The Diagnostic Cage: When “Support” Is a Strategy of Containment

Trans youth don’t need scrutiny disguised as support. They need trust, not tests. This piece exposes how diagnosis is used to control, not care—and how autistic trans femmes unmask what the system fears most: sovereignty.

Introduction

To an autistic mind, this isn’t surprising—it’s a pattern. Not an anomaly. Not a misguided policy with unintended consequences. A pattern. One that is painfully familiar to those of us who live at the interstices of classification, who have learned to see beyond what the system says it’s doing and recognise what it’s actually doing. The UK’s proposed move to screen all trans youth for autism and ADHD before granting access to gender-affirming care is being presented, predictably, as a measure of safety, of support, of holistic concern. But to those of us who are both autistic and trans, it rings with a different tone. This is not about care. It’s about containment. It’s about creating a pause point—one that looks neutral on paper, but functions as a gate. A diagnostic delay that grants the appearance of due diligence while making young lives wait, explain, justify. It’s a tactic we’ve seen before. And we know what comes next.

This piece is a companion to my earlier writing on sovereignty, on the archetype of the Cailleach, and on the fear that systems hold for those who do not fit within their definitions. There, I wrote about trans women not as distortions of womanhood, but as its unmasking—those who move through its structures and reveal the scaffolding beneath. This time, I write from the same place of pattern recognition, but now with a focus sharpened by the clinical coldness of institutional policy. Because what is being framed as “comprehensive mental health assessment” is, in fact, a strategy of reclassification: a way to insert doubt where there should be affirmation. To delay by diagnosing. To question the validity of gender by interrogating the mind that knows it. And to anyone who has spent a lifetime being asked to prove themselves before they are helped, it is unmistakable. The logic is not new. The frame is not neutral. The outcome is not accidental.

The Setup: Diagnosis as a Gate, Not a Guide

The NHS proposal is being framed, as these things so often are, in the language of care. Trans youth, we’re told, will be offered “comprehensive assessments”—not just for gender dysphoria, but for autism, ADHD, trauma responses, disordered eating, and more. On the surface, it sounds like support. It sounds like concern. But to those of us who have been in systems like this—those of us who’ve watched diagnosis used not as a tool for understanding, but as a mechanism for control—it sounds different. It sounds like containment. This is not about knowing these young people more deeply. It’s about narrowing the terms on which they’re allowed to be believed.

The proposal fits a long-standing pattern. Diagnosis, when wielded by systems that distrust autonomy, becomes a gate. Not a guide. It becomes the thing that must be passed, performed, endured—before access is granted. Before care is given. Trans youth are already made to navigate a world that treats their identity as a claim to be vetted, not a truth to be respected. Now, with this policy, their neurotype may be used as another reason to pause, to question, to delay. Studies have shown this clearly. What begins as “assessment” often ends up functioning as a filter: determining whose stories are acceptable, whose presentations are “compliant,” whose experiences are deemed coherent enough to warrant care (Speer & Parsons, 2006; Faccio et al., 2023).

This isn’t new. Trans people—especially those of us who are neurodivergent—have long been told we must fit a script. That we must narrate our lives in particular ways to be understood. That we must omit parts of ourselves to be believed (Faccio et al., 2023). And the more diagnoses we carry, the more complex our needs, the more likely it is that those systems will read us not as full human beings but as contradictions. Risk factors. Liabilities. Neri et al. (2022) write of how mental health professionals themselves question the role diagnosis plays in this space—not as something helpful, but as something hierarchical. A structure of control. Something that privileges certain narratives over others and erodes the very trust it claims to build.

This is the quiet violence of gatekeeping: the performance it requires, the narrowing it imposes, the erosion of self that occurs when care is conditional. It is not benign. Verbeek et al. (2022) describe how “mental readiness” becomes a euphemism—an administrative way to say not yet, not now, not you. Breckenkamp et al. (2022) speak of “diagnosis fatigue” in trans communities—of the exhaustion that comes from having to constantly rejustify your own needs in the language the system prefers. And Ashley et al. (2025) remind us that these structures not only fail those seeking care—they also harm those who later detransition, because care that is conditional can never be truly informed.

So let’s call it what it is. This isn’t about support. It’s about surveillance. It’s about embedding suspicion into the very framework of access. When the state fears sovereignty—especially in youth, especially in those who do not conform—it reaches not for solidarity, but for diagnostics. It seeks to pathologise what it cannot control. And it does so with a calm voice and a clipboard, under the banner of care.

