Pedagogical Approach of Students with Intellectual Disability and Gender Dysphoria

Gender dysphoria (GD) in adolescents refers to the discomfort expressed due to the incongruence between social and biological gender identity. Scientific research primarily focuses on individuals with Autism Spectrum Disorder (ASD), while studies regarding Intellectual Disability (ID) are limited. The methodology in this research pertains to a case study of a female student with ID and GD. The results highlight deficits in emotional organization skills related to the neurodevelopmental domain. The conclusions emphasize the need for personalized educational programs to help students with ID and GD express their emotions, display interest in learning, and cooperate with school personnel.

Introduction

The prevalence of diagnosed Gender Dysphoria (GD) is 1:10,000 to 2:20,000 in men and 1:30,000 to 1:50,000 in women (Van Der Miesenet al., 2018; Zucker & Lawrence, 2009). Historically, the dominant population with GD has been male adults. However, in recent years, the largest population group with DF is children and, more specifically, adolescent girls (La Malfaet al., 2004). According to Spiliadis (2023), to shift this ratio, factors such as the sexualization of girls in the patriarchal context or girls’ relationship with their bodies need to be explored.

The concept of gender is a complex term and may be confusing for adolescents whose bodies, like their brains, are undergoing changes (La Malfaet al., 2004). Biological sex is defined as a combination of characteristics such as chromosomes, hormones, and internal and external reproductive organs. This differs from gender identity, which is a person’s subjective sense of their own gender as male, female, or another gender. Gender expression is how a person presents themselves through the style of dress and behavior, while sexual orientation refers to emotional and sexual attraction to people of either the opposite sex, the same sex, or more than one gender (Janssen & Busa, 2018; Theofilopoulos & Paganis, 2019).

Individuals experiencing a discrepancy between biological sex and gender identity experience intense stress, and it is not surprising that transgender adolescents often experience high rates of mental health problems (Janssen & Busa, 2018).

According to Øienet al. (2018), in recent years, more emphasis has been placed by researchers on understanding gender identity issues in “marginalized” populations that share this experience and the right to express themselves freely. Such groups include people with Autism Spectrum Disorder (ASD) or Intellectual Disability (ID), who face challenges, including the right to express their sexuality (Brown & McCann, 2018).

Clare (2021) emphasizes that people with ID who belong to the LGBTQI (Lesbian, Gay, Bisexual, Trans, Queer, Intersex) community experience double marginalization. They are treated by society as a “minority within another minority.” Despite significant changes in state policy over the past thirty years with deinstitutionalization, according to the social model of disability, the extent to which people with ID have control over their lives and the opportunity to realize their potential and rights remains questionable, including the expression of their sexuality (Brown & McCann, 2018). Historically, there has been a tendency to view them as “children” without a sexual aspect or expression (Richards & Barrett, 2021). Therefore, this issue needs to be approached from a people-centred perspective, placing the rights, choices, and voices of these individuals at the center of developments in health, social care, and education (Brown & McCann, 2018; Drossinou-Korea, 2016).

The research community may not be able to identify the number of students with special educational needs (SEN) and GD, but educators need to recognize that this population exists in order to meet their learning and psychosocial needs in the school environment (Clare, 2021).

The present research studies students with SEN and GD in a special education and training (SEE) school. Through the methodology of observation of special educational needs (Avramidis & Kalyva, 2006; Drossinou-Korea, 2017), the skills of specific students in the area of emotional organization are investigated in order to design individualized teaching interventions so that students express self-emotion linguistically show interest in learning and understand rules of cooperation with their classmates.

Intellectual Disability

The term “intellectual disability” refers to the revision of two major classifications of mental disorders (Harris & Greenspan, 2016). In Diagnostic and Statistical Manual of Mental Disorders (DSM-V), the term “intellectual disability” or “intellectual developmental disorder” is attributed and refers to the disorder that begins during the developmental period of the individual and includes deficits that present individuals in cognitive abilities (such as reasoning skills, problem-solving, planning, abstract thinking, judgment, academic and experiential learning) and adaptive behaviors, regarding how individuals function and solve everyday problems in three skill areas, such as perceptual skills, social and practical skills (American Psychiatric Association, 2013).

Also, the 11^th edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) refers to intellectual disability as “disorders of intellectual development” (WHO, 2023).

