Um Estudo de Acompanhamento de Meninos com Transtorno de Identidade de Gênero

Estudos de coorte e registros Desistência na infância

Authors: Devita Singh, Susan J. Bradley, Kenneth J. Zucker
Journal: Frontiers in Psychiatry
Year: 2021
Source: www.frontiersin.org/articles/10.3389/fpsyt.2021.632784/full

Summary

Researchers at Toronto's gender clinic re-contacted boys first seen in childhood, at about age 7, and assessed them again at about age 21. Of 139 boys, 12.2% still had gender distress and 87.8% no longer did. Most grew out of it even among boys who had met the full diagnosis (86.4%). Most grew up attracted to men or to both sexes. Boys whose distress continued tended to be older when first seen, from poorer families, and more strongly gender non-conforming as children. It is the largest study of its kind, and 95.9% of those approached took part. But more than half of eligible patients were never contacted, and the ways of measuring changed over time. The boys were also seen in an era when early social transition was rare and therapy often tried to reduce cross-gender behaviour. So its rates may not apply to children seen at clinics today.

Key findings

De 139 meninos atendidos na infância por questões de identidade de gênero, 17 (12,2%) ainda tinham sofrimento de gênero por volta dos 21 anos e 122 (87,8%) não tinham mais.
A maioria superou o quadro mesmo entre os 88 meninos que preenchiam o diagnóstico completo na infância: 12 (13,6%) ainda tinham sofrimento, contra 5 de 51 (9,8%) dos meninos que não o preenchiam, uma diferença que poderia facilmente ser acaso.
Como adultos jovens, a maioria sentia atração por homens ou por ambos os sexos: 63,6% de 129 em suas fantasias e 47,2% de 108 em sua vida sexual, enquanto 25,9% relataram nenhuma atividade sexual.
Os meninos cujo sofrimento continuou tendiam a ser mais velhos quando atendidos pela primeira vez, de famílias mais pobres e mais não conformes ao gênero na infância do que os meninos atraídos por homens cujo sofrimento desapareceu.
Dos 145 pacientes abordados, apenas 6 recusaram (95,9% participaram), mas 163 pacientes elegíveis nunca foram contatados porque o estudo não tinha recursos, e 19 não puderam ser encontrados.
Apenas um menino havia feito a transição social antes da puberdade, portanto o estudo mostra o que aconteceu sob uma abordagem em grande parte sem transição, muitas vezes baseada em terapia, e não sob o atendimento afirmativo de hoje.
Os autores dizem que os resultados coincidem com estudos de acompanhamento anteriores que mostram que a maioria dos meninos atendidos em clínicas supera o sofrimento de gênero.

Abstract

This study reports follow-up data on the largest sample to date of boys clinic-referred for gender dysphoria (n = 139) with regard to gender identity and sexual orientation. In childhood, the boys were assessed at a mean age of 7.49 years (range, 3.33-12.99) at a mean year of 1989 and followed-up at a mean age of 20.58 years (range, 13.07- 39.15) at a mean year of 2002. In childhood, 88 (63.3%) of the boys met the DSM-III, III-R, or IV criteria for gender identity disorder; the remaining 51 (36.7%) boys were subthreshold for the criteria. At follow-up, gender identity/dysphoria was assessed via multiple methods and the participants were classified as either persisters or desisters. Sexual orientation was ascertained for both fantasy and behavior and then dichotomized as either biphilic/androphilic or gynephilic. Of the 139 participants, 17 (12.2%) were classified as persisters and the remaining 122 (87.8%) were classified as desisters. Data on sexual orientation in fantasy were available for 129 participants: 82 (63.6%) were classified as biphilic/androphilic, 43 (33.3%) were classified as gynephilic, and 4 (3.1%) reported no sexual fantasies. For sexual orientation in behavior, data were available for 108 participants: 51 (47.2%) were classified as biphilic/androphilic, 29 (26.9%) were classified as gynephilic, and 28 (25.9%) reported no sexual behaviors. Multinomial logistic regression examined predictors of outcome for the biphilic/androphilic persisters and the gynephilic desisters, with the biphilic/androphilic desisters as the reference group. Compared to the reference group, the biphilic/androphilic persisters tended to be older at the time of the assessment in childhood, were from a lower social class background, and, on a dimensional composite of sex-typed behavior in childhood were more gender- variant. The biphilic/androphilic desisters were more gender-variant compared to the gynephilic desisters. Boys clinic-referred for gender identity concerns in childhood had a high rate of desistance and a high rate of a biphilic/androphilic sexual orientation. The implications of the data for current models of care for the treatment of gender dysphoria in children are discussed.

