• Autism and psychiatric disorders are common in females who identify as transgender or non-binary. These females may be especially harmed by transition treatments.
  • Most transgender individuals do not have physical “intersex” conditions or physical disorders of sex development.
  • Many females with gender dysphoria do have polycystic ovary syndrome (PCOS) or high testosterone. These are not disorders of sex development.
  • Females with PCOS may be especially harmed by transition treatments.

Autism & Psychiatric Disorders

A recent study indicates that 40% or more of young females who identify as transgender or non-binary may have autism diagnoses or indicators of undiagnosed autism. Psychiatric disorders are also common in such females.

Females with autism or psychiatric disorders may be even more susceptible to the adverse brain effects of high testosterone/low estrogen female-to-male (FtM) treatments than typical females would be, for several reasons.

Females with autism tend to have high testosterone conditions, and testosterone drugs appear to trigger autism-like effects in females. This suggests that females are more likely to develop autism if they have high testosterone, and that females with autism may be especially sensitive to the brain and behavioral effects of high testosterone.

High testosterone conditions have also been associated with many psychiatric disorders in females, including bipolar disorder, borderline personality disorder, and schizophrenia. This suggests that high testosterone can trigger psychiatric disorders in females. Females who already have psychiatric disorders may be especially sensitive to the effects of high testosterone.

People with autism or psychiatric disorders may be especially sensitive to overly high or low levels of sex hormones or social hormones such as oxytocin because of genetic or other factors. Animal studies suggest that high testosterone can suppress the oxytocin system.

People with autism or psychiatric disorders may be more likely to have abnormalities in brain structures or brain activity, which can affect behavior.

FtM treatments affect brain structures and brain activity in ways that may aggravate all of these risk factors, resulting in problems such as impaired social cognition and decision making, increased anger and aggression proneness, impaired verbal abilities, and so forth. People who already have risk factors associated with autism or psychiatric disorders may be especially affected.

Here’s an analogy: Females with cancer may have genetic factors that make them especially likely to get cancer. So, while it is dangerous for any female to smoke cigarettes, it is especially dangerous for females who already have cancer to smoke cigarettes.

Similarly, it may be especially dangerous for females who already have autism or psychiatric disorders to use FtM drugs. That may be especially true if those females already have high testosterone conditions before getting FtM treatments, because prior exposure to high testosterone may increase the brain’s response to FtM drugs.

PCOS: Polycystic Ovary Syndrome

Many females with gender difficulties have non-intersex conditions such as polycystic ovary syndrome (PCOS), a condition involving chronic high testosterone. PCOS is a very common condition in females generally, not just in females who identify as transgender. PCOS affects approximately 1 in 10 women of childbearing age. It can emerge during or after puberty but can go undiagnosed for many years or even decades. An estimated 50 to 70 percent of women with PCOS are undiagnosed.

Doctors have known for a long time that PCOS or high testosterone might cause mental health problems in females. One expert said: “PCOS is one of the most common conditions affecting young women today, and the effect on mental health is still under appreciated” (PCOS 2018).

The “level of testosterone in women with PCOS remains typically within the upper part of the normal range” for females. Researchers say that female-to-male transsexuals “are biologically and endocrinologically female” even though they may have elevated testosterone.

There are high rates of PCOS and other high testosterone condition in biological female gender patients, according to studies in 1986, 1993, 1997, 2007, 2008, 2013, and 2014. This suggests that high testosterone may trigger gender difficulties, but it does not mean that raising testosterone even higher is safe or necessary. It certainly does not mean that PCOS patients should be rushed into FtM treatments without being warned about the risk of adverse effects.

Studies have linked PCOS or high testosterone to autism and psychiatric disorders in females. One study found that women with PCOS had a 50% increased odds of having a psychiatric disorder.

Normally, doctors treat PCOS with drugs or other measures to reduce testosterone in females. Studies indicate that proper treatment may reduce patients’ physical and mental health problems (see Rasgon 2002; Soleman 2016). However, gender clinic doctors do the opposite: They use drugs to raise testosterone to very high levels and suppress estrogen. This may worsen patients’ mental health problems, due to the brain effects of testosterone-raising and estrogen-suppressing drugs.