The Pattern: Five Moves of Containment

There’s a pattern to how containment is built. It rarely arrives as a wall. It arrives as care. As policy. As a series of small, seemingly reasonable steps that together create something very hard to escape. This moment—the NHS proposal—is just the latest iteration of a deeper architecture, one I’ve come to think of as five moves. Five familiar manoeuvres that systems use to discredit, delay, and deny. They don’t always come in the same order, but once you’ve seen them, you can’t unsee them. They operate in schools, in hospitals, in family courts, in clinic intake rooms. And now, increasingly, in policies that promise to “support” trans youth while quietly ensuring fewer of them make it through the door.

First, diagnosis is used to justify the withholding of rights. This is a very old move. Disabled people know it well—from sterilisation laws to the denial of legal autonomy. In trans healthcare, it shows up in phrases like “mental readiness”—a euphemism for waiting until you’re more palatable, more legible, less distressed, less neurodivergent (Verbeek et al., 2022). For autistic trans youth, the danger is acute. The diagnosis of autism becomes not a lens for support, but a pretext to pause. To doubt. To defer. Greene et al. (2024) show how autism is increasingly cited in ways that delay access to care, treating neurodivergence not as a co-occurrence, but as a contradiction.

Then comes the second move: blaming identity for distress, rather than the environment. Trans and neurodivergent young people are often told—implicitly or explicitly—that their pain is just part of who they are. That their suffering is intrinsic. That it arises not from discrimination, exclusion, or misrecognition, but from the nature of their identity itself. Moore (2022) names how this erases the role of structural harm in mental health outcomes. Sitas et al. (2023) describe how the distress of trans youth is medicalised, reframed as confusion or pathology rather than a response to living in a world that constantly questions their existence.

Third, the system treats difference as disorder. Autism and trans identity, when seen together, are too often framed as evidence of distortion. Not simply different ways of being, but mistaken ones. Bouzy et al. (2023) trace how clinical literature continues to pathologise this overlap, viewing trans identity in autistic youth as suspect—something less valid, less stable, less “real.” Greene et al. (2024) show how this logic infiltrates assessment procedures, where autistic traits are used to call gender self-understanding into question. The message is clear: if you don’t match the expected affect, if your communication doesn’t follow the right script, your identity is presumed faulty.

The fourth move is perhaps the cruelest: requiring proof of suffering whilst denying support. This is the double-bind. You must be distressed enough to need help—but not so distressed that your judgement is suspect. You must articulate pain, but do so calmly. You must want care, but not too much. And if you’re neurodivergent—if your distress doesn’t look the way they expect—it becomes one more reason to question your truth. Speer and Parsons (2006) exposed how even psychiatric questioning itself becomes a test. Strauss et al. (2021) show that autistic trans youth often face increased scrutiny, where both their autism and their gender are grounds for withholding support. You are asked to prove yourself in a system designed not to believe you.

And then, finally, the mask: saying it’s about care whilst delivering containment instead. This is where the trap springs shut. The language is always soft. Always concerned. But what it hides is a deep mistrust—of autonomy, of noncompliance, of those who do not conform. Sitas et al. (2023) and Raghuram (2024) both document how “care” becomes a regulatory function—how systems insist on protection whilst embedding surveillance, filtering, and institutional doubt. It is not about wellbeing. It is about managing threat. And in this schema, a trans youth who knows who they are, especially one who is also autistic, is always already too much: too confident, too different, too hard to fold back into the script.

Across each of these moves, diagnosis is not offered as a guide—it is deployed as a gate. It disciplines. It restricts. It filters those who pass from those who won’t. And it is never neutral. It is shaped by fear. Fear of autonomy. Fear of liminality. Fear of those who don’t perform identity in the way the system prefers. But when you live at those edges, when you’ve already been made to explain yourself for simply existing, you learn to recognise the shape of the cage. Even when it’s wrapped in care.

The Mythic Frame: What the System Truly Fears

This was never about logic. Not really. The state doesn’t fear contradiction—it generates contradiction constantly. What it fears is something older. Something quieter, but harder to contain. It fears those who move through its structures and expose the scaffolding. Who remind the system that its categories are not natural, only enforced. That its boundaries are not sacred, only inherited. This is the fear that lives beneath the policy language, beneath the paperwork: the fear of the sovereign. The unclassifiable. The returning.

