internationally that the evidence base is weak and long-term data is lacking.

“The [Cass] report was highly critical of endocrinological intervention in minors with gender incongruence. We therefore believe that the work [on Denmark’s draft framework] should be resumed and the guidelines revised on the basis of this new knowledge,” the society says.

Nor is the paediatric society impressed by the idea that two years of self-reported gender incongruence reveals a condition persistent enough to warrant medical intervention.

“Early onset of gender incongruence should be central to assessment and treatment considerations for minors,” the society says in its consultation commentary. “A symptom duration of two years seems, in this context, a very short period of time and thus a vague and insufficient diagnostic criterion.”

There is concern that a false positive diagnosis of gender incongruence could lead to unnecessary and irreversible medicalisation.

The society notes that the framework sets clinicians a nearly impossible task: to weigh the benefits of gender medical treatment against its adverse effects.

“This is difficult to determine, as there is a lack of long-term follow-up on the possible adverse effects of endocrinological treatment,” the society says.

The framework’s minimum age of 15 for cross-sex hormones applies “unless it is considered medically irresponsible for the individual child or young person to wait before starting treatment.”

That concept of medical irresponsibility “seems imprecise and worryingly elastic to us,” the society says.

The newspaper Kristeligt Dagblad sums up the paediatric society’s position as stating—

“The long-term effects are unknown. And we don’t actually know if it is better to treat than not to treat children who don’t feel like their biological sex.”

The newspaper quotes the chair of the society’s Adolescent Medicine Committee, Dr Kirsten Arntz Boisen, who is a senior physician.

“The fact that the long-term consequences of different medical treatments are unknown is not in itself a special case,” she says. “And it’s not something that necessarily means you can’t use the medication. But it’s different when it comes to children and adolescents.

“Children and young people are in a field of development and growth—biologically, psychologically, and socially. They are in a very vulnerable place in life, where everything is at stake and their identity is under constant construction. Therefore, much more caution needs to be exercised.”

Dr Nina Tejs Jørring, chairperson of the Child and Adolescent Psychiatric Society, is quoted as expressing apprehension about a bias towards medicalisation in the new framework from the health authority.

“There is a risk of focusing on the medical treatment, and I am very concerned that the guidance overlooks the importance of psychosocial and social educational treatment,” she says. “The problem with medical treatment is that in some cases you can’t go back once you’ve started.”

She cites research supporting the general proposition that symptoms—and therefore, the diagnosis—can change during childhood. “It is very difficult to assess whether a young person can understand the consequences of this [hormonal] treatment when it is even difficult for professionals.”

In its consultation response to the draft guidance, the Child and Adolescent Psychiatric Society stresses the “uncertain evidence” for gender treatment of minors.

It also points to doubts about the predictive value and stability of gender incongruence as a diagnosis and the lack of clarity on how a clinician might distinguish between “temporary identity exploration” and “a flare-up of persistent gender incongruence.”

The society sees the need for a more specific treatment guideline for handling gender distress in minors. It also requests guidance from the health authority on how to help and support people who cease hormonal treatment and regret ever having it.

And the society’s commentary challenges the assertion in the draft framework that “delayed [hormonal] treatment may result in long-term physical and psychosocial harm in the event of unwanted pubertal development towards the sex assigned at birth.”

This is a variation on the activist cry that “trans kids” must be saved from the “irreversible harm” of going through the “wrong puberty”.

The society’s terse comment is that “there are no studies that can confirm or refute that such puberty development in itself is harmful.”

The Danish Rainbow Council—guided by its medical advisor, Lasse Sørensen, a specialist in child and adolescent psychiatry at Bispebjerg Hospital—warns that this trans-affirmative “framing of the potential ‘harm’ of natural puberty can create a nocebo [or negative placebo] effect, which simply reinforces the anxiety and discomfort of the child and parents. This can become a perpetuating and reinforcing factor for gender dysphoria.”

Thanks to NeuroPoppins for alerting me to the important critique from the Autism and Asperger’s Association

1. The draft framework covers both minors and adults; I focus chiefly on the former.

2. The researchers responsible for the puberty blocker-driven “Dutch protocol” of paediatric medical transition have protested that clinics outside the Netherlands should not have applied this protocol to a different patient group without doing their own research. Although the Dutch research has its shortcomings, there was virtually no data to support the international expansion of the protocol to today’s predominantly female patients with rapid-onset gender dysphoria.

3. Ms Ingerslev has had to launch a crowdfunder to aid her defence against “misgendering” charge arising from one of her blog posts.

4. There is increasing concern internationally about the number of adolescents with immature brains under the age of 25—especially if they have mental health disorders and neurodiverse conditions—being medicalised in adult gender clinics.