Gender Dysphoria and Intellectual Disability Dr Georgina Parkes Consultant Psychiatrist Welwyn and Hatfield

What is gender identity? Psychological concept of self as masculine or feminine regardless of anatomic sex. GENDER roles men and women play socially constructed not biologically determined. IDENTITY fact of person or thing as an unchanging property throughout existence. Flexible evolving concept throughout life

Commonly used terms Gender dysphoria gender identity disorder transsexualism primary secondary cross-dressing transvestite

DSM V Has its own chapter separate from sexual dysfunction and paraphillias. 1. Gender Dysphoria replaces Gender Identity Disorder Removing term disorder reducing stigma 2. separate criteria for children; adolescents and adults together.

DSM V continued 3. Symptoms present for >6 months 4. New categories of Other specified Gender Dysphoria And Unspecified Gender Dysphoria Replace GIDNOS Also new specifiers DSD/ living full time sexual orientation has been removed.

Gender identity disorder ICD(10) Classified under disorders of adult personality and behaviour. diagnostic guidelines are given for GID of childhood. Transexualism: present for>2 years exclusions

AETIOLOGY No universally accepted theory. Cultural differences: e.g. rates of previous marriage; New Zealand Biological: hypothalamus Zhou et al 1995 and LeVay 1991. Family Constellations Stoller 1968 Loss of attachment figure in early childhood

Aetiology continued Other trauma inc. abuse The earlier the trauma the more rigid the organisation of the atypical gender identity Parent’s wish for child of opposite gender. Most likely multifactorial rarity explained by need for number of factors to be present simultaneously at a critical period in development.

Aetiology in ID Case studies and case series have shown high rates of childhood sexual abuse Also sexual assault as an adult Difficulty coming to terms with sexual orientation which is seen as rigidity around gender roles (seen in children without ID age 3 to 5) therefore a developmental factor here.

Aetiology continued Seen as an escape/ anger control Wanting to become someone else to be more accepted by society Absence of fulfilling sexual relationship Associated with aggression in some case studies Higher prevalence in those with ASD (rigidity of gender roles)

Epidemiology Baird et al 1% Varies hugely averages out at around 1 in 18,000 Originally male to female ratios were thought to be 8:1, now some clinics 1:1. Higher rates in ID Higher rates in ASD

Gender dysphoria and ID prevalence Bedrad et al Surveyed 32 people with ID re sexual and gender identity 4 (12.5%) had gender dyphoria Unexpected finding Known to professionals for many years and only 1 had voiced this before.

ASD and gender dysphoria De Vries et al 2010 204 children Used DISCO on 26 suspected had ASD 16 confirmed (7.8%) Of those 2 had ID Mean IQ 82 in ASD group and 104 in Non ASD group.

ASD and gender Dysphoria Extreme male brain papers Trans men have significantly higher autistic traits on self report AQ than general population. Postulate unable to assimilate with females so drift towards male peer group and due to rigidity of thinking become gender dysphoric

No difference in AQ trans women BUT 6 (3%) of the 198 in the study were diagnosed with ASD already. Extreme male brain theory??

GID and Learning Disability Many case studies some with ASD An audit of referrals to GID unit Portman clinic 10 young people had learning disabilities. Parkes et al 2008 retrospective case notes review of 13 cross dressing to CONSENT 12 with ID. One ASD and borderline

Parkes et al 2008 continued 12 males, 1 female 62% (n=8) CSA 7 gender dysphoric: 3 met criteria for GID: 1 living full time 3 unhappy with being gay -seeking SRS 1 wanted to male and female at the same time

2 TF 1 escape anger be someone else 1 not enough info 2 unclear to themselves

GID in children rare more common in boys cross gender play/ clothes more acceptable in girls Developmental/ developmental lag in gender constancy Wishes of parents play a role 15% continue into adolescence to seek SRS Higher % than gen popn resolve in gay/lesbian

Conclusions Higher rates than in general population Higher rates in ASD Longer assessments, attention to assessment of developmental issues needed May need psycho education and information May need counselling to address abuse and assault issues

Conclusions cont Are seen frequently in Mainstream Gender clinics and given treatments- capacity and capability issues Need help to access main stream services and to support cross dressing, lifestyle Need help to develop personal identity