Gender Dysphoria

“Gender dysphoria” or “gender discrepancy” (according to the World Health Organization) refers to the “discomfort” experienced by individuals due to a significant discrepancy and mismatch between the gender they self-identify with and the gender they identify with were born (American Psychiatric Association, 2013). With the compared term, the discomfort is approached as the clinical problem and not the identity as such, as was the case with the previous term “gender identity disorder” (American Psychiatric Association, 2013). This change is cited in the literature as an important milestone for social recognition, destigmatization, and acceptance of the gender-diverse population (Bonifacio & Rosenthal, 2015).

Children and adolescents may be diagnosed with GD if they experience distress and stress for at least six months and exhibit characteristics such as a strong desire to belong to or identify with a different gender. Also, they tend to want to get rid of their primary and secondary sexual characteristics, rejecting clothing and toys or activities that are “related” to their gender. They dislike their sexual anatomy when their body changes during puberty and prefer to acquire characteristics of the opposite sex. They choose friends of the opposite sex and want to be treated as such in the community they live in while expressing a strong belief that their feelings and reactions are identified with the opposite sex (American Psychiatric Association, 2013).

According to DSM V, girls may claim to be boys or wish to grow up to be boys. They ask to be called by a boy’s name, and there is a chance that they will refuse to attend school or social events. Sports or rough play are more often preferred, and they estimate that growing up, they will end up with the gender they identify with. The above symptoms make their functionality weak in a school environment. Finally, there is a risk that they become socially isolated or experience depression, low self-esteem, and suicidal tendencies (American Psychiatric Association, 2013).

Emotional Organization

Emotional organization is one of the neurodevelopmental areas of learning readiness, as defined by the Special Education Analytical Program Framework (Ministry of National Education and Religious Pedagogical Institute, 2009) in Greece. It is related to the self-esteem of students with SEN, their interest in learning, and their cooperation with others. The ideas they have about themselves, the acceptance or not of any problems, and the acceptance or not of other persons greatly influence the development of their personality, as well as the type and degree of their social adaptation (Drossinou-Korea, 2017).

More specifically, self-esteem refers to the emotional side of the self-view and is expressed positively as a positive self-image and negatively as a feeling of inferiority. The SEN teacher is called upon to assess students with ID and plan activities aimed at accepting their failure, dealing with their problems, presenting a good self-image, and recognizing their success (Drossinou-Korea, 2017). Regarding the interest in learning, the presence or absence of interest affects the emotional organization of students with GD. Interest enhances their attention. In the design of teaching programs, which focus on the interest in learning, the activities aim to cultivate skills that refer both to the cognitive interests of the individual and to his emotional needs (Christakis, 2011). Finally, cooperation with others refers to the establishment of social contacts and the acquisition of social skills, with an emphasis on teaching strategies that help students with AN in the social understanding of their interpersonal relationships with the aim of their socialization. Their cooperation with others is cultivated with activities aimed at understanding and accepting the rules of cooperation (Drossinou-Korea, 2017).

Gender Dysphoria and Disability

Few research studies have been conducted regarding the coexistence of gender dysphoria (GD) and disability. Most of these involve adolescents and adults with Autism Spectrum Disorder (ASD) (Warrieret al., 2020). In a study, it was found that children with ASD are four times more likely to present GD compared to children without ASD (Hisle-Gormanet al., 2019). Warrieret al. (2020) examined rates of ASD in transgender individuals. In their research, they found that ASD is 3 to 6 times more common in them than in non-transgender people.

Furthermore, surveys in Europe and America have shown that a significant percentage of people who enter Gender Identity services are diagnosed with ASD. More specifically, Shumeret al. (2016) investigated the percentages of people with DF and Asperger syndrome. In 23% of the sample, with an average age of 15.8 years, ASD and GD coexisted. Similarly, the prevalence of individuals with ASD and GD is increasing, according to research by Heylenset al. (2018), since 6% of adult participants with GD were found to have ASD symptoms. However, it is still not clear why this coexistence is common. Van Der Miesen, Hurley, and De Vries state that much more needs to be understood about the ways in which the difficulties (e.g., social communication, thinking, isolation) experienced by individuals with ASD correspond to those of individuals with GD (Van Der Miesenet al., 2018).

In contrast, with studies examining the comorbidity between ASD and GD, research in individuals with ID is limited and, in the majority, investigates GD when it coexists with ASD in individuals with GD (Bevan & Laws, 2019). Although they are considered different disorders, they often coexist. La Malfa et al. found that 40% of individuals with GD have features of ASD, and 70% of individuals with ASD have symptoms of ID (La Malfaet al., 2004). Taking into account the increasing rate of diagnosis of people with ASD and GD, research has been carried out in recent years regarding GD, which appears in people with ASD and ID (Walker & Walton, 2023).

