Crianças com disforia de gênero tinham em geral apego de alto risco — como crianças com outros transtornos psiquiátricos

Padrões de apego em crianças e adolescentes com disforia de gênero

Estudos de coorte e registros Autismo, trauma e condições coexistentes

Authors: Kasia Kozlowska, Catherine Chudleigh, Georgia McClure, Ann M. Maguire, Geoffrey R. Ambler
Journal: Frontiers in Psychology
Year: 2021
Source: https://doi.org/10.3389/fpsyg.2020.582688

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 de 70 crianças encaminhadas ao serviço de gênero de Westmead entre dezembro de 2013 e junho de 2017 participaram de entrevistas estruturadas sobre apego, usando versões desenhadas para crianças em idade escolar e adolescentes mais velhos.
As crianças com sofrimento de gênero foram em sua maioria classificadas como tendo apego de alto risco, ao contrário de 57 crianças da comunidade da mesma idade e sexo. Apenas 8 (14%) mostraram padrões típicos e saudáveis. A diferença foi grande demais para ser acaso.
Também tinham muito mais perda ou trauma não resolvidos do que as crianças da comunidade.
Seus padrões de apego e as taxas de perda ou trauma não resolvidos não diferiram dos de 51 crianças com diversos problemas de saúde mental.
50 de 57 (88%) tinham outros diagnósticos de saúde mental, e seu funcionamento no dia a dia estava prejudicado, com pontuação em torno de 55 em 100 em média.
As crianças encaminhadas por questões de gênero tiveram em média 5,5 experiências difíceis na infância, como abuso, negligência ou rompimento familiar, contra 1,7 nas crianças da comunidade. Apenas 35% moravam com ambos os pais biológicos, contra 75%.
Menor renda e status familiar, uma configuração familiar não tradicional e experiências difíceis, incluindo abuso ou negligência, estavam ligados ao apego de alto risco.

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.

Methodological limitations

One snapshot in time: Attachment was measured once when children arrived at the clinic. So the study cannot show whether attachment problems came before, contributed to, or resulted from gender distress, as the authors admit.
One clinic: All children came from one hospital gender service. 57 of 70 referred children (81%) took part, and those who said no may differ.
Poorly matched mental health group: The mental health comparison group was recruited years earlier for another study, was younger (aged 5 to 12, vs 8 to 15) and had a different mix of boys and girls. That weakens the key conclusion that these children are 'like' other mental health patients.
Community children found differently: The community group was recruited through hospital staff, their friends and youth clubs. These families may differ from referred families in ways that have nothing to do with gender distress.
Specialised scoring system: The attachment scoring method is used by a fairly small group of trained coders. Two coders agreed 85% of the time for one interview type, but only 70% (only fair agreement) for the school-age interviews.
Clinicians agreed ratings among themselves: Ratings of distress and family functioning were agreed by the clinicians together, without a formal check that different raters would score them the same way, as the authors note.
Other mental health problems may explain it: With 88% having other diagnoses, the attachment findings may reflect mental health problems in general rather than anything specific to gender distress. This fits with there being no difference from the mental health group.
Extra analyses done after the fact: What predicted high-risk attachment was explored in extra analyses after the main ones, which raises the risk of findings that are just flukes.
Parents' and grandparents' history not measured: The authors note they did not measure hardship in parents and grandparents, even though they use passed-down family problems to explain their results.
Authors' viewpoint: The team works from a whole-person, attachment-focused approach. The study was funded by money the authors raised from teaching, and no commercial conflicts were declared.

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Summary

Key findings

Abstract

Conclusion