Gender dysphoria is not equivalent to gender nonconformity

Gender dysphoria is not equivalent to gender nonconformity

Abstract

A widespread assumption often used to explain why autistic persons are far more likely than non autistic persons to be transgender, is that they are less conforming to gender norms, and because of this are more likely to be transgender. I first explain why the assumption that gender dysphoria is caused by nonconformity is flawed, then I show using research on congenital adrenal hyperplasia that gender nonconformity does not explain dysphoria or being transgender.

Introduction

With growing evidence that gender dysphoria is associated with autism, many have suggested that this is not due to gender dysphoria being “caused” by autism, but that autistic people are more gender nonconforming, and that gender non-conformity causes gender dysphoria. The assumption that gender dysphoria and transgenderism is equivalent to gender non-conformity has also been the basis of the suggestion that the diagnosis of “gender dysphoria” is inaccurately “pathologizing” gender nonconformity. Is this idea true?

Gender Nonconformity

Gender nonconformity is behavior and expression which does not match what is typical for ones sex. Examples may include: dressing as the opposite sex, having interests typical of the opposite sex, preferring friends of the opposite sex, etc. Gender nonconformity is not a conscious choice by a person to behave like the opposite sex: it is a natural preference towards what is typical of the opposite sex, with a lack of motivation to conform to what is typical for their sex. Being transgender on the other hand, by self reported experience seems to be a conscious desire to be seen as the opposite sex, which is often, but not always accompanied by distress at when being seen as, or seeing themselves as their assigned sex at birth, which results in behavior intended to accomplish this. Someone who is gender nonconforming may feel like they are more “like” the opposite sex, and less like they are their sex, but this is almost opposite to gender dysphoria: a gender non-conforming female may naturally feel like they are “one of the boys”, but a transgender female wishes they were seen as and to feel as such.

Congenital Adrenal Hyperplasia

Congenital adrenal hyperplasia (CAH) is a disorder in which a person is exposed to excessive levels of prenatal testosterone, resulting in certain masculinized characteristics in females. Females with CAH very frequently are gender non-conforming, with large effect sizes shown for gendered behavior compared to control females (Pasterski et al. 2011)(Hines & Kaufman 1994)(Spencer et al. 2021)(Berenbaum & Hines 1992)(Servin et al. 2003)(Paterski et al. 2015). If gender dysphoria is primarily a result of gender nonconformity, it would be expected that girls with CAH are mostly transgender. However, this does not appear to be the case - while CAH girls were more likely to be gender dysphoric in three studies, the prevalence was very small (5%, 9%, 5.2%) and one study found they were less likely to be dysphoric, however this effect was small and non-significant [Table 1]. In three of the studies which assessed gender dysphoria, the prevalence of gender non-conformity was disproportionate to that of gender dysphoria: in two studies, over half preferred masculine roles over female ones (51%, 58%) but the prevalence of wishing to be the opposite sex or not being happy as a girl was 5% and 9%. The third study used a dimensional measure of gender dysphoria and gendered behavior, and found that CAH girls had much higher masculine toy and dress preferences (d=1.11, 1.02) but not gender dysphoric features.

The higher prevalence of gender dysphoria in females with CAH may appear to indicate that while the effect is small, gender nonconformity may lead to transgender identity in some cases, however this increased prevalence might be due to females with CAH often showing impairments in theory of mind via the reading the mind in the eyes task (RMET) (Khorashad et al. 2018), and worse RMET task is a very strong predictor of gender dysphoria, explaining up to 50% of the variance in gender dysphoric experiences (Kallitsounaki & Williams 2020). 

Table 1

Study	Finding
Paterski et al. (2015)	20.5% of girls with CAH occasionally wished to be the opposite sex, but only 5% did so frequently. Atleast 41% prefered opposite sex games, roles, or playmates, and 51% preferred opposite sex games only.
Berenbaum & Bailey (2003)	58% of CAH girls did not like dresses compared to 35% of control females, however only 9% felt they were not happy as a girl
Meyer-Bahlberg et al. (2004)	CAH girls were far more likely than control girls to prefer masculine toys & dress up (d=1.11, 1.02), however were not more likely to show gender dysphoric features (d=-0.15 - -0.19, not significant)
Dessens et al. (2005)	5.2% of CAH girls developed gender dysphoria
Lee & Witchel (2005)	6 CAH girls originally assigned male due to severely ambiguous genitalia were reassigned female, none developed gender dysphoria

Conclusion

There does not appear to be very much evidence to support the widespread assumption that being transgender or gender dysphoria are simply a result of not conforming to the behaviors or roles of ones assigned sex at birth, and that it's etiology is more complex.

1. Kallitsounaki & Williams (2020) Mentalising Moderates the Link between Autism Traits and Current Gender Dysphoric Features in Primarily Non-autistic, Cisgender Individuals

2. Pasterski et al. (2011) Prenatal hormones and childhood sex-segregation: Playmate and play style preferences in girls with congenital adrenal hyperplasia

3. Hines & Kaufman (1994) Androgen and the Development of Human Sex-Typical Behavior: Rough-and-Tumble Play and Sex of Preferred Playmates in Children with Congenital Adrenal Hyperplasia (CAH)

4. Spencer et al. (2021) Prenatal androgen exposure and children's gender-typed behavior and toy and playmate preferences

5. Berenbaum & Hines (1992) Early Androgens Are Related to Childhood Sex-Typed Toy Preferences

6. Servin et al. (2003) Prenatal Androgens and Gender-Typed Behavior: A Study of Girls With Mild and Severe Forms of Congenital Adrenal Hyperplasia

7. Paterski et al. (2015) Increased Cross-Gender Identification Independent of Gender Role Behavior in Girls with Congenital Adrenal Hyperplasia

8. Berenbaum & Bailey (2003) Effects on Gender Identity of Prenatal Androgens and Genital Appearance: Evidence from Girls with Congenital Adrenal Hyperplasia 

9. Meyer-Bahlberg et al. (2004) Prenatal androgenization affects gender-related behavior but not gender identity in 5–12-year-old girls with congenital adrenal hyperplasia

10. Dessens et al. (2005) Gender dysphoria and gender change in chromosomal females with congenital adrenal hyperplasia

11. Lee & Witchel (2005) 46,XX patients with congenital adrenal hyperplasia: initial assignment as male, reassigned female

12. Khorashad et al. (2018) Prenatal testosterone and theory of mind development: Findings from disorders of sex development