Trans-ADHD: A Theory of Developing Trans Identities

Trans-ADHD: A Theory of Developing Trans Identities

What's up with so many transgender people also struggling with ADHD, anxiety, and depression? What does it mean, and what should we do with this information?

I recently had a new doctor's visit to re-up my ADHD meds and he noted that the majority of his transgender patients also have ADHD, which didn't surprise me at all. You might have noticed this yourself if you know a lot of trans people, but it's also well-established in medical research that the incidence of mental health conditions like ADHD, depression, anxiety, and autism are highly correlated with being transgender. Quote from a Kaiser study in 2018:

"We looked at mental health in transgender and gender-nonconforming youth retrospectively between 2006 and 2014 and found that these youths had three to 13 times the mental health conditions of their cisgender counterparts."
- Tracy A. Becerra-Culqui, PhD, MPH (source)

Additional studies reporting the same can be read here and here. You can Google for more. I don't think it should take much persuading for you to agree that the overlap is present. The most common diagnoses for transgender and gender-nonconforming children and adolescents mentioned in the research quoted above were:

  • Attention deficit disorder (transfeminine: 15 percent, transmasculine: 16 percent). These numbers are 3 to 7 times higher than the matched cisgender reference group.
  • Depressive disorder (transfeminine: 49 percent, transmasculine: 62 percent). These numbers are 4 to 7 times higher than the matched cisgender reference group.

In the past, when people have observed the overlap here, a frequent point that gets brought up goes something like, "Duh, of course trans people have anxiety and depression! Look at how the world treats us. Wouldn't you?"

But this doesn't explain the ADHD incidence and fails to account for the fact that many of these conditions begin presenting in childhood, long before others (or even the transitioner themselves) might be aware that they're trans and could treat them differently because of it. I also don't think you can chalk all of this up even to the internal experience of grappling with the "wrongness" of their gender sometimes reported by transgender people.

What's going on here? It sure is weird, but there doesn't seem to be a whole lot more to say about it than, "Yeah, I guess trans people suffer from lots of mental health issues." Or at least, there wasn't until I read Scattered Minds, an excellent book about ADHD by Dr. Gabor Maté which proposes a theory for how ADHD develops in childhood due to a combination of specific biological factors which predispose them to the condition and early environmental factors.

The book immediately resonated with me by mapping to memories of my life and early childhood experiences and has helped me to understand a possible explanation for my own struggles with depression, anxiety, and ADHD throughout my life and work through them more productively.

But even more interesting to me is that there may be a clue to how gender dysphoria develops here too--given that there's so much overlap between these disorders and gender dysphoria, is it possible that (at least in some cases, for some individuals) dysphoria arises from the same combination of biological and environmental factors described in the book, and is preceded and reinforced by them?

Understanding ADHD Through Scattered Minds

It's important to understand some of the background claims made by Scattered Minds to appreciate the rest of this essay, so let's go through them (briefly). Here are the relevant points proposed by Maté:

  • The core premise of Scattered Minds is that ADHD symptoms are caused by a combination of genetic predisposition to high emotional stimuli sensitivity and an environment in infancy and early childhood where chronic anxiety and stress exist for mother or child.
  • These stresses interfere with the attachment or attunement between child and primary care-giving parent necessary for proper development of emotional regulation, attention processing, and impulse control in the child and can eventually lead to other social issues.
  • If the primary caregiver (usually a mother-figure) is unable to read or respond to her child’s distressed emotional states consistently (for example, due to her own traumatic childhood experiences or because of a stressful home situation), this can interfere with the child’s ability to emotionally attune to others.
  • Attachment and emotional attunement difficulty can lead to a chronic tendency to feel isolated, alone, and to have a sense that no one can understand or share in the feelings of the child as they develop.
  • High stress environments in infancy which lead to attunement and attachment issues also hamper the normal development of the prefrontal cortex, which impairs emotional regulation and attention processing.

These attunement challenges can manifest in difficulty reading the emotional cues of other people, which is critical for proper socialization and acceptance by peers—an issue exacerbated by hypersensitivity, difficulty regulating internal emotional states, and attention processing, which make the child’s responses to normal interactions seem atypical and alarming.

