A small Norwegian study is offering an unusually intimate account of how autism and gender incongruence can combine to make puberty, personal care and even the sensation of inhabiting a body profoundly difficult. In interviews with 12 autistic adolescents aged 14 to 18, participants described gender-related distress not only as an abstract question of identity, but as a physical and sensory experience woven through ordinary moments: getting dressed, looking in a mirror, showering, brushing teeth, sleeping under a duvet or feeling water drip across the skin. Several said that parts of their bodies seemed foreign, intrusive or fundamentally “not right”. The researchers argue that these accounts show why services supporting autistic young people experiencing gender incongruence need to consider sensory processing, executive functioning, communication style and bodily distress together, rather than treating them as separate clinical issues.
The study, led by researchers associated with Oslo University Hospital and the University of Oslo, addresses a gap in a rapidly expanding research field. Autism diagnoses and autistic traits are reported more frequently among people referred to gender-identity services than in the general population. A 2022 meta-analysis estimated a pooled prevalence of autism of about 11 percent among people experiencing gender dysphoria or gender incongruence, compared with broad population estimates of roughly 1 to 3 percent, although the figures vary substantially between studies and clinical settings. These statistics describe an association, not a causal relationship: autism does not determine a person’s gender identity, and gender incongruence is not an expression of autism. What has been less clear is how autistic adolescents themselves experience the overlap, particularly during puberty and before gender-affirming medical treatment. The new work focuses on that lived experience.
The researchers used a phenomenological approach, a tradition designed to examine how people experience events from a first-person perspective. Rather than reducing distress to a score on a questionnaire, the team asked participants to describe concrete episodes in their everyday lives. Semi-structured interviews covered the emergence of gender incongruence, relationships, school, puberty, body image and wishes concerning gender-affirming treatment. The interviews also incorporated “life-mode” questions, including an invitation to talk through the previous day. This method encouraged detailed descriptions of waking, preparing for school, using the bathroom, showering, dressing, looking in the mirror and interacting with other people. The interviews lasted between 45 and 100 minutes and were conducted privately in Oslo during the winter and early spring of 2024. Parents waited nearby but were not present unless requested, which did not occur.
All 12 participants had previously received an ICD-10 diagnosis of Asperger syndrome through local health services and had self-reported gender incongruence. Ten had been assigned female at birth and two assigned male at birth. They were recruited purposively from a clinical quality registry connected to Norway’s National Gender Team and were at different stages of assessment. None had yet received gender-affirming medical treatment: some were waiting for an initial appointment, some were approaching possible medical intervention, and others had experienced a pause in assessment. Sixteen adolescents initially consented, but illness and severe winter weather led to cancellations, leaving 12 completed interviews. The research team transcribed and coded the material using reflexive thematic analysis, an iterative process in which researchers move repeatedly between interview passages, codes, themes and broader interpretations. Four people with lived experience of autism and/or gender incongruence also advised on the interview guide and later discussed the emerging themes.
The analysis produced three overarching patterns. The first concerned the emergence of a mismatch between gender identity and the changing body during puberty. Participants often portrayed childhood as relatively simple and adolescence as increasingly complicated, unpredictable and difficult to explain. Puberty was not experienced uniformly: gradual changes could be easier to absorb than sudden ones, while menstruation or the rapid development of particular body parts could produce shock, disgust or helplessness. Some participants had initially interpreted feeling different as a consequence of entering puberty earlier than their peers. Others said that they sensed something was wrong for years before acquiring the language to describe gender incongruence. This delay may be relevant to alexithymia, a term used for difficulty identifying, understanding or communicating emotional states, which occurs in some autistic people. The researchers stress that not every autistic person has alexithymia, and that difficulty finding words should not be mistaken for an absence of a clear internal experience.
The second pattern involved the hidden labour of daily routines. For many participants, hygiene was not a neutral sequence of simple tasks but a demanding chain of sensory, cognitive and emotional transitions. Showering could combine the discomfort of undressing and seeing the body with the physical shock of moving between hot and cold water, wet and dry skin, dripping hair and clammy clothing. One participant described remaining motionless after a shower because the sensation of being both wet and dry was overwhelming. Others avoided showering for long periods or completed bathroom routines as quickly as possible to escape them. Nearly all participants reported avoiding toothbrushing in the morning, while one described brushing excessively. The study links these patterns to several mechanisms associated with autism, including heightened or atypical sensory sensitivity, difficulty initiating tasks, problems shifting between activities and the cognitive load involved in planning a sequence of actions.
