Recent studies have highlighted the co-occurrence of gender dysphoria (GD) in adolescence
and Autism Spectrum Conditions (ASC). De Vries, Noens, Cohen-Kettenis, van
Berckelaer-Onnes and Doreleijers (
Systemising and empathising are two psychological dimensions that have been linked to
ASC. Empathy tends to be lower in people with ASC, whereas systemising tends to be
average or above average (
Empathy and systemising show typical sex differences on average in the general
population: females tend to score higher on empathising and males higher on systemising,
both in adulthood (
GD in young people is a complex and rare condition where there is an incongruence between
the young person’s perceived gender identity and their natal gender. The
diagnostic criteria for gender dysphoria in adolescents and adults are defined in DSM-V.
This includes the expression of an experienced gender that is in contrast to the gender
assigned at birth, the conviction that one has the typical feelings and reactions of the
other gender, a strong desire to get rid of one’s primary and secondary sex
characteristics and acquire those of the other gender, as well as a strong desire to be
of the other gender and to be treated as the other gender or some alternative gender
different from the gender assigned at birth (
The Systemising Quotient (SQ) and Empathy Quotient (EQ) were devised to measure the two
dimensions of systemising and empathising. As well as the reported sexual dimorphism on
these scales (males on average score higher on SQ while females on average score higher
on EQ), people with ASC score below average on EQ and average or above average on SQ,
compared to controls. Therefore, it is the discrepancy between the EQ and SQ that
determines the likelihood of having an ASC (
The extreme male brain theory of ASC is based on the empathising and systemising theory in which these two dimensions are used to characterise individual differences in the population and between the two genders. As adolescents with GD identify with the other gender and since previous studies have shown that there is an over-representation of people with ASC in this group, we tested whether the patterns in empathising and systemising, associated with the two genders, are seen in this population in line with the gender with which the adolescents identified, rather than their natal gender. In addition we tested whether this pattern applies to both female-to-male and male-to-female gender dysphoric adolescents.
Studies in non-human mammals have identified a clear link between exposure to hormones,
such as testosterone, during critical periods for sexual differentiation of the brain,
and sex-typical behavior in later life (
Based on the results of previous studies of ASC and GD, we predicted that if the young
people shared aspects of the ‘broader autism phenotype’ (i.e. mild features
of autism) (
This is a preliminary study that explored the value of research into empathising and systemising in young people with GD.
191 parents of adolescents (age 12–18) were included in the study. This included a gender dysphoric group and a control group. 35 parents of adolescents (mean age = 15.74, SD = 1.72) attending the Gender Identity Development Service (GIDS) in the Tavistock Centre in London (gender dysphoric group) took part in the study, out of which 60% (n = 21) of the adolescents were natal females. These adolescents fulfilled the criteria for Gender identity Disorder (now called gender dysphoria) according to DSM-IV, and had attended the service for varying amounts of time. At the time of the study, the DSM-V criteria for gender dysphoria had not yet been published. Participants were not excluded on the basis of associated psychological difficulties. Parents of adolescents aged 12–18 years with gender dysphoria attending the GIDS were contacted by letter, explaining the study. The letter included the SQ, EQ and a consent form.
The control group consisted of 156 parents of adolescents between the ages of
12–18 (mean age = 15.47, SD = 1.48, 53.2% female) recruited from the
general population via the Cambridge University research website (
The difference in sample sizes between the gender dysphoric group and control group are due to the fact that gender dysphoria is a rare condition. Statistically, this may have influenced the results, to which we return in the discussion. The participants volunteered to take part in the study and received no monetary incentive. The research received ethical approval from the National Research Ethics Service (NRES) Committee London- Camden and Islington.
We employed a 2x2 between subjects design, with the two independent variables being natal gender (male or female) and group (gender dysphoric or control) and the dependent variable being total empathising or systemising score.
All participants completed both the Empathy Quotient (EQ) and the Systemising
Quotient (SQ) – Adolescent versions (
Z-scores were calculated to check for outliers. Less than 5% had absolute values
greater than 1.96 and none were greater than 3.29 and so no cases had to be removed
(
Mean SQ and EQ are given in Table
Means (and standard deviations) on EQ and SQ in participants in the transgender or typical control group.
EQ | SQ | |||||
---|---|---|---|---|---|---|
|
||||||
Gender dysphoric group | Control group | Cohen’s d | Gender dysphoric group | Control group | Cohen’s d | |
|
||||||
Natal |
32.242 |
45.591 |
.89 | 38.10 |
33.304 |
.35 |
|
||||||
Natal |
28.433 |
38.90 |
.62 | 37.46 |
41.93* |
.29 |
1 Typical females have marginally higher EQ than typical males (p = 0.056).
2 Female-to-male adolescents with gender dysphoria have lower EQ than female controls (p<0.01).
3 Male-to-female adolescents with gender dysphoria have lower EQ than the female controls (p<0.01).
4 Typical males have higher SQ than typical females (p<0.01).
* Effect size (using Cohen’s d) between .2 and .4 is
considered to be small. A value between .5 and .7 is considered a medium
effect size and a value greater than .8 is considered a large effect
size (
A between-group ANOVA was run with empathising as the dependent variable, and with group (control or gender dysphoric) and natal gender (female or male) as independent variables. There was a significant main effect of group (F (1,187) = 14.78, p<0.001), indicating that mean EQ scores were significantly different in the control group and the gender dysphoric group. There was also a significant main effect of gender (F (1,187) = 6.75, p<0.05, indicating that the means on the EQ questionnaire were significantly different for natal females and natal males. There was no significant interaction between group and gender (F (1,187) = 0.21, p = 0.64).