This creates a vicious cycle, where the hypersensitive child is continually yearning for attachment and feeling rejected when their failure to read and act appropriately in response to social cues leads to ostracism by these same peers and creates the impression that something is deeply wrong with them.

Because the child is not able to learn or apply appropriate behavioral responses, their feelings of isolation, yearning for unmet attachment, and inability to correct these problems persist as issues throughout childhood and into their adult lives, even if some coping mechanisms are formed to create the external impression of normal functioning.

Their lack of baseline security and internal narrative of isolation combined with their hypersensitivity to emotional loss or rejection will cause any perceived social rejection (no matter how small it may seem to others) to seem absolutely devastating and be further apparent confirmation that “something is wrong with them.”

Contextualizing a Developing Transgender Identity

So what does any of this have to do with being transgender?

Recall that we already know the incidence of depression, anxiety, and ADHD is unusually high for transgender people and has been since childhood for many of us. If we accept the developmental model proposed above, it's reasonable to expect that some or all of the challenges previously described will resonate at an unusually high level for transgender people and that these issues may have developed in response to those challenges. They would have also developed in conjunction with their dysphoria, which is often described as initially presenting between the ages of 5 - 7 in some form, whether or not the person recognized those feelings as such at the time.

To understand why this might be relevant to their burgeoning gender dysphoria, we have to unpack what it even means to "experience gender dysphoria" at these ages. An interesting note is that this is the same age range across which children develop a more concrete awareness of their biological sex (Kohlberg) and understand how the social role arising from that creates expectations for them which will continue throughout their life, and others have argued that childhood development of identity is a result of an interaction of behavior, the person, and their environment (Bandura).

At such a young age, prior to puberty and romantic considerations, it's hard to imagine how dysphoria could be shaped and experienced in anything except a social context. Typical male-pattern or female-pattern modes of interaction, presentation, or activities may feel objectionable in difficult-to-describe ways that are mostly commonly described as simply feeling "wrong." Depression or anxiety, to the extent that the experiencer notices it, may often be attributed to this sense of wrongness.

The modern talking points on gender identity tend to lean in a direction that trans identities arise genetically ("born this way") and are expressed in opposition to social expectations and innate perception of and attitude toward one's own sex characteristics. It's gauche to suggest that under a different set of circumstances, with the same biology, someone might not have developed gender dysphoria.

But it also seems fairly obvious that our attitudes toward gender in general are shaped quite extensively from our experiences during this period from 2-7 as we're forming our earliest opinions about gender and our place in the world.

Let's step back for a moment and consider the typical-pattern internal world of a child struggling with the conditions of Dr. Maté's observations: we have a child who struggles with hypersensitivity to emotional stimulus, yearns for attachment, feels isolated from and rejected by their social world due to the manifestation of their attachment issues, and is deeply emotionally affected by that rejection. They perceive that "something is wrong with them," even if they can't themselves explain what it is. Also consider that prior to age 7 or so, gender boundaries are enforced much less rigidly for many children than they are thereafter.

It's not hard to imagine just a tiny handful of experiences of positive emotional reinforcement in ways that code opposite to their biological sex could have an outsized impact on the self-perception of a hyper-sensitive child during these developmental stages. If a child feels anxious, detached, depressed, socially awkward, or "wrong" most of the time, and some of their most resonant positive emotional responses come from situations or experiences that they perceive as strongly "belonging" to the opposite sex as they develop their identity, it's easy to see how that might influence their self-perception of gender at this stage.

What gets interesting about this is what happens next: As kids age into pre-adolescence and puberty, sharp gendered lines begin to be drawn between male and female experiences both socially and within the context of their changing bodies.

Girls and boys start to separate into different social contexts more and have less access to the internal lives of their biological counterparts. New social dynamics are injected into their environment which encourage stronger gender boundaries than they've experienced previously, and feelings of loss, jealousy, and resentment may arise.

