Diagnostic criteria for intellectual disability, borderline personality disorder, and gender dysphoria all emphasize functional impairments over simple trait descriptions (1). Individuals with intellectual disability have functional deficits in conceptual, social, and practical domains. Social deficits include difficulty perceiving and interpreting social cues with peers, problems with emotional regulation, and limited understanding of risk in social situations. As in the case of Ms. A, these individuals are at risk for being manipulated by others, especially in romantic relationships. The deficits in borderline personality disorder are similarly characterized by a defining pattern of instability of self-image, personal goals, interpersonal relationships, and affect, as well as impairment in domains of identity, self-direction, empathy, and intimacy (1). Individuals with gender dysphoria also experience internal conflict, distress, and varied psychiatric symptoms, in part as a result of the personal and societal stressors they face in understanding their situation.
Discussion
There can be significant overlap in presentation of individuals with combinations of gender dysphoria, intellectual disability, and borderline personality disorder (Figure 1). However, care is typically partitioned to service agencies focusing specifically on intellectual disability, mental health, or gender care. This type of segregated treatment can easily mistake symptoms of one condition for those of another. In the case of Ms. A, many of her childlike, developmentally consistent frustrations over her gender expression were treated as poor coping responses, consistent with borderline personality disorder. Subsequent treatment focused on her borderline personality disorder, without addressing her gender identity concerns. This segregation of diagnoses can create parallel systems that may force clients to choose between treatment for one condition over another. Ms. A often faced both group homes and inpatient psychiatric hospitals that housed clients by gender, creating sex-segregated barriers to care for her and other transgender clients.
Transgender individuals, even without the complexities of multiple diagnoses, face barriers when trying to access health care, including medical knowledge deficits; limitations in the availability of transition-related medical care; and health system discrimination. In a 2011 report on a national survey (2), 25% of transgender people surveyed reported having been harassed or disrespected in a doctor’s office or hospital, and 19% of transgender people reported having been refused medical care because they were transgender.
People with intellectual disability also frequently have difficulty accessing appropriate sexual and gender health care (3). Appropriate sexual expression has long been a source of potential conflict for persons with intellectual disability, especially those who live in highly structured settings (4). Individuals with intellectual disability often have lower sexual education, higher rates of sexual abuse, less understanding of sexual appropriateness, and delayed sexual and relational developmental milestones. These factors predispose them to escalating incidents of sexually acting out when they are not allowed appropriate venues to explore and express their sexuality (5). The risk of sexual vulnerability and issues of consent within relationships are important concerns within this population. Historically, these concerns often led to discouragement of any type of sexual expression. People with intellectual disability often face an environment that universally represses sexuality (6).
A person with both intellectual disability and open transgender identity currently has few opportunities for peer support or dedicated resources within the intellectual disability community. While suppression of gender or sexuality variances for someone with an intellectual disability may help them avoid some painful confrontations, this unacknowledged part of their identity can manifest in greater dependency as well as unsafe and undisclosed relationship behaviors that can leave the person open to victimization and suffering.
In the case of Ms. A, who consistently voiced her gender distress, her treatment team identified her need for appropriate gender treatment as part of her mental health care. Because of Ms. A and other transgender clients, the hospital initiated staff sensitivity training and reviews of gender policies to develop more transgender-sensitive care.
Conclusions
The case of Ms. A highlights the challenges and complexities in the formulation, treatment, and provision of services for individuals with combinations of intellectual development, mental health, and sexual and gender identity needs. Currently, there are growing resources for sexual and gender minorities, but these systems often do not routinely have collaborative treatment services for management of shared clients. Systems are more often prepared to deal with only one problem at a time. There are likely many people with gender dysphoria, intellectual disability, and mental health issues who will need transitional services as it becomes safer for them to publicly transition.
References
1.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed, DSM-5. Washington, DC, American Psychiatric Association, 2013
Grant JM, Mottet LA, Tanis J, et al: Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington, DC, National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011
O’Callaghan AC, Murphy GH: Sexual relationships in adults with intellectual disabilities: understanding the law. J Intellect Disabil Res 2007; 51:197–206
From the Department of Psychiatry and Behavioral Neuroscience, Saint Louis University, St. Louis; and the Department of Psychiatry and Behavioral Neuroscience, University of California Davis, Sacramento.
From the Department of Psychiatry and Behavioral Neuroscience, Saint Louis University, St. Louis; and the Department of Psychiatry and Behavioral Neuroscience, University of California Davis, Sacramento.
From the Department of Psychiatry and Behavioral Neuroscience, Saint Louis University, St. Louis; and the Department of Psychiatry and Behavioral Neuroscience, University of California Davis, Sacramento.
The authors report no financial relationships with commercial interests.
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