A couple of years ago, it was impossible to be both transgender and mentally healthy—at least according to the International Classification of Diseases, an enormous guidebook doctors the world over used to diagnose their patients. For decades, “transsexualism” and “gender identity disorder of childhood” sat beside personality disorders and paraphilias, or atypical sexual interests, in the ICD’s mental illness section.
Finally, in the edition that took effect last year, gender-related diagnoses were reclassified as sexual health conditions, a major move toward destigmatizing transness. Around the same time, the World Professional Association of Transgender Health (WPATH) updated its guidance on the medical treatment of transgender people to no longer recommend a full psychological assessment before someone can obtain hormones or gender-affirming surgery. “There is a letting go of older models that saw trans identities as a mental illness to be questioned and potentially ‘cured,’” says Laura Erickson-Schroth, chief medical officer at the Jed Foundation, who contributed to that updated guidance.
But just as the medical establishment has moved in one direction, political forces have pushed the opposite way. In April, the attorney general of Missouri introduced an emergency rule that would have required all clinicians providing gender-affirming medical care to screen their patients for autism and ensure they have no current “psychiatric symptoms.” Patients would also have had to receive almost two years of therapy focused on their gender identity.
The emergency rule, which represented a direct attack on the medical autonomy of trans adults among a recent flood of anti-trans policy, was ultimately blocked by a judge. But in specifically targeting autistic trans people and trans people who may be experiencing mental health conditions, it reflects a powerful strand of rhetoric in the anti-trans movement. Some research has suggested that trans people may be statistically more likely than their cis peers to be autistic or to experience mental health conditions, an idea that anti-trans campaigners have leveraged to cast doubt on the validity of trans identities. They assert that some trans people are “really just autistic” or “really just mentally ill” and won’t respond well to gender-affirming care—medical interventions such as hormone therapy and surgery to support their gender identity.
While it is conceivable that autistic people or those with certain types of mental illness could fare worse than their neurotypical peers after receiving gender-affirming care—there’s little evidence on either side. But Florence Ashley, an assistant professor of law at the University of Alberta, says a lack of evidence can’t be used to deny people the care that they choose for themselves. “The burden is not on trans people to prove the importance of gender-affirming care,” they say. “It’s on those who want to force barriers to care, or remove access to gender-affirming care, to prove that that’s absolutely necessary.”
The Missouri emergency rule cites research drawing links between trans identity and the frequency of mental illness or autism—but no studies proving that mental illness or autism lead to poor outcomes in gender-affirming care. There’s a good reason for that: There are no such studies. One study found that neurodiverse people and those experiencing mental illness are less likely to complete their intended courses of gender-affirming care, but it did not evaluate why—and factors unrelated to poor medical outcomes, like socioeconomic difficulties, could play a role. Another study found that autistic youth were no more likely than non-autistic youth to change their requests for gender-affirming care, but the group was too small to demonstrate anything conclusive.