This would be especially true for children with attachment issues arising from the same conditions described by Maté in the development of ADHD (which, again, has a strong correlation with being transgender). Any sense of attachment to an opposite-sex activity which promoted feelings of belonging or a friendship which is severed or changed by the shifting gender dynamics would be felt particularly strongly by such a child, even if it looked relatively minor to an external observer.

This could present in a myriad of possible contexts: maybe your best friend (and your only felt strong attachment) is the opposite sex, and budding adolescence changes the dynamic of your relationship in a way it wouldn't if you were the same sex. Maybe you're shamed or barred from playing a gender-coded game you derived a high level of emotional satisfaction from by feeling like a member of the group, and you're unable to find an immediately satisfying replacement in your new social context.

It's important to remember that children with the characteristics described by Dr. Maté would experience these losses much more keenly than a child with strongly felt secure attachments, and are likely to experience any resulting depression or separation anxiety from the loss more sharply as well.

If your biological sex takes a subconscious focal role in your own mind as the "reason" for these losses, which would be much more of a felt emotional reaction than a logically derived one in the mind of a 7-year-old, it's easy to imagine how this could be the seed of a self-perpetuating emotional narrative that grows and develops as you age and continue to struggle with emotional regulation, a lack of perceived (and possibly actual) social acceptance, and attention processing issues.

This would be further reinforced if you try to continue engaging in your gender-atypical patterns of engagement in a bid to try to reclaim that feeling of attachment and receive social feedback that you're wrong for doing so, which will trigger confusing and volatile emotional states as you overreact emotionally to criticism for trying to access prior sources of emotional comfort and stability.

A securely attached child would find this relatively untroubling, as their emotional needs would be met even in the changing contexts of the adolescent years to come (which is challenging enough on its own for everyone!), but if your emotional or social issues prevented you from doing so, you would continue to yearn for your "lost" source of emotional comfort with a heightened sense of urgency as it faded ever further into an emotionally resonant and idealized past in the same way any child might miss a lost source of attachment.

Furthermore, as a child, you would have little chance of understanding the nuanced complexity of the sources of these big emotions, let alone satisfactorily explaining all of these emotional states and triggers and responses to even the most invested and caring adult with an appropriate level of analysis and depth. You're probably not even aware of most of these layers and factors driving them. The best you'll be able to do is say you feel "wrong" and unhappy, which you may attribute to your gender.

This is what I think is happening, at least for some people, when they describe experiencing gender dysphoria at these very young pre-adolescent ages.

Narrative Reinforcement

Our sense of self is derived from the stories we tell ourselves about our lives, and we build on past models over time and continually update ourselves. We all use our past experiences to inform who we are in the present and contextualize our current experiences and emotions, and in this way, we decide who we are and what being that person means to us.

The experiences and emotional reactions that are hardest for us to re-define, change, or even fully understand are our earliest ones, because they're the dimmest in our memories and form the lowest layer of our personhood. Everything we've learned and experienced since then is shaped in some way by the echoes of echoes of our earliest recollections. Patterns form and calcify.

If one of our earliest experiences is a dysphoric rejection of our gendered social role driven by our impaired developmental struggles with a lack of felt attachment and social acceptance, that narrative will continue to inform our perceptions and emotional reactions as we grow and progress through subsequent developmental stages. We tend to see what we're looking for, and if you're building on a seed of dysphoria, you'll spot all kinds of things that reinforce your established negative conception of self with respect to gender and entrench the previous patterns, like ever-deepening erosions in stone.

Some people will read this and interpret what I'm saying to mean that transgender identity is entirely a product of social reinforcement colliding with unmet internal needs and reinforced by the mental challenges of being a child experiencing the world through the lens of hypersensitivity and attachment issues, and I want to be clear that I think it's more complicated than this (and also that this is simply one explanation that may apply to some transgender people and not others).

After all, the positive emotional responses that I'm suggesting may have arisen from gendered activities and relationships during early childhood development still have to come from somewhere, and children do appear to express innate clustered preferences across biological sexes (with wide distributions at the tails, of course) for modes of behavior and engagement. I don't believe that an internal perception of gender is entirely socially constructed, or that it can be readily deconstructed or altered.

