Pedagogical Approach of Students with Intellectual Disability and Gender Dysphoria
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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 11th 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 1st semester of the formal education in kindergarten to the number 15th semester of the formal education of the sixth grade corresponding to the school and chronological age of the student (1st grade of Middle School, 1st semester = 15th 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 (1st grade of Middle School, 1st semester = 15th 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.
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 (15th semester of study) was recorded in the area of “clear and precise expression” (7th semester of study = 3rd grade of Primary School, 1st semester). He presents a better image in the area of listening (12th semester of study = 5th grade of Primary School, 2nd 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 5th semester of study (2nd grade of Primary School, 1st semester). In the area of mental abilities, the auditory memory of the sample shows an improved picture, as the performances correspond to the 11th semester of study (5th grade of Primary School, 1st 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 3rd semester of study (1st grade of Primary School, 1st 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).
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.
References
-
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM V) (5th ed.). American Psychiatric Publishing.
Google Scholar
1
-
Avramidis, H., & Kalyva, E. (2006). Research methods in special education. Theory and applications. Papazisis [in Greek].
Google Scholar
2
-
Bedard, C., Zhang, H., & Zucker, K. (2010). Gender identity and sexual orientation in people with developmental disabilities. Sexuality and Disability, 28(3), 165-175. https://doi.org/10.1007/s11195-010-9155-7
Google Scholar
3
-
Bevan, R., & Laws, A. (2019). Gender Dysphoria and People with Intellectual Disability. University of Hertfordshire. http://www.intellectualdisability.info/mental-health/articles/gender-dysphoria-and-people-with-intellectual-disability
Google Scholar
4
-
Bonifacio, H., & Rosenthal, S. (2015). Gender Variance and Dysphori in Children and Adolescents. Pediatric Clinics of North America, 62(4), 1001–1016. https://doi.org/10.1016/j.pcl.2015.04.013
Google Scholar
5
-
Brown, M., & McCann, E. (2018). Sexuality issues and the voices of adults with intellectual disabilities: A systematic review of the literature. Research in Developmental Disabilities, 74, 124-138. https://doi.org/10.1016/j.ridd.2018.01.009
Google Scholar
6
-
Christakis, K. (2011). Behavioral problems at school age. Assessment-Prevention-Record-Treatment. Diadrasi [in Greek].
Google Scholar
7
-
Clare, J. (2021). Including All Students: Supporting Adolescents with Intellectual Disabilities Who Are Gender Nonconforming. [Doctoral dissertation] University of the Pacific.
Google Scholar
8
-
Coleman-Smith, R. S., Smith, R., Milne, E., & Thompson, A. R. (2020). Conflict versus Congruence: A Qualitative Study Exploring the Experience of Gender Dysphoria for Adults with Autism Spectrum Disorder. Journal of Autism and Developmental Disorders, 50(8), 2643–2657. https://doi.org/10.1007/s10803-019-04296-3
Google Scholar
9
-
Drossinou-Korea, M. (2016). Human-centered model and special educational services for children and youth with cognitive, social, emotional difficulties and behavioral problems. In A. D. Markantonatos (Ed.), Scientific yearbook, University of Peloponnese, Faculty of Humanities and Cultural Studies (pp.221-241). Herodotus [in Greek].
Google Scholar
10
-
Drossinou-Korea, M. (2017). Special Education and Training. The “through” special education proposal for the education of children and young people with special needs. Opportuna [in Greek].
Google Scholar
11
-
Drossinou-Korea, M. (2020). Handbook of special education and education narratives. Opportuna [in Greek].
Google Scholar
12
-
Drossinou-Korea, M., & Panopoulos, N. (2018). Language skills for the sexual education in individuals with Intellectual disability, International Journal of Latest Research in Humanities and Social Science, 1(4), 67-76.
Google Scholar
13
-
Harris, J. C., & Greenspan, S. (2016). Definition and nature of intellectual disability . In N.N Singn (Ed.), Handbook of Evidence- Based Practices in Intellectual and Developmental Disabilities (pp. 11-39). Springer.
Google Scholar
14
-
Heylens, G., Aspeslagh, L., Dierickx, J., Baetens, K., Van Hoorde, B., De Cuypere, G., & Elaut, E. (2018). The co-occurrence of gender dysphoria and autism spectrum disorder in adults: An analysis of cross-sectional and clinical chart data. Journal of Autism and Developmental Disorders, 48, 2217-2223. https://doi.org/10.1007/s10803-018-3480-6
Google Scholar
15
-
Hisle-Gorman, E., Landis, C., Susi, A., Schvey, N., Gorman, G. G., Nylund, C., & Klein, D. (2019). Gender dysphoria in children with autism spectrum disorder. LGBT health, 6(3), 95-100. https://doi.org/10.1089/lgbt.2018.0252
Google Scholar
16
-
Janssen, A., & Busa, S. (2018). Gender dysphoria in childhood and adolescence. In Complex Disorders in Pediatric Psychiatry: A Clinician’s Guide (σσ. 1-10). Elsevier.