Walker and Walton conducted a systematic review of the research literature in order to present current knowledge about the presentation of GD in individuals with ASD and ID (Walker & Walton, 2023). They systematically searched online databases for articles from 1984 to 2021. From a total of 149 articles, 4 case studies, 2 cross-sectional studies, and 4 systematic article reviews were included in their search. Based on their conclusions, GD occurs in individuals with ASD and ID, in whom it can lead to distress, anxiety, subsequent self-injury, or even suicide. Williams, Allard, and Sears examined 5 case studies of individuals with ASD, ID, and GD, with a mean age of 12.8 years, and found that this sample exhibited common gender expression behaviors (e.g., specific clothing appearance) and showed from young age indifference to activities defined by their biological sex. Furthermore, three out of five participants exhibited genital disgust, and two reported self-injury or suicidal thoughts (Williamset al., 1996).

Regarding those with ID and GD, some studies suggest that DF may be more common in people with ID compared to people without ID. However, prevalence estimates are based on a small sample, preventing any type of documentation (Bedardet al., 2010).

The scientific literature presents a number of possible reasons why people with ID engage in issues related to their gender, such as (Bevan & Laws, 2019): a means of escape from their life or disability, a way of managing their anger, lack of relationship fulfillment and internal conflict arising from their non-heterosexuality. Furthermore, GD in individuals with ID may be affected by their delayed psychosocial development, cognitive deficits, and reduced learning opportunities (Parkeset al., 2009; Wood & Halder, 2014). Finally, it is unlikely to occur in individuals with ID who are non-verbal, given that the criteria are based on the ability to primarily verbally express distress relative to their gender (Drossinou-Korea, 2020).

During the evaluation and treatment process of people with ID and GD, effective communication is vital. An important part of assessment and therapeutic intervention for people with ID involves helping someone explore their gender identity by thinking and talking about it. People may need safety to express themselves without fear of being ridiculed. According to Bedardet al. (2010), people with ID and GD need to have opportunities to express and explore themselves. Through language communication, they explain their experiences, sexuality, concerns, interests, and feelings (Drossinou-Korea, 2017).

Clare studied how schools support students with SEN and GD. More specifically, the purpose of the study was to investigate SEN teachers’ knowledge of school support for students with LD and GD. In the results of her research, it is stated that in school environments, due to discrimination and harassment, these students show limited academic achievements and low self-esteem. It is also pointed out that further training is needed on the part of teachers so that they better understand how to discuss issues of the LGBTI community. The researcher emphasizes that future studies need to project more voices and experiences of specific students and intervention strategies in order to create an inclusive learning environment (Clare, 2021).

Research Purpose

The limited research data on students with SEN and GD led to the present research being conducted. Its purpose is twofold and emerges from the scientific literature, which focuses on the emotional effects presented by people with ID and GD but also highlights the lack of information on the part of the educational community about issues related to disability and gender identity. Therefore, the research questions are as follows:

a) What emotional organization skills do students with SEN and GD display in secondary education?

b) How can the SEN teacher-philologist intervene in order to approach the specific issue pedagogically?

Methodology

A case study is considered in this research. According to Avramidis and Kalyva (2006), this particular methodology is utilized as it allows for a thorough study of disability. Still, it is considered widespread in the research field of SEN, as it is difficult to collect a sample.

Case Study

She is a 13-year-old student (N = 1) who attends the first grade of a special high school in a Greek urban area. According to the diagnosis by the relevant Center for Interdisciplinary Assessment and Counseling Support (CIACS), the student presents a mild intellectual disability (ID) with obvious characteristics that refer to Gender Dysphoria (GD). The student belongs to a family of four. The parents seem to not provide the required care and neglect the student. In terms of learning skills, the student has a limited vocabulary with some speech articulation difficulties and expressive errors. He also has difficulty focusing on a topic of conversation. Her handwriting is illegible. She follows a slow reading pace with several errors in decoding words, while her reading comprehension is characterized as weak.

