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

• 2013年12月から2017年6月にWestmeadのジェンダーサービスに紹介された70人の子どものうち57人が、学童向けと年長の10代向けに設計された版を用いた、愛着についての構造化面接に参加しました。
• 性別への苦痛のある子どもは、同じ年齢・性別の地域の子ども57人とは違って、大半がリスクの高い愛着と分類されました。典型的で健康的なパターンを示したのは8人（14%）だけでした。この差は、偶然とするには大きすぎるものでした。
• 彼らはまた、地域の子どもよりもはるかに多くの未解決の喪失やトラウマを抱えていました。
• 彼らの愛着のパターンと未解決の喪失やトラウマの割合は、さまざまなメンタルヘルスの問題のある子ども51人と違いがありませんでした。
• 57人中50人（88%）に他のメンタルヘルスの診断があり、日常の機能は損なわれていて、平均して100点中約55点でした。
• 性別を理由に紹介された子どもは、虐待、ネグレクト、家族の崩壊などの子ども時代のつらい経験が平均5.5件あり、地域の子どもでは1.7件でした。生みの親の両方と暮らしていたのは35%だけで、地域の子どもでは75%でした。
• 低い家庭の収入や地位、従来とは異なる家族の形、虐待やネグレクトを含むつらい経験は、リスクの高い愛着と関連していました。

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.