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

• 2013년 12월부터 2017년 6월 사이 웨스트미드 성별 서비스에 의뢰된 아동 70명 중 57명이 학령기 아동과 나이 든 청소년을 위해 설계된 버전으로 애착에 관한 구조화된 인터뷰에 참여했습니다.
• 성별 불쾌감이 있는 아동은 같은 나이와 성별의 지역사회 아동 57명과 달리 대부분 고위험 애착으로 분류되었습니다. 전형적이고 건강한 양상을 보인 아동은 8명(14%)뿐이었습니다. 차이는 우연이라고 하기에는 훨씬 컸습니다.
• 또한 지역사회 아동보다 해결되지 않은 상실이나 트라우마가 훨씬 많았습니다.
• 애착 양상과 해결되지 않은 상실 또는 트라우마의 비율은 다양한 정신 건강 문제가 있는 아동 51명과 다르지 않았습니다.
• 57명 중 50명(88%)이 다른 정신 건강 진단이 있었고, 일상 기능이 손상되어 평균 약 100점 만점에 55점이었습니다.
• 성별로 의뢰된 아동은 학대, 방임, 가족 붕괴 같은 어린 시절의 힘든 경험이 평균 5.5개로, 지역사회 아동의 1.7개와 비교됩니다. 친부모와 함께 사는 아동은 75%에 비해 35%뿐이었습니다.
• 낮은 가족 소득과 지위, 전통적이지 않은 가족 구성, 학대나 방임을 포함한 힘든 경험이 고위험 애착과 관련이 있었습니다.

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.