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Supporting Transgender Autistic Youth and Adults: A Guide for Professionals and Families (2020) by Finn V. Gratton. Jessica Kingsley Publishers. ISBN: 9781785928031

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Reviewed by: Louis Spence

Book Review

It seems appropriate to begin, as Gratton does in this book’s preface, by situating myself in relation to this subject matter. I am a queer, allistic (non-autistic), neurodivergent, non-binary, transgender psychotherapist. Gratton shares all of these identifications with me, except that they are autistic, and they draw on both personal and clinical experience in writing this book, in addition to their own and others’ research and specialised resources.

In my practice, I work primarily with queer and transgender (abbreviated as “trans”) people and their families. Recently, one of my numerous trans, autistic clients asked me if I had ever met a neurotypical trans person, and it transpired that, if we were excluding people with ADHD, dyslexia, and/or autism, all of which fall under the “neurodivergent” umbrella, neither of us could think of any. This is not to say that they don’t exist–of course they do. However, it is uncontroversial to observe that neurodivergent people are statistically over-represented in the transgender population, and vice versa. While (according to research cited by Gratton) about 1% of the population is autistic, and about 0.5% is transgender, the rate of autistic traits among people with gender dysphoria ranges between 5% and 23% in different studies.

Measuring the true size of either population, and of the overlap, is confounded by a multitude of difficulties, not least of which is that the terms “autism” and “gender dysphoria” have largely been created and policed based on how they appear to cisgender and neurotypical people. Theorising the reasons for the overlap is also fraught with complexity, and risks pathologising both trans and autistic people. In addition, the internet has allowed trans and autistic people to find each other and communicate in ways that were never possible before, leading to an increase in the number of people who recognise themselves as being trans, autistic, or both. These numbers are likely to continue increasing as previously under-represented segments of the population, such as assigned-female-at-birth (AFAB) autistic adults and non-binary trans people, come to recognise and claim their identities, and in some cases seek diagnosis or gender-affirming care. It is crucial, then, that any practitioner who works with either group is informed about both.

Given the prevalence of this population in my own practice, I am exceedingly grateful for the existence of texts like Gratton’s, as well as other recent texts like Unmasking Autism by trans autistic writer and psychologist Devon Price, and Working with Autistic Transgender and Non-Binary People by non-binary autistic researcher and writer Marianthi Kourti, which have helped me understand more about the complex experiences, pressures, and unmet needs of this population. Early in the text, Gratton cites the axiom of minority organising–“nothing about us without us”–which speaks to the need for centring and prioritising the voices and perspectives of marginalised people when discussing them. This is one of the great strengths of this text. The author is well-placed not only to invite readers into the experiences of trans and autistic people, but also to describe neurotypical and cisgender perspectives and assumptions in illuminating detail, rather than taking them for granted.

Gratton describes this book as “‘do-it-yourself’ training in working with trans autistic people” (p. 12), and as such the book is extremely approachable and practical, each chapter concluding with a list of activities and further resources aimed at helping the reader to develop a deeper understanding of the experiences of trans autistic people, and to dismantle existing assumptions.

In seeking qualitative accounts of the experiences of this population, Gratton designed a research tool called the Neuroqueer Survey (included as an appendix). In the responses they received it was clear that while trans autistic people are likely to engage with numerous mental health and other health providers throughout their lifetimes, very few of these professionals have sufficient (if any) training in this area, leading to poor experiences in general for those needing support. At the risk of radically oversimplifying the histories and current states of the autistic and transgender healthcare systems, transgender people have good reason to view healthcare providers as potentially hostile gatekeepers of needed care, and many autistic people have had their autistic behaviour and expression stigmatised and controlled by medical professionals since childhood with traumatic effects. In addition, a diagnosis of autism is often used to deny or delay access to gender-affirming care, based on an infantilising assumption that autistic people cannot understand or consent to transition-related health care, and the prevalence of autism in the transgender community has become a rhetorical tool that is used to discredit our abilities to understand and make decisions about our bodies and lives, and to imply that transgender identity emerges from an autistic special interest, or a failure to understand or conform to social expectations around gender.

Gratton’s do-it-yourself training begins with an invitation for readers to examine and reorganise our mental frameworks around gender and neurodiversity in order to deconstruct our biases. Some of this comes about through seeking out trans and autistic perspectives, or through analysing our own privileges, assumptions, and blind spots. Other exercises are more experiential–for example, they suggest that next time you attend a crowded event, imagine that you are transgender and autistic, and that this may or may not be apparent to others, and might become apparent based on things you say or do, or based on the scrutiny to which you are subjected. They invite readers to notice how we feel before, during, and after this experience, and to repeat it in different contexts, around different people. This exercise captures an aspect of transgender experience I have rarely seen alluded to–that of constant uncertainty about when and whether your trans status is apparent to others, when and whether you are in a closet of some kind, and what expectations people might be projecting onto you as a result of however they happen to be reading you. It also captures the anxiety of not knowing what you might say or do that will change how someone is perceiving you, and not knowing how the other person will react to this change in their perception of you. The inclusion of autism makes this dance even more complex, and this sort of exercise may go a long way in helping practitioners to understand the emotional, physical, and cognitive cost of leaving the house, socialising, working, and even attending appointments for clients with this lived experience.