What I believe is that emotional responses to gendered modes of interaction in social contexts (both active and receptive) are heavily genetically predisposed within a range (as with sexual spectrums) and that we all have strong or weak innate emotional responses to these modes of engagement which may or may not align with our biological sex. However, this differs from some innate "sense of gender identity," which I believe solidifies later.

I suspect that one's innate position on this spectrum of involuntary emotional response can be influenced by social factors during early childhood (2-7) while conceptions of gender are forming, but that they become somewhat immutably fixed after that point as one's sense of selfhood forms and begins to self-reinforce an internal narrative about who you are and what you like and don't like in terms of how you experience and engage with the world.

Furthermore, it seems that the same conditions which give rise to mental issues like ADHD, anxiety, and depression in early childhood may put people at a higher risk of pushing their innate position on this spectrum of emotional response in one direction or the other further than people without those challenges because of their hypersensitivity, strong emotional reactions, and felt sense of "wrongness" arising from these issues being conflated with developing notions of gender in a confused and challenging environment.

This might be why we see such a high rate of these mental health conditions in the transgender population: not anxiety or depression arising from some "innate sense of wrong gender identity", but rather a transgender identity arising due to a misattributed emotional response from these conditions, which then becomes a fixed aspect of their self-perception of their gender as a child ages.

An "Innate" Sense of Gender

I want to take a moment to clarify this concept of emotions which arise involuntarily in response to how those in your social world relate to you, because this is key to an understanding of how anyone experiences their gender, in my opinion. It's the only way to make sense of what people might mean when they claim to feel a strongly feminine or strongly masculine identity (even for cisgender people).

As a child, I believed and accepted that I was male because I had a male body and had been told I was. But I never strongly identified with some innate internal sense of either “maleness” or “femaleness” rising up from my deepest self.

I admit that I struggle to understand what anyone could possibly mean by an “innate internal sense” of their gender outside of the context of their perceptions of themselves and the ways in which they relate to the world around them. Even for those who describe extreme distaste and discomfort with the changes their bodies begin to undergo in puberty, I have difficulty appreciating the origins of these feelings outside of some personal value judgment or deep discomfort arising from that judgment which they ascribe to those changes.

Our bodies all go through changes throughout our lives, and absent of personal or social judgment arising from a set of social values or aesthetic preferences, how can we say anything about these changes except that they either feel physically comfortable or do not?

Having had many conversations with both trans and cisgender people and lived over half my life being broadly accepted and read as male, as well as over a decade being broadly accepted and read as female, I have come to see the experience of one’s internal “sense” of gender as a largely experiential phenomenon defined by the emotions which arise in relation to their interactions with other people and their own bodies. While there are obvious and innate biological differences between male and female bodies that limit reproductive possibilities and influence various other traits, the biology itself has little to do with how comfortable any particular individual feels with the aesthetics and opportunities afforded by society to the body in which they find themselves in.

A cisgender woman can have children without feeling strong positive emotional states toward the aesthetics and functions of her own body or the ways it causes people to interact with her in society, and in such a case might claim to not strongly identify with a feminine identity. Similarly, a cisgender man might feel very strong positive emotions in response to the felt and observed aesthetics and functions of his masculine body and experience similar feelings when people interact with him in ways that are typical of his expectations for appropriate behavior toward men. He may then claim to feel a strong internal sense of “male identity.”

The origin of such feelings (or lack of feelings) only comes into question when we observe that someone exhibits strong emotional responses to the aesthetics, functions, or interactions related to their body which are out of alignment with their biological sex, and this further raises the question of the degree to which these emotional responses should be attributed to genetics, environment, or developmental disorder.

If we look to theories of childhood development, it appears that many of these preferences (or lack of preferences) begin to form in cisgender people to some degree between the ages of 2 and 7, just as they do with transgender people, whether or not they are able to satisfy these preferences at their current life stage, and reinforce themselves throughout their lives. A cisgender man with strong preferences for male modes of aesthetics and interaction may set out to become much more masculine as he ages, eventually satisfying his own conception of his idealized preference for masculinity as he grows into the man he one day hoped he would become.

