Eleven-year follow up of boy with Asperger’s syndrome and comorbid gender identity disorder of childhood

The relation between gender dysphoria (GD) and autism spectrum disorder (ASD) has been reported.^1,2 In ICD-10, gender identity disorder (GID) of childhood for boys is defined by persistent distress about being a boy and an intense desire to be a girl. Although the prevalence rate of childhood GID is higher than that of adulthood, many child cases will not continue to fulfill the diagnostic criteria in adulthood.

We previously reported on a boy with Asperger’s syndrome (AS) and GID of childhood.³ In this letter, we report the clinical course of the case during our 11-year follow up. Informed written consent was obtained.

The boy was referred to child psychiatry when he was 5 years old because of poor social skills, such as limited interaction with others and difficulty in understanding social situations. He had a lot of his own rules and was particular about them. His intelligence level was normal. We diagnosed him as having AS and followed up to facilitate his social skills. At the age of 7, he verbalized a strong aversion to being a boy and desired to be a girl. The boy behaved as if he were a girl and preferred to play with girls. Based on his clinical symptoms that lasted more than 6 months, the comorbid diagnosis of GID was made according to ICD-10 criteria.

After entering school, he exhibited behaviors such as using stationery with Disney princesses and dressing himself in clothes with flowers. He rarely went to the bathroom because he did not want to be seen urinating in a standing position. He skipped swimming classes at school to avoid exposing his chest. Only at his home, the boy wore skirts and makeup. At school, he was bullied by classmates because of his feminine behaviors. However, as school teachers were supportive and intervened appropriately, he never refused to attend school. At the age of 11, when puberty started, he became confused and repeatedly shaved his body hair. He tried to keep his voice tone high. However, as puberty progressed his gender dysphoria gradually alleviated.

In Japan, in general, junior high school students are required to wear school uniforms based on their biological sex, typically a skirt for girls and trousers for boys. They are also requested to obey school regulations related to length of hair, though the strictness is highly school-dependent. Our patient entered a public school in his residential district and had to behave as a typical male student. As a consequence, his gender-related manifestations fell below the threshold for the diagnosis of GID as of age 16 (the time of this writing).

In DSM-5, the term GID was changed to GD.¹ DSM-5 notes that the rate of ASD is higher in GD compared to the general population and reports that less than 30% of cases of GD of childhood in biologically male individuals continue to meet the criteria for GD in adulthood. A recent study demonstrated the close relation between GID and ASD.² However, there exists limited evidence of comorbid GID of childhood in ASD. To the best of our knowledge, this is the first reported case of AS and GID of childhood with follow up from early childhood to adolescence. Careful long-term clinical observation and further studies are needed.