As Gratton puts it, “it is considerably more difficult navigating a day anywhere as a queer transgender person than it is as a straight cisgender person. It is much harder living in the world as an autistic person than it is for a neurotypical person” (p. 66). This is because the constructed world that we all navigate is implicitly a cisgender, neurotypical one, and thus exclusionary to those who cannot conform to these expectations. Developing an understanding of normative society as inherently exclusionary allows us, as practitioners, to move away from pathologising our clients’ difficulties in fitting into it, succeeding on its terms, or embracing it. Instead, it is helpful to view these difficulties through the lenses of trauma and minority stress, as Gratton does here.

Ongoing experiences of bullying, violence, discrimination, misattunement from caregivers, masking/hiding rejected elements of the self, and exclusion from full participation in civic and social life all contribute to the high levels of trauma and minority stress that trans and autistic people face. A lifetime of such experiences often leads to a sense of personal failure, weakness, and helplessness. A therapist who understands these experiences as originating in societal prejudice, rather than in individual pathology or disorder, will be better equipped to support trans autistic clients in creating boundaries, finding community, communicating their needs or seeking accommodations, and perhaps even taking action or advocating on behalf of themselves and their communities. This perspective allows both practitioner and client to see the connections between systemic oppression and anxiety, depression, and suicidality, and guides treatment priorities towards trauma work, seeking to find or create accessible forms of community, working with the families and loved ones where appropriate to increase their understanding and support for the client, highlighting strengths and resilience, and encouraging authentic self-expression. There is scope for corrective emotional experiences when, expecting stigmatisation or misattunement, clients instead receive validation and (genuine attempts at) understanding. It is also important that we as practitioners can validate our clients’ anger and mistrust of the systems we may, because of our professional roles or various forms of privilege, appear to represent and uphold, without defensiveness.

Gratton spends a whole chapter exploring in detail the various facets of living as a trans autistic person in a cisgender, neurotypical world, including experiences of education, housing, employment, social services, and the criminal justice system. Drawing on case examples, studies, and responses to their Neuroqueer Survey, they paint a complex picture of the layered inaccessibility and hostility of many of these basic systems as they are experienced by those whose communication style, legal paperwork, physical embodiment, and/or sensory needs are not designed for or even imagined. They make a convincing case that it is important to understand our clients’ issues as human rights issues, not only as mental health ones. They also provide practical suggestions and further readings and resources for supporting trans autistic people in coping with such a world.

One of the areas in which this coping and resourcing comes into focus is in the body. Gratton is a somatic therapist, and despite some initial apprehension from many among a client population who often experience sensory overwhelm, chronic pain and illness, chronically high levels of nervous system activation, gender dysphoria and associated discomfort with paying attention to the body, and emotional hypersensitivity, they have found that taking a somatic approach with clients has been highly salient and effective. In the text they explore the physiological bases for and impacts of autistic burnout, meltdowns, hypervigilance, hypoarousal, and dissociation, and provide some useful frameworks for helping clients to manage their embodied experiences through sensory diets, pursuing gender-affirming care or social transition, and finding appropriate care for chronic health conditions.

In Gratton’s view, and based on the many respondents to their survey who expressed a wish to have been diagnosed with autism or made aware of their gender diversity earlier, it is important for practitioners not only to be aware that these are populations which overlap, but to learn to recognise and screen for gender diversity among autistic clients, and autism among gender diverse clients. It is also important to signal to these clients that we would be a safe and non-judgemental person with whom to share their exploration of these identities should they wish to. This is a delicate matter, and one that Gratton explores in detail, providing not only a wealth of information about the common sensory, health, communicative, sexual, emotional, and social experiences described by many trans and/or autistic people, to aid in practitioners’ ability to recognise these traits and experiences, but also specific signs that someone may belong to one or both communities, and suggestions about how to broach this topic. It is worth noting that individuals may have good reasons to fear diagnosis or labelling, and that we should give our clients some say before affixing them with a diagnosis which may impede their access to transition-related care, for instance.

There is much in this compact, thorough text that I have not touched on, including an excellent chapter on attachment and relationships, as well as one focusing on crisis intervention and preparation. It is difficult to imagine emerging from this book without a substantially richer understanding of the transgender autistic experience, or of the cisgender neurotypical one for that matter. The book is full of practical advice and sound approaches, and works something like an empathic immersion course, inviting readers to expand the way they see the world. This quality makes lived experience perspectives like this so fundamentally useful and important.

 

Louis Spence (MCouns) is a Melbourne-based psychotherapist, working in both private practice and community health settings. They have a particular interest in working with members of the LGBTQIA+ community and those in non-normative relationships. Louis can be contacted at louis.spence.psychotherapy@gmail.com


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