In my earlier writing, I called her the Cailleach—the ancient figure who walks alone, veiled but not hidden, outside the reach of kings and councils. She’s not legible to power, and that is why she is dangerous. Not because she breaks the rules, but because she reveals them as inventions. That same energy stirs in the autistic trans femme. Not as metaphor, but as memory. As architecture unmasked. As presence that disrupts not through protest, but through refusal to conform.

We disrupt simply by existing. Because we do not follow the timeline the system prefers. We do not transition on cue. We do not present distress in the way it expects. We do not narrate our identities with tidy arcs and linear resolutions. Jake Pyne (2021) calls this the refusal of “chrononormativity”—the pressure to be coherent, productive, and legible on a timeline not of our choosing. Our bodies and rhythms defy that timeline. Our way of knowing and becoming interrupts it.

And so, the system tries to neutralise us. Through assessments. Through waiting lists. Through diagnostic codes that turn complexity into contradiction. Paine (2018) names this embodied disruption—how autistic trans femmes confound clinical spaces, not through intention, but by simply refusing to resolve. We do not collapse neatly into binary logics. We do not offer a singular explanation. And because of that, we are often labelled as “too complex” for care. Too much. Too difficult. Not because we are incoherent—but because we reflect back the incoherence of the system itself.

This is not a glitch. It’s a defence. Bruce et al. (2023) and Moore (2022) show how institutions respond to our presence not with curiosity, but with tightening. With misrecognition. With erasure. When you live at the intersection of neurodivergence and trans identity, care becomes conditional. And the more you reveal—through your embodiment, your perception, your refusal to comply—the more the system tries to disappear you. This isn’t just medical. It’s epistemic. It’s political.

But there’s power in this disruption. McAuliffe et al. (2022) describe how autistic LGBTQIA+ people become knowledge-holders—precisely because of their exclusion. Because living in the margins sharpens your view of the centre. Because when you are not allowed in, you begin to name the architecture that kept you out. That’s what we do, many of us—not just endure, but narrate. We name. We document. We remember out loud. And in doing so, we produce new possibilities. Not just for ourselves, but for all those who were never meant to fit.

Strang et al. (2023) and Fischbach et al. (2024) both remind us that autistic trans youth are not “less clear” in their identities. They are simply less willing—or less able—to pretend. To script their truth in the language that clinicians prefer. And for that, they are often punished. But that is also their power. Our power. We do not offer clean narratives. We offer thresholds. Disruptions. Openings. And that is what the system truly fears: not chaos, but change. Not disorder, but revelation.

Because once you’ve seen the scaffolding, you can’t unsee it. And once you’ve named it, you can begin to dismantle it. Not in rage. Not in haste. But in knowing. In the slow, deliberate rhythm of someone who has walked through fire and frost, and returned—not to ask for entry, but to show where the walls have always been weakest.

The Liminal Warning: Why Autistic Brains See It Coming

There’s a reason we see it coming. Not because we’re cynical. Not because we expect the worst. But because our minds are tuned differently—wired for pattern, for shift, for the quiet movements of systems beneath their stated intentions. Autistic perception isn’t random or chaotic. It’s rhythmic. Recursive. It notices what repeats, what deviates, what doesn’t add up. And when you live in a world that insists its inconsistencies are normal, that kind of noticing becomes both a gift and a burden.

Pattern isn’t just something we see—it’s how we understand. Crespi (2021) suggests that pattern recognition is the thread that weaves together autistic cognition, perception, and behaviour. The detestable Baron-Cohen and his colleagues (2009) call it hyper-systemising: an ability to detect rules and structures with such precision that even minor distortions are felt. We see the shape of things before they finish forming. And so, when a proposal like this one appears—one that dresses itself in care but carries the contours of control—we don’t need to read every line of policy to feel the pressure building beneath it. We already know the script. We’ve lived it.

But it’s not just cognitive. It’s bodily. Sensory. Autistic people process the world through a finely attuned radar—internal and external. Feldman et al. (2020) and Proff et al. (2021) both show how sensory responsiveness is tightly interwoven with how we process threat, rhythm, safety, and disruption. It’s not about being overwhelmed by noise—it’s about detecting what others miss. The slight shift in tone. The friction in a room. The policy that doesn’t say what it means. This kind of perception is often dismissed as oversensitivity. But it’s nothing of the sort. It’s signal clarity in a noisy world.

