When Asperger Syndrome and Gender Dysphoria meet

SUMMARY
Introduction. In recent years, an increasing number of cases have been reported that describe gender concerns among people with autistic spectrum disorders. Th e number of evidence regarding the incidence of autism specifi c characteristics among children and adolescents with gender dysphoria is steadily increasing. Th ere is a need for a complex approach, not only from the scientifi c point of view, but also from the point of view of the management of these cases. Methods. We would like to present to you the case of a 17-year-old adolescent at the fi rst admission to the Pediatric Psychiatry Clinic and Toxicomania Cluj, for unstructured suicidal ideas, prevalent thoughts of self-blame and devaluation, episodically slightly unstructured thinking, diffi culties in establishing social relationships, diffi culties in maintaining attention and school bullying. Th e case was interpreted with the following diagnoses: Asperger Syndrome. Severe Depressive Disorder with suicidal ideation. Gender Dysphoria. Tonic-Clonic Stutter. according to the DSM-5 and ICD-10 criteria, and treatment with an antidepressant and an antipsychotic associated with psychotherapy sessions was initiated. Results. Under medical treatment and psychotherapy, the evolution of the case is slow. Suicidal ideas and school denial are no longer so prominent, but the diffi culties of interaction and school adaptation persist, as well as the desire to belong to a gender other than the one assigned to birth. Conclusions. Although the literature contributes signifi cantly to raising awareness of the presence of gender concerns among children and adolescents with Autistic Spectrum Disorder, further help is needed in understanding these aspects, how they appear, and how these cases should be addressed. An important help could be the greater attention of both clinicians and parents to gender identity formation among children with autistic spectrum disorders at the earliest age. Key words: Asperger syndrome, gender dysphoria, autism spectrum disorder

INTRODUCTION
In recent years, an increasing number of cases have been reported that describe gender concerns among people with autistic spectrum disorders. The number of evidence regarding the incidence of autism specific characteristics among children and adolescents with gender dysphoria is steadily increasing. There is a need for a complex approach, not only from the scientific point of view, but also from the point of view of the management of these cases.

METHODS
We would like to present to you the case of a 17-year-old adolescent at the first admission to the Pediatric Psychiatry Clinic and Toxicomania Cluj, for unstructured suicidal ideas, prevalent thoughts of self-blame and devaluation, episodically slightly unstructured thinking, difficulties in establishing social relationships, difficulties in maintaining attention and school bullying. His medical history is a small one, the teenager being diagnosed with Fallot Tetralogy that he had surgery for at the age of 10 months. Of the family medical history, we mention the mother’s emotional disorders, that are not medically documented. Since joining the community, there have been difficulties in adapting, which is why he has changed the kindergarten three times, but the problems of understanding the rules and social norms persist. Currently, he reports that he has no friends, classmates marginalize him, mark him as different and notice he has special concerns compared to those of teenagers of the same age. We also mention that the teenager comes from a disorganized family, the parents are divorced, the mother remarried, but the relationship with the biological father is still good. The boy does not present negative feelings or regrets about his family situation but takes an indifferent attitude when he talks about it. During the interview, the dialogue is spontaneous, it is easy to do, one can observe expressive facies, but partly appropriate with affective feelings, a gesture, and a partial, adequate, exaggerated mimic and a tonic-clonic stutter. His psychopathological picture is characterized by labile, fatigued attention, global hypoprosexia with sectoral hyperprosexia centered on activities of interest, easily distracted by irrelevant environmental stimuli. Cognitive development is appropriate to chronological age (IQ 118) but presents a partially coherent and organized ideatic rhythm with episodic difficulties in structuring thinking, with prevailing ideas of self-censorship and devaluation. Suicidal ideas occurred a few months before the presentation, accentuating over the past two weeks. The teenager says he considered various ways he could take his life, but that no way seemed appropriate and effective. Affectivity is marked by a hypo thymic background disposition with episodes of ciclomy, impulsivity, reduced tolerance to frustration with a tendency to self-aggression (he hits himself with his fists at times when it feels wrong) and situational anxiety with vegetative reactions. His good school results in the past have begun to decline, with the lack of motivation for sustained cognitive effort and school reluctance claiming that school is a stressful environment marked by school bullying. Throughout the interview, in an attempt to discover the true reasons behind the suicidal ideation and understanding of emotional feelings, he said he feels a „blank,” indicating the chest area, feeling something is right, and he finally admitted that, for about two years, he did not feel well in his own body and that he would like to become a woman. For this reason, the GIDYQ-AA (Gender Identity/ Gender Dysphoria Questionnaire for Adults and Adolescents) questionnaire was applied to those with a male gender assured at birth at which a Raw Score of 57 and a Scaled Score of 2.17 were obtained which fits the case with those with gender dysphoria. The case was interpreted with the following diagnoses: Asperger Syndrome. Severe Depressive Disorder with suicidal ideation.