Since this is the first study of its kind, we were interested in looking at all comparisons between the different groups, despite there being no significant interaction between group and gender.
Pairwise multiple comparisons using Tukey’s Honestly Significant Difference
(HSD) to correct for experiment-wise error rates were performed. We used
Tukey’s HSD as it controls for Type 1 errors very well (see
A between-group ANOVA was run with systemising as the dependent variable and group (control or gender dysphoric) and natal gender (female or male) as independent variables. There was a significant main effect of gender (F (1,174) = 9.97, p<0.001), indicating that the means on the SQ were significantly different for natal females and natal males. However, the main effect of group was non-significant, indicating that the mean SQ score was not significantly different in the control and gender dysphoric groups (F (1,174) = 2.66, p = 0.10). Nor was there a significant interaction between group and gender (F (1,174) = 2.66, p = 0.10). There were 13 systemising questionnaires missing in the control group, which may have affected the results.
Tukey’s (HSD) pairwise multiple comparisons showed that the mean SQ score
was not significantly higher for the female-to-male gender dysphoric group than
female controls (p = 0.54). There was also no significant difference on the SQ
for the female-to-male gender dysphoric group and the male controls (p = 0.72).
For the male-to-female gender dysphoric group there was no significant
difference in the SQ scores compared to male controls (p = 0.74). There was no
significant difference on SQ for the male-to-female gender dysphoric group and
the female controls (p = 0.78) and no significant difference on SQ for natal
males and natal females in the gender dysphoric group (p = 0.99). However, the
mean SQ was significantly higher for males than females in the control group, as
expected (p<0.01) (see Table
The present study found that female-to-male adolescents with gender dysphoria have,
on average, significantly lower EQ scores compared to typical female controls. The
lower EQ scores in the female-to-male transgender adolescents are in line with our
earlier study (
Our study shows that a subgroup of adolescents with GD, particularly natal females, have lower empathy than controls. Female-to-male gender dysphoric adolescents seem to function, in terms of empathising, more like control males. Whether this similarity, together with other factors, contributes to their identification as males remains an open question. The male-to-female gender dysphoric group seems to show levels of empathy more similar to male controls than to female controls. One cannot say that their level of empathising could be a contributory factor to their female identification as the EQ score is significantly lower than that of female controls. This discrepancy indicates that there may be different pathways leading to atypical gender identity development or GD.
Whether or not empathy plays a particular role in atypical gender identity development, lower empathy may affect an individual’s capacity for communicating and taking on board other people’s views and feelings, and influences the quality of relationships with family members and peers. Moreover, for young people with gender dysphoria, lower empathy may affect the ability to consider, in depth, options for dealing with the incongruence between self-perception and body structure and/or functions. It may be helpful for adolesents with gender dysphoria with low empathy scores to be offered psychological interventions which improve their communication skills and their ability to take on board other people’s views and perspectives. This would support their development and may enable them to make informed decisions regarding treatment and physical intervention options during adolescence and beyond.
A potential limitation of this study was the risk of a bias in filling in the
questionnaires as the participants (i.e. the parents) may have tried to guess what
the expected answers should be in connection with gender stereotypes. However, there
is no evidence for such a bias since, in that case, the adolescents with
male-to-female gender dysphoria should have scored in the typical female range on
the EQ. Secondly, in this study we took a dimensional rather than diagnostic
approach. However, it would be interesting to also measure autistic traits (e.g.,
using the AQ-Adolescent Version,
This study is a preliminary effort at quantitatively studying systemising and
empathising in adolescents with GD. It will be important to replicate the study with
a larger sample and using additional measures. Future research could also study the
persistence and desistence of GD in the transition from childhood to adolescence and
the possible link between our findings and the three factors described by Steensma,
Biemond, de Boer and Cohen-Kettenis (
In summary, female-to-male transgender adolescents have, on average, lower empathy
than female adolescent controls. In the male-to-female transgender adolescents,
empathy was not significantly lower than in male controls, but it was not as high as
in female controls, as one might have expected given their female identity. No
single cause has yet been found to explain the development of atypical gender
identity. A number of biological and psychosocial factors interact during
development to lead to atypical gender identity (
The findings from this study are tentative given its preliminary nature, but indicate that further research with a larger group of gender dysphoric adolescents and additional measures such as the AQ would be useful.