Summary

Clinicians at the Children's Hospital at Westmead in Sydney interviewed 57 children and teens referred for gender distress. The interviews measured attachment, meaning how a child bonds with and relies on carers, and were scored by coders who did not know which group the child was in. Compared with matched children from the community, the gender-referred children were far more likely to show 'at-risk' attachment and unresolved loss or trauma. They had more hard childhood experiences such as abuse or family breakdown (5.5 vs 1.7 on average), and only 35% lived with both birth parents. Their attachment patterns looked the same as those of children referred for other mental health problems. The authors call for assessment of the whole child and family. The study cannot show that attachment problems cause gender distress, and it comes from one clinic using a specialised scoring system.

Key findings

• 57 מתוך 70 ילדים שהופנו לשירות המגדר Westmead בין דצמבר 2013 ליוני 2017 השתתפו בראיונות מובנים על התקשרות, בגרסאות שתוכננו לילדי בית ספר ולבני נוער מבוגרים יותר.
• ילדים עם מצוקה מגדרית סווגו ברובם כבעלי התקשרות בסיכון גבוה, בניגוד ל-57 ילדי קהילה מאותו גיל ומין. רק 8 (14%) הראו דפוסים אופייניים ובריאים. ההבדל היה גדול מדי מכדי להיות מקרי.
• היה להם גם הרבה יותר אובדן או טראומה לא פתורים מאשר לילדי הקהילה.
• דפוסי ההתקשרות שלהם ושיעורי האובדן או הטראומה הלא פתורים לא היו שונים מאלה של 51 ילדים עם בעיות בריאות נפשית שונות.
• ל-50 מתוך 57 (88%) היו אבחנות בריאות נפשית אחרות, והתפקוד היומיומי שלהם היה לקוי, עם ציון של כ-55 מתוך 100 בממוצע.
• לילדים שהופנו בגלל מגדר היו בממוצע 5.5 חוויות ילדות קשות, כמו התעללות, הזנחה או התפרקות משפחה, לעומת 1.7 בילדי קהילה. רק 35% חיו עם שני ההורים הביולוגיים, לעומת 75%.
• הכנסה ומעמד משפחתיים נמוכים יותר, מבנה משפחתי לא מסורתי וחוויות קשות כולל התעללות או הזנחה נקשרו להתקשרות בסיכון גבוה.

Abstract

The current study examines patterns of attachment/self-protective strategies and rates of unresolved loss/trauma in children and adolescents presenting to a multidisciplinary gender service. Fifty-seven children and adolescents (8.42-15.92 years; 24 birth-assigned males and 33 birth-assigned females) presenting with gender dysphoria participated in structured attachment interviews coded using dynamic-maturational model (DMM) discourse analysis. The children with gender dysphoria were compared to age- and sex-matched children from the community (non-clinical group) and a group of school-age children with mixed psychiatric disorders (mixed psychiatric group). Information about adverse childhood experiences (ACEs), mental health diagnoses, and global level of functioning was also collected. In contrast to children in the non-clinical group, who were classified primarily into the normative attachment patterns (A1-2, B1-5, and C1-2) and who had low rates of unresolved loss/trauma, children with gender dysphoria were mostly classified into the high-risk attachment patterns (A3-4, A5-6, C3-4, C5-6, and A/C) (χ2 = 52.66; p < 0.001) and had a high rate of unresolved loss/trauma (χ2 = 18.64; p < 0.001). Comorbid psychiatric diagnoses (n = 50; 87.7%) and a history of self-harm, suicidal ideation, or symptoms of distress were also common. Global level of functioning was impaired (range 25-95/100; mean = 54.88; SD = 15.40; median = 55.00). There were no differences between children with gender dysphoria and children with mixed psychiatric disorders on attachment patterns (χ2 = 2.43; p = 0.30) and rates of unresolved loss and trauma (χ2 = 0.70; p = 0.40). Post hoc analyses showed that lower SES, family constellation (a non-traditional family unit), ACEs-including maltreatment (physical abuse, sexual abuse, emotional abuse, neglect, and exposure to domestic violence)-increased the likelihood of the child being classified into a high risk attachment pattern. Akin to children with other forms of psychological distress, children with gender dysphoria present in the context of multiple interacting risk factors that include at-risk attachment, unresolved loss/trauma, family conflict and loss of family cohesion, and exposure to multiple ACEs.

Conclusion

Akin to children with other forms of psychological distress, children with gender dysphoria present in the context of multiple interacting risk factors that include at-risk attachment, unresolved loss/trauma, family conflict and loss of family cohesion, and exposure to multiple ACEs. The authors conclude that gender dysphoria in children arises in association with developmental pathways shaped by disruptions to family stability, adverse experiences and socioeconomic status, and that treatment requires a comprehensive biopsychosocial assessment of the child and family, followed by interventions addressing the breadth of interconnected factors.