Gender Dysphoria.
Tonic-Clonic Stutter. according to the DSM-5 and ICD-10 criteria, and treatment with an antidepressant and an antipsychotic associated with psychotherapy sessions was initiated. Gender Dysphoria According to Diagnostic and Statistical Manual and Mental Disorders DSM-5, gender gissatisfaction is represented by a marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least two of the following:
1. A marked incongruence one’s experienced/ expressed gender and primary and/or secondary sex characteristics (or in young adolesccents, the anticipated secondary sex characteristics).
2. A strong desire to be rid of one’s primary and/ or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).
3. A strong desire for the primary and/or secondary sex characteristics of the other gender.
4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender). 6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender). The condition is associated with clinically significant distress or impairment in social, occupational or other important areas of functioning [1]. In the case of the adolescent presented in our clinic, 5 of the 6 diagnostic criteria were manifested, along with significant deficits in the day-to-day activities. Specialty literature Various hypotheses attempt to explain this possible coexistence between autistic spectrum symptoms and gender dysphoria. These include the role of resistance to change, stereotyped behaviors and prenatal exposure to testosterone [2]. In this regard, a retrospective study was performed on a group of 39 patients aged between 8 and 20 years (average age 15.8 years, 22 male subjects, 17 female subjects) who came to be evaluated in a multidisciplinary clinic in the United States of America focused on gender issues in 2007-2011 to assess the prevalence of Autistic Spectrum Disorder among this population. Thus, 23.1% of patients with dysphoric disorder presented symptoms of Asperger’s syndrome using ASDS (Asperger Syndrome Diagnostic Scale). Also, a higher prevalence of autistic spectrum disturbance among those with gender dysphoria was observed compared to the prevalence of autism spectrum disorder among the general population [3].
Another study, published in 2017, tried to prove the possible coexistence between resistance to change, stereotyped behaviors and prenatal exposure to testosterone. This study consisted of evaluating the symptoms of autism spectrum disorder by applying the Children’s Social Behavior Questionnaire (CSBQ) to two groups of children: a batch of 490 children with dysphoric disorder and a batch of 2507 neuropathic children. The group of children with dysphoric disorder revealed increased levels of autism spectrum related syndromes in all sub-domains, not just stereotypical behaviors and resistance to change. Moreover, there was no difference in the sex of the children and the results, which makes the hypothesis of prenatal exposure to testosterone unlikely [2].

RESULTS
Under medical treatment and psychotherapy, the evolution of the case is slow. Suicidal ideas and school denial are no longer so prominent, but the difficulties of interaction and school adaptation persist, as well as the desire to belong to a gender other than the one assigned to birth.

CONCLUSIONS
Although the literature contributes significantly to raising awareness of the presence of gender concerns among children and adolescents with Autistic Spectrum Disorder, further help is needed in understanding these aspects, how they appear, and how these cases should be addressed. An important help could be the greater attention of both clinicians and parents to gender identity formation among children with autistic spectrum disorders at the earliest age.