Because perfect understanding of the emotions underlying another person’s language is impossible, it becomes very difficult to understand the complex emotions a person might be experiencing when they say their “body feels wrong” or that they feel a strong identification with a masculine or feminine identity.

When people who are transgender attempt to describe their specific feelings toward their biological sex characteristics, the most common words I see are “hatred,” “resentment,” and “discomfort,” and often a sense of simple “wrongness.”

The first two words can only arise in the face of a value judgment of either personal aesthetic preference or anticipated social limitation or obligation that these characteristics may place upon them, and the second two imply a level of discomfort which can only be understood as emotional in nature, as obviously they are in no more physical pain than any other human who shares their approximate biological sex.

This seems to suggest that people who are transgender are experiencing a complex negative set of emotions that arise spontaneously in the consideration of their secondary sex characteristics or in social interactions which are judged to be gender-normative for their biological sex, and a complex positive set of emotions in response to the opposite condition, which is sufficiently severe to drive them to alter their mode of presentation. It also appears that these gender-relative emotions of approval, distress, or neutrality arise to different degrees in every human during some stage of their development.

It might sound like I’m saying “transgender women like being treated like women and don’t like being treated like men,” to which the obvious response is a resounding, “Duh.”

But what I’m proposing is more nuanced than that. To reiterate my point at the end of the last section: I’m suggesting that their may be a genetic predisposition which influences any given human’s innate emotional inclinations toward both the physical aesthetics and social interactions produced by their biological sex, and that this is somewhat malleable until an internal sense of gender is shaped by their life experiences and fixed somewhere between the ages of 5 and 7 for most people.

Those directional nudges may be heightened considerably when strong emotional reactions and motivations are present, as in the case of highly anxious or trauma-motivated children with attachment issues, such that their genetic predisposition toward opposite-gender inclinations becomes magnified to a degree that it causes them an exceptional amount of distress to ignore it, as a less sensitive or more secure child might learn to do.

What Do We Do With This?

So what do we do with this information and the knowledge of a large overlap between dysphoria, ADHD, depression, and anxiety, assuming that these observations are correct for some portion of transgender people? Well, at least in the case of children, it suggests some avenues for early intervention which may significantly decrease the degree of dysphoria experienced later in life.

In this context, the modern social permissiveness with respect to gender identity and experimentation is actually a very good thing, as it allows children the space to talk about dysphoria they're experiencing in a safe and accepting framework instead of hiding it out of shame or fear as earlier generations did, and having to process these feelings on their own without either professional help or much ability to self-analyze what they're experiencing at that age.

This opens up a broader range of opportunity for analysis and treatment of the underlying issues and an exploration of treatment which may reduce dysphoria without requiring medical intervention. I don't know what the preferred psychological approach is for addressing attachment issues and emotional reactivity in young children, but if I were a therapist working with a transgender patient in this age range, I'd be digging pretty dang hard at understanding and addressing any attachment issues that might be interfering with their ability to feel secure as a potential underlying contributor to the emotional states of distress. I'd also be looking at this model for the development of ADHD, depression, and anxiety symptoms and using whatever tools were available to me to address those issues as a very high priority if I observed evidence of them.

Neither reinforcement of strong emotional connections to a specific gendered presentation or modes of interaction by pushing them in a hard direction, nor forbidding a child from experiencing a sense of safety and comfort arising from attunement to those modes of interaction seems optimal here.

Trying to divert a child into more positive gendered activities and modes of interaction congruent with their biological sex seems very bad here, as well, if that's the primary strategy. Remember that when you're 7, seven years is your entire life (and you probably only remember 3 or 4 of those years). You're not going to fix deep and established issues of self-perception and satisfaction with a gender identity formed over the course of their entire set of experiences with a few instances of positive reinforcement while a negative feedback loop is still playing out in their head.

I don't know what the optimal treatment strategy is, but ensuring that the child feels safe, secure, and has their social needs met feels like the number one priority to begin reducing a sense of dysphoria in this context.