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

2. 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

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

4. 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.

5. 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.

6. 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

7. 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

8. 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.

9. 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.

10. 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)

11. 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

12. 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.

13. 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.

14. 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

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

16. 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

17. 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

18. 2 TF
1 escape anger be someone else
1 not enough info
2 unclear to themselves

19. 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

20. 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

21. 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