Research Tools

In the present research, an informal pedagogical assessment was applied with Basic Skills Checklists (BAC) concerning the neurodevelopmental areas of learning readiness, such as oral language, psychomotor skills, mental abilities, and emotional organization. Also, the student’s written documents and didactic interaction forms, in which the SEN researcher-educator recorded his pedagogical reflection, were used to collect qualitative data.

Research Process

The researcher-educator initially made a systematic empirical observation to record the individual, school, and family history of the student. He then conducted an informal pedagogical assessment by completing the BASs and taking notes through his peer and self-observations in the Teaching Interaction Forms, taking into account the written documents of the sample.

The qualitative data, after 12 weeks of observation (8 hours/week), were tabulated in an Excel file. For the needs of this study, the data from the excel table were displayed in a graph (Fig. 1). The horizontal lines of the table recorded the skills of each neurodevelopmental area related to learning readiness. The vertical lines show the semesters of education according to standard education. In Greece the standard education of students includes 2 years in kindergarten (4 semesters), 6 years in Primary School (12 semesters), 3 years in Middle School (6 semesters) and 3 years in High School (6 semesters). Therefore, on the vertical lines of the graph, they are recorded in an ascending scale from the number 1 corresponding to the 1^st semester of the formal education in kindergarten to the number 15^th semester of the formal education of the sixth grade corresponding to the school and chronological age of the student (1^st grade of Middle School, 1^st semester = 15^th semester of study). A horizontal solid line (red line), the “baseline,” intersected the horizontal lines indicating the student’s current semester of study according to her chronological and school age (1^st grade of Middle School, 1^st semester = 15^th semester of study) (Table I). The researcher-educator of special education noted the semester of education where he estimates that it corresponds to the level of achievement of each skill. When this process was completed, a checkered line (blue line) was created showing the student’s highest and lowest deviation from the baseline (Drossinou-Korea, 2017). Finally, the results were described, and conclusions were drawn.

Fig. 1. Initial assessment of learning readiness (N = 1, age = 13, didactic priority: emotional organization).

Table I. Basic Skills Checklist of Emotional Organization

1. Self-esteem	Baseline skill	Levels/Semester of study
She expresses her difficulties	15th semester of study
She knows and accepts her difficulties
She knows and faces her difficulties
She knows and expresses her feelings
She understands rules of cooperation to deal with her difficulties
Knows and understands rules of personal care showing a good image to others
Understands rules and applies them to participate in school events in order to  present a good image to others
Understands rules to accept others (girls, boys, teachers)
Understands and expresses emotions when successful (joy, excitement)
Understands and expresses feelings when he fails (anger, irritation, crying)
2. Interest in learning	Baseline skill	Levels/Semester of study
She is verbal about her interests	15th semester of study
She reads and understands texts that interest her
Seeks and understands information about new interests
She expresses himself verbally when he has questions
She understands rules for how to maintain her interest in learning
She learns new things by meeting emotional needs
She keeps her attention on what interests her
3. Collaboration with others	Baseline skill	Levels/Semester of study
Understands and applies rules of behavior within the classroom	15th semester of study
Understands and applies rules of behavior outside the classroom
Understands and applies rules of cooperation with classmates and adults
Understands and applies rules for developing and maintaining relationships
Expresses himself with appropriate vocabulary when cooperating
She understands and applies rules to improve her cooperation with others
She is verbal when she needs to point out her mistakes
She verbalizes her mistakes when cooperating
Verbalizes when help is needed

Results

The student presents several deviations from her school and chronological age in learning readiness skills (Fig. 1). In oral language, a greater deviation from the baseline (15^th semester of study) was recorded in the area of “clear and precise expression” (7^th semester of study = 3^rd grade of Primary School, 1^st semester). He presents a better image in the area of listening (12^th semester of study = 5^th grade of Primary School, 2^nd semester). Regarding the psychomotor area, it is noted that the student shows lower performance, since the gross and mainly fine motor skills correspond to the 5^th semester of study (2^nd grade of Primary School, 1^st semester). In the area of mental abilities, the auditory memory of the sample shows an improved picture, as the performances correspond to the 11^th semester of study (5^th grade of Primary School, 1^st semester). However, there was an 11-semester deviation from baseline in “attention”. In the area of emotional organization, the lowest performance rates for the student are observed since in skills related to “self-feeling” and “cooperation with others,” the line of variation was recorded in the 3^rd semester of study (1^st grade of Primary School, 1^st semester).