Mirrors and self-recognition formed another source of distress. Some adolescents said they knew intellectually that the reflected body was theirs but did not experience it as belonging to them. Others avoided mirrors until they were fully dressed or described seeing a stranger rather than themselves. These accounts are consistent with the clinical concept of gender dysphoria, which refers to distress associated with an incongruence between experienced gender and sex-related bodily characteristics, but the researchers caution against assuming that all participants understood or described their experience in the same way. For some, the most painful aspect was an internal sense that specific body parts were foreign. For others, it was the way their voice, face, hair or body was perceived by other people. Social expectations also mattered: participants who did not fit comfortably into binary categories described pressure from others to be classified as either a boy or a girl.
The third pattern was described as bodily estrangement and a “chain reaction of discomfort”. Participants sometimes used striking metaphors, comparing unwanted body parts with an illness, an alien object or something grafted onto the body. Such language should not be read as a literal medical belief; it was a way of communicating the intensity and physical immediacy of distress. The researchers interpret these descriptions through the idea of embodiment, in which the body is not merely an object a person possesses but the primary means through which they perceive and act in the world. Autism-related sensory sensitivity could magnify gender-related discomfort, while dysphoria could make otherwise manageable sensations harder to tolerate. One adolescent described keeping a duvet over the body to conceal areas associated with dysphoria, even though the resulting heat was itself highly uncomfortable. Another said that dysphoria affected autism-related sensory experiences “like a chain reaction”—one source of distress triggering another until everything became overwhelming.
Several theories may help explain these experiences, but the study does not claim to prove any of them. Detail-focused processing, sometimes discussed under the framework of weak central coherence, might help explain why particular body parts, textures or sensations become unusually salient, although the concept remains debated and cannot be applied to every autistic person. Interoception—the sensing of internal bodily states such as temperature, tension or heartbeat—may also influence how bodily change is noticed and interpreted, but research on interoception in autism has produced varied findings. Mentalising, or inferring thoughts and feelings in oneself and others, becomes more complex during adolescence and may be especially demanding when social expectations are changing rapidly. Minority stress may add another layer when external scrutiny, stigma or pressure to conform turns the body into a perceived social problem. These frameworks are interpretive tools, the authors note, not explanations imposed directly on participants’ words.
The clinical implications are practical rather than prescriptive. The authors recommend that puberty be treated as a potentially high-stress transition for autistic adolescents experiencing gender incongruence, with clear, autism-informed explanations of what changes may occur and how they might feel. Clinicians could ask about sensory experiences and specific body parts instead of relying only on broad questions about identity or distress. Predictable appointments, reduced noise and harsh lighting, shorter waiting periods, breaks and communication adapted to individual preferences may make it easier for young people to participate. Support for hygiene should address both sensory barriers and executive-function difficulties, while respecting autonomy and avoiding shame. The researchers also call for multidisciplinary collaboration among professionals working in autism, adolescent medicine, mental health and gender care. When gender-affirming treatment is considered, they argue for individualized pacing, explicit information and appropriate support—not automatic delay or withholding of care. Non-binary identities must also be recognized, since some participants struggled with the assumption that everyone belongs neatly in one of two categories.
The findings come with substantial limitations. Twelve interviews can provide rich qualitative evidence about meaning and experience, but they cannot establish prevalence, causal mechanisms or outcomes for autistic adolescents more broadly. The sample was recruited from a specialist Norwegian gender service, included far more participants assigned female at birth than male, and excluded young people unable to take part in an in-depth Norwegian-language interview. There was no comparison group of autistic adolescents without gender incongruence, making it impossible to determine which sensory, self-care or body-related difficulties were specific to the intersection of autism and gender incongruence. The study also did not include participants who had already received gender-affirming medical treatment, and detailed measures of autism-related support needs and cognitive functioning were not consistently available. Future research will need broader samples, alternative communication methods, longitudinal designs and comparisons across different clinical and cultural settings. Even so, the adolescents’ accounts point to a central lesson: for some young people, gender-related distress is experienced not only in identity labels or social interactions, but through the textures, temperatures, routines and changing contours of everyday life.