There is more information about mental health issues in PCOS at the bottom of this page.

Disorders of Sex Development (DSDs)

Some people with gender difficulties have physical “intersex” conditions or physical “disorders of sex development (DSDs).” Transition treatments may be appropriate for some of those patients. However, medical studies show that the vast majority of transgender individuals are not “intersex” and do not have “disorders of sex development (DSDs). Moreover, it is unethical for doctors to provide transition treatments to patients with or without DSDs without warning them about the risk of adverse brain effects.

Johanna Olson-Kennedy, MD and her colleagues acknowledge that “the majority of transgender individuals do not have a disorder of sex development.” Dr. Olson-Kennedy is the medical director of the largest transgender youth clinic in the United States and has served as a consultant to a drug company that sells transition drugs.

Disorders of sex development are different from other hormonal problems that emerge during or after puberty in females, such as PCOS or endometriosis. Disorders of sex development (DSDs) are conditions one is born with that entail unusual chromosomes (such as XXY), abnormally formed reproductive organs or prenatal hormone-related disorders.

Chromosomal DSDs are rare in transgender or gender dysphoric individuals. A 2018 study found “no sex chromosome abnormalities directly suggestive of a DSD” in a group of pediatric gender service patients. A 2013 study reported chromosomal abnormalities in just 1.5% of transsexuals overall. A 2011 study reported “normal findings” in 97.55% of transsexuals.

Congenital Adrenal Hyperplasia

Classic congenital adrenal hyperplasia (CAH) is a hormonal disorder that exposes females (and males) to excess testosterone before birth. It does not cause gender dysphoria in the vast majority of females. The vast majority of females with CAH in a survey disagreed with CAH being called a disorder of sex development. Many believed that CAH should be classified as simply a hormonal disorder.

A 2004 study found that CAH did not affect 5-12 year old girls’ gender identity. A 2005 study reported that 94.8% of CAH females raised as females “later developed a gender identity as girls and women and did not feel gender dysphoric.” A 2016 study found that CAH girls “reported positive attitudes about being a girl.” A 2018 study found “no differences in emotional or behavioral problems” between CAH girls and their unaffected sisters. These studies suggest that female gender dysphoria may not result from prenatal excess testosterone exposure, and they show that CAH does not usually cause gender dysphoria.

A few CAH females (perhaps 5%) have a masculinized gender identity and may have a masculinized genital appearance due to prenatal testosterone exposure. Transition treatments might be appropriate for some of them, but only if they are given adequate information about potential adverse brain effects and other effects from transition treatments.

CAH occurs in approximately 1 in every 15,000 live births worldwide. There is also a non-classic form of CAH called non-classic 21-OHD CAH. Only 1%-3% of all females with hyperandrogenism (high testosterone or other high “androgen” hormones) have this. Ashkenazi Jews have the highest rate of non-classic 21-OHD CAH.

Mental Health Issues in PCOS & Other High Testosterone Conditions

PCOS and other high testosterone conditions should be diagnosed and treated, because they may cause mental health problems. A doctor who provides FtM treatments without attempting to diagnose or treat PCOS/high testosterone may be guilty of malpractice.

In medical studies, PCOS and/or high testosterone have been associated with female

Low estrogen may be a problem, too. Researchers have linked low estrogen in females to cognitive problems and psychiatric disorders including

Autism, ADHD, bipolar disorder, borderline personality disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), anxiety, and depression are common in females with gender difficulties (see Becerra-Culqui 2015; Chen 2016; Jones 2011; Kaltiala-Heino 2015; Nahata 2017; Marchiano 2016; Oswalt 2017; “Survey” 2016; Vrangalova 2017).

Dysphoric females might have mental health problems because they have high testosterone, PCOS or low estrogen. This does not mean that it is safe to give FtM treatments to such patients.

Studies indicate that females who already have high testosterone at the start of FtM treatments might experience especially strong brain effects from those treatments (e.g., Rametti 2012). Therefore, all of the adverse effects of FtM treatments may be stronger and worse in patients who already had PCOS before getting FtM treatments. Patients should be warned about this.