Alexithymia and Gender: When You Cannot Feel What You Are Supposed to Feel

The problem in one sentence. Nearly every route into gender assessment asks how you feel about your body, and alexithymia is difficulty identifying and describing how you feel about anything.

Why this lands hardest on autistic people. Alexithymia occurs at much higher rates in autistic populations than in the general population. Autistic people are also more likely to be gender diverse. So the trait that makes the standard assessment question unanswerable is concentrated in the population most likely to be asked it.

What it looks like clinically. The person reports that something is wrong without being able to locate it, or answers questions about feeling with descriptions of situations, or says they do not know and is treated as uncertain about their gender when they are uncertain about their access to their own interior.

The misread that follows. Difficulty describing internal states gets recorded as ambivalence, and ambivalence delays care. The assessment instrument creates the finding.

What works better. Behavioral evidence rather than felt evidence. What you do, avoid, notice, and repeat. Relief is easier to detect than distress, and euphoria is easier to report than dysphoria.

Read the long version if you are autistic and stuck on whether you are trans, you have been told to sit with it and cannot, or you assess gender clinically and keep getting "I don't know."

Alexithymia is difficulty identifying and describing emotional states. It is a trait rather than a diagnosis and it occurs across populations, but it appears at substantially elevated rates in autistic people. Related to it, and often co-occurring, is unreliable interoception, the sense that reports on internal bodily signals such as hunger, temperature, pain, and the vague physical texture of emotion.

Separately, autistic people are more likely than non-autistic people to be transgender or gender diverse, and gender diverse people are more likely to be autistic. This is well enough established that the researchers who built the Gender Self-Report deliberately included autistic collaborators in developing the item set, precisely so that the measure would not fail on the population most likely to need it.

Put those together and you get a structural trap. The population most likely to be assessed for gender diversity is disproportionately the population least able to answer questions phrased as "how do you feel."

Consider what has to be true for a person to answer a question like whether they feel distress about their chest.

They have to notice an internal signal. They have to separate it from the other signals present. They have to identify it as emotional rather than physical. They have to attribute it to a source. They have to find a word for it. Then they have to judge its intensity against some remembered baseline.

That is a long chain, and alexithymia breaks it early. What comes out is either a description of circumstances rather than feeling or a flat report that something is off.

A clinician hearing that has a decision to make, and the field's default has been to hear uncertainty. Uncertainty in gender assessment produces a recommendation to wait. So a trait of information processing gets converted into a delay in care, and the delay is recorded as clinically indicated.

The instruction to sit with it and see how you feel is the standard advice, and for someone with alexithymia it is an instruction to perform the exact operation they cannot perform.

Worse, the failure is usually read as meaningful. If sitting with it does not produce clarity, the conclusion drawn is that the feeling is not strong enough to be real. The person concludes it too, often more harshly than the clinician does. I have heard many versions of the thought that if it were real it would hurt more, from people whose access to knowing that anything hurts is limited across the board.

The alternative is to stop asking about felt states and start asking about observable ones. Alexithymia impairs the ability to report on the interior while leaving the interior itself and behavior intact.

Track what you do rather than what you feel. Which pronouns you go out of your way to avoid using about yourself. Which photographs you delete. Which clothes you own and never wear, and which you wear until they fall apart. What you have googled at two in the morning more than once.

Use relief as the signal. Distress is diffuse and hard to locate. Relief has an edge to it, and it is easier to catch because it is a change rather than a state. The moment after a stranger uses a different word for you. The week your voice was lower from a cold. Note the absence of something rather than the presence.

Use euphoria rather than dysphoria. This is the reframing the Gender Self-Report was built around, and it asks a different question. Asking what you want to be rather than what you cannot bear produces answers from people who cannot access what they cannot bear.

Look for repetition. A single instance is data you cannot interpret. The same thing arriving for the eleventh time over four years is a pattern, and patterns are visible from outside without any interior access at all.

Ask other people what they have noticed. This is uncomfortable and it works. People who know you have been watching your behavior without the reporting problem you have.

If you want structure, there are instruments. The Perth Alexithymia Questionnaire is the current standard for measuring alexithymia dimensionally, and understanding your own profile on it is useful context for interpreting everything above. Knowing that your difficulty is specifically in identifying negative valence states, for example, tells you which questions will fail and which will work.

For gender, the Gender Self-Report is the measure developed with autistic input, and it asks about self-perception and wishes rather than about distress. Neither instrument makes a determination about you, and neither is a substitute for working with someone who knows both fields.

Our self-assessment page has the instruments, and the Gender Lab is a less formal way into the same questions.

If your assessment produces "I don't know" from an autistic client, consider that you may have asked a question the person's neurology does not support answering before you record uncertainty about gender.

Rephrase to behavior. Ask what they do and what they have repeated. Ask what would be different if it had gone the other way, and what they have looked up. You will frequently get a clear and consistent picture from someone who could not tell you how they feel about any of it.

And be careful in the letter. Writing that a client is uncertain when what happened is that they could not describe a feeling puts a delay into a document that will follow them.

Related reading on this site

• Perth Alexithymia Questionnaire
• The Gender Lab
• What a therapist letter under SOC-8 requires

Lexicon terms used in this article: alexithymia, interoception, gender euphoria, gender dysphoria, autistic

Educational content only. Nothing here creates a therapist–client relationship or constitutes clinical or legal advice about your situation.

Mx. Love C. Dialogos, LMFT · Licensed Marriage and Family Therapist · Buddhist Chaplain · Love Psychotherapy, LLC