And that clarity comes at a cost. Because to name the pattern is to break the spell. And systems don’t reward that. We are called paranoid. Rigid. Alarmist. We are told we’re reading too much into things. That we’re too anxious, too activated, too “online.” But what we are—what we always have been—is accurate. Ruggieri (2025) links this persistent clarity to burnout: the price of never being allowed to look away. Leekam et al. (2007) show how ongoing sensory and cognitive pressure makes social participation exhausting—not because we don’t care, but because we care enough to keep noticing.

Still, this perception—this pattern-recognition, this liminal clarity—is not just burden. It is power. It’s what allows us to track shifts before they’re named. To recognise harm even when it wears the clothes of help. Baron-Cohen et al. (2009) argue that this systemising ability enables strengths in ethics, art, and analysis. Crespi (2021) reframes it not as deficit but as divergent intelligence. And I would add: as prophecy. Not in the mystical sense, but in the literal one—we see what is coming because we recognise what has already been. We don’t need to be convinced something is wrong. We felt it before you did.

So yes, we see it coming. Not because we want to. Not because we’re predisposed to fear. But because our minds move in circles that systems tried to make into lines. And we’ve spent years following those loops—not getting lost, but getting wise. Pattern doesn’t just explain our world. It prepares us to challenge it.

Sovereignty, Not Diagnosis, Is the Threat

This was never about diagnosis. Not really. Diagnosis is the tool, not the aim. The aim is to challenge the idea that a young person could know themselves—without permission, without delay, without explanation. That is the threat. Not confusion, but clarity. Not disorder, but sovereignty.

Because what’s being tested here isn’t mental health. It’s legitimacy. It’s the right to define oneself without first having to be dismantled, dissected, doubted. The NHS proposal doesn’t seek to understand these youth—it seeks to qualify them. It treats identity not as something lived and embodied, but as a claim that must pass inspection. A permit to be issued only after rigorous review. And those of us who live at these intersections—autistic, trans, gender expansive—we already know what that process looks like. It’s not care. It’s containment.

There’s a particular cruelty in the way it’s framed. Wrapped in language about safety, about thoroughness, about making sure nothing is missed. But what gets missed in that framing is the youth themselves. The knowing they carry. The truths they already hold. The systems would rather trust a checklist than a child. They would rather delay care than admit that certainty can exist outside their models. And when they encounter someone who does not bend to those models—who moves with clarity rather than compliance—the response is to diagnose, defer, and discredit.

But the truth is simple. Trans youth do not need to be scrutinised to be supported. They do not need to be dissected to be heard. They do not need to be tested for autism to have their gender affirmed. What they need is space. Safety. Trust. What they need is not more hoops, but fewer. Not more doubt, but recognition. Not pathology, but presence.

Because it is not diagnosis that scares the system. It is sovereignty. It is the young person who walks in and says, “This is who I am,” and means it. It is the refusal to ask for permission. The refusal to collapse into someone else’s narrative. That is what threatens power. And that is why, again and again, it responds not with listening—but with labels.

But we see it. And we name it. Because no matter how they try to dress it up, scrutiny is not support. Delay is not protection. And sovereignty is not a disorder. It is a right.

Final thoughts …

She returns, as she always does—not to plead, but to unmask. Not to argue for her place, but to remind the world it was never theirs to gatekeep. The sovereign doesn’t come seeking approval. She comes with the storm, with the frost, with the knowing. And this time, she wears the face of the unclassifiable. The autistic trans femme who does not fit the frame, who does not follow the script, who cannot be neatly filed away in a system built on legibility.

We are not new. We are not anomalies. We are not some modern crisis to be solved. We are the return. The resurfacing of truths older than the structures trying to erase us. Our presence is not the rupture—it is the reckoning. We are what was buried. What was warned against. What was named too rarely, too carefully, because to name us was to name the fragility of the world they built. We do not break their categories. We show that they were brittle to begin with.

And so we must stay awake. Vigilant. Not just for ourselves, but for those coming next. Because the language of care is clever. It speaks softly. It offers concern. It asks only for “assessment,” for “readiness,” for “clarity”—but what it delivers is control. And if we are not careful, we will be told that our erasure is for our own good. That our delay is protection. That our doubt is health.

But we know better. We’ve always known better. Not because someone taught us, but because our bodies remembered. Because our senses caught the signal beneath the noise. Because our minds moved differently—and so we saw differently.

So we return. Not with a petition. Not with proof. But with presence. With pattern. With stories that do not resolve, and truths that do not ask to be believed. We are not here to pass your test. We are here to show that the test itself was never just. And when we do, the system will call us disruptive. Difficult. Dangerous. But we have been all those things before. And still, we remain.