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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.
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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