Google Scholar
17
-
La Malfa, G., Lassi, S., Bertelli, M., Salvini, R., & Placidi, G. F. (2004). Autism and intellectual disability: a study of prevalence on a sample of the Italian population. Journal of Intellectual Disability Research, 48(3), 262-267. https://doi.org/10.1111/j.1365-2788.2003.00567.x
Google Scholar
18
-
Ministry of National Education and Religious Pedagogical Institute. (2009). Methodological guidelines. In M. Drosinou Κorea (Ed.), Learning Readiness Activities. Speech Language, Psychomotor, Mental Abilities, Emotional Organization. Book for the Special Education teacher (pp. 28-40). Pedagogical Institute, Teaching Books Publishing Organization [in Greek].
Google Scholar
19
-
Øien, R., Cicchetti, D., & Nordahl-Hansen, A. (2018). Gender Dysphoria, Sexuality and Autism Spectrum Disorders: A Systematic Map Review. Journal of Autism and Developmental Disorders, 48(12), 4028–4037. https://doi.org/10.1007/s10803-018-3686-7
Google Scholar
20
-
Parkes, G., Hall, I., & Wilson, D. (2009). Cross dressing and gender dysphoria in people with learning disabilities: a descriptive study. British Journal of Learning Disabilities, 151-156(37), 151-156. https://doi.org/10.1111/j.1468-3156.2008.00538.x
Google Scholar
21
-
Richards, C., & Barrett, J. (2021). Trans and non-binary gender healthcare. Cambridge University Press.
Google Scholar
22
-
Shumer, D., Reisner, S., Edwards-Leeper, L., & Tishelman, A. (2016). Evaluation of Asperger syndrome in youth presenting to a gender dysphoria clinic. LGBT Health, 3(5), 387-390. https://doi.org/10.1089/lgbt.2015.0070
Google Scholar
23
-
Spiliadis, A. (2023). Gender dysphoria and gender nonconformity in adolescents and young adults: exploration or confirmation as therapeutic and clinical dilemmas. 8th Panhellenic Conference on Autism. Hellenic Scientific Network for Autism Spectrum Disorders.
Google Scholar
24
-
Theofilopoulos, T., & Paganis, F. (2019). The LGBT community and the media: a guide for media professionals. KMOP - Center for Social Action and Innovation & Color Youth LGBTQ Youth Community of Athens.
Google Scholar
25
-
Van Der Miesen, A., Hurley, H., & De Vries, A. (2018). Gender dysphoria and autism spectrum disorder: A narrative review. Gender Dysphoria and Gender Incongruence, 82-9. https://doi.org/10.3109/09540261.2015.1111199
Google Scholar
26
-
Walker, Ε., & Walton, C. (2023). Gender Dysphoria, Autism and Intellectual Disability: A Systematic Review. Review Journal of Autism and Developmental Disorders, 1-14. https://doi.org/10.1007/s40489-023-00365-7
Google Scholar
27
-
Warrier, V., Greenberg, D., M. Weir, E., Buckingham, C., Smith, P. P., Lai, M., Allison, C., & Baron-Cohen, S. (2020). Elevated rates of autism, other neurodevelopmental and psychiatric diagnoses, and autistic traits in transgender and gender-diverse individuals. Nature communications, 11(1), 1-12. https://doi.org/10.1038/s41467-020-17794-1
Google Scholar
28
-
WHO. (2023). The 11th revision of the international classification of diseases (ICD-11). World Health Organization. http://www.who.int/classifications/icd/revision/en/
Google Scholar
29
-
Williams, P., Allard, A., & Sears, L. (1996). Case study: Cross-gender preoccupations in two male children with autism. Journal of Autism and Developmental Disorders, 26(6), 635-642. https://doi.org/10.1007/BF02172352
Google Scholar
30
-
Wood, Ε., & Halder, Ν. (2014). Gender disorders in learning disability–a systematic review. Tizard Learning Disability Review, 19(4), 158-165. https://doi.org/10.1108/TLDR-01-2013-0004
Google Scholar
31
-
Zucker, K., & Lawrence, A. (2009). Epidemiology of gender identity disorder: Recommendations for the standards of care of the world professional association for transgender health. International Journal of Transgenderism, 11(1), 8–18. https://doi.org/10.1080/15532730902799946
Google Scholar
32