The low performance of the student in the neurodevelopmental area of emotional organization is reflected in the written documents and in the printed interactive teaching materials. Regarding self-esteem, the student does not particularly take care of her image. She treats herself “as a bit of a girl,” as she tells her friends. He mostly wears baggy sports clothes. He does not participate in school events where boys and girls dress differently (e.g., parades and school parties). He is afraid of the dark, and when asked, “How does he feel?” “Dude,” he replies. According to the reports, the student challenges the students to engage in fights with her to show her dynamic superiority. However, when he “loses,” he bursts into tears and claims: “Lord, it’s not fair for me to lose!” She seems not to recognize and accept her failure and the difficulties she encounters. When she feels that she has failed, she loses control and slams her hands on the desk in an abusive manner.

In terms of interest in learning, interests are limited. In the classroom, the student mainly wants to talk about gender and sexuality issues, which she wants to discuss with people she trusts (e.g., a teacher). In her spare time, she watches pornographic films. Her favorite actress is Jenna Ortega, whom she expressed a desire to marry (Student: Sir, write the name Jenna Ortega on the board. I don’t know how to spell it. I want to marry her! Is it bad? I don’t want you to tell anyone!). When he wants to paint, he mainly draws male figures, emphasizing the masculine element. When you feel safe (e.g., with the teacher), express sexual preferences (e.g., Students are asked to write a sentence with the word “love”. The student writes: I love my bitch! After the teacher marks for the vocabulary, s/he renders the sentence as follows: I love my girlfriend!

Regarding cooperation skills, the student often disrupts the smooth classroom climate as she exhibits intense mobility and a lack of concentration. She reports exclusion from her classmates and is often involved in fights during breaks. Uses sexually abusive words in front of classmates and teachers belittling them (Student: Blimey, sir! Why do all the men (teachers) at school have arms!). He wishes to have the role of leader in games. She mainly plays with boys and engages in stereotypically male activities such as football, bras de fer [Student: I like to throw bouquets, like X. (classmate)]. Sometimes, she approaches her classmates, on whom she feels she can impose herself, with the intention of kissing them on the cheek (Teacher: “What do you love?” Student: “the kiss!”). Also, regarding the partnerships she develops, she makes her sexual preferences clear to others, especially when she confides in them (Student: Sir, don’t call us boys and girls, but by our names!). Also, the student, in the future, in social situations, wishes not to be called by her real name but by a different name, mostly given to boys [Student: I want to be an actress in United States and be called “Alex” (male name)] (Fig. 2).

Fig. 2. The student has drawn herself with the name she wants to be called (Axel instead of Alex).

Conclusion and Discussion

Conducting the present case study was undertaken to confirm that students with ID can experience and express emotions indicative of GD (Walker & Walton, 2023). Teachers who come into contact with students with this diagnosis need to be aware of GD and consider it as a possible diagnosis (Wood & Halder, 2014). The present research highlights that students with ID and GD present difficulties in their emotional organization and this is also made clear by the scientific literature, as this population group presents social difficulties, reduced self-esteem, academic difficulties, anxiety and distress (Bevan & Laws, 2019; Coleman-Smithet al., 2020).

SEN teachers have the possibility to approach issues of emotional organization pedagogically by applying informal pedagogical assessment with some Basic Skills Checklists (Table I). By building trust with the student community, they can intervene so that students with SEN and GD verbalize feelings and thoughts related to gender nonconformity. SEN philologists by designing targeted individually structured inclusion programs of special education and education are able to set goals for the cultivation of language skills, so that the students in question express their sense of self, discover new interests through the learning process and understand rules of behavior to cooperate with the persons of the school. According to Walker and Walton, people with GD may have a limited vocabulary or lack the opportunity to articulate thoughts and feelings about their gender (Walker & Walton, 2023). In research by Drossinou-Korea and Panopoulos (2018), deficits in social skills are one of the criteria taken into account to determine GD. Social skills related to the sexual behavior of people with ID affect their inclusion in the school community. Understanding social stories and using correct vocabulary in students’ interpersonal relationships appear to control the sexual and social behavior of students with GD. The unclear and incomplete information of the school community about sexuality puts students with GD at risk of social exclusion by reducing their chances of social interaction with their peers.

Research Limitations

This research refers to a case study. Internationally, research investigating the issue of disability and gender dysphoria is limited and mainly case studies. Therefore, more studies are needed to confirm what was supported in our research results. In the future, action research could be carried out by teachers in order to cultivate language skills in students with ID and GD to express what they feel about their sexuality.