Conclusion

This study provided follow-up data on the largest sample to date of boys clinic-referred for gender dysphoria (n = 139). Three key findings emerged: (1) The persistence of gender dysphoria was relatively low at 12.2% (17 persisters), while desistance was 87.8% (122 desisters); (2) A high percentage had a biphilic/androphilic sexual orientation—in fantasy, 63.6% (82 of 129 participants), and in behavior, 47.2% (51 of 108 participants); (3) Predictors of outcome included childhood age at assessment, social class, and degree of childhood gender-variant behavior. Specifically, biphilic/androphilic persisters tended to be older at childhood assessment, from lower social class backgrounds, and more gender-variant in childhood. Biphilic/androphilic desisters were more gender-variant than gynephilic desisters. The threshold vs. subthreshold GID diagnostic status in childhood did not significantly predict persistence. The authors note that these data were collected during a period when gender social transition prior to puberty was not commonly recommended, contrasting with more recent clinical approaches. The findings support prior research showing that desistance from gender dysphoria is the more common outcome in childhood-referred boys, and that dimensional measures of childhood sex-typed behavior provide added nuance in predicting long-term trajectories. The implications of these data for current models of care for treating gender dysphoria in children are discussed, particularly in light of contemporary approaches that may include earlier social transition and puberty-blocking interventions.

Methodological limitations

One clinic, long ago: All boys were seen at one Toronto clinic between 1975 and 2009 (on average in 1989). Results reflect that clinic and era. They may not apply to today's larger clinic numbers, which are now mostly girls.
Different treatment back then: Most boys were seen when therapy often aimed to reduce cross-gender behaviour (talk therapy, parent counselling, encouraging friendships with other boys). Only one had socially transitioned. So it is impossible to tell whether that treatment affected the results, or whether boys would have changed anyway.
Many never contacted: 163 eligible patients were never contacted because of limited resources, and 19 could not be found. Those who took part had slightly higher childhood IQ than those not contacted, and were more likely to come from two-parent homes than those who could not be found.
Some came back for help: 32 people (23%) joined after getting back in touch with the clinic for care. They had more cross-gender behaviour and emotional problems as children, and somewhat more ongoing distress (22% vs 9%), though this gap could be chance.
Measured in different ways: Ongoing distress was judged with a newer questionnaire for 64 people, an older one for 42, and by interview, parent report or medical records for 33 (24%). So accuracy may differ between groups.
Some judgement calls: Two people whose questionnaire scores suggested no ongoing distress were still counted as having it, based on clinical judgement. This shows the line between the two groups was partly a matter of opinion.
One check-in, sometimes very young: Each person was assessed only once. 29 (20.9%) were under 16 at follow-up (the youngest was 13), so distress that returned or appeared later would be missed.
Older diagnoses and milder cases included: Childhood diagnoses used older rule books, and 36.7% of boys did not meet the full diagnosis. Critics argue older rules caught gender non-conforming children who would not meet today's diagnosis (Temple Newhook et al., 2018, Int J Transgenderism). But here, ongoing distress was low in both groups.
Only two outcome groups: Sorting people into 'still distressed' or 'not' misses non-binary or changing identities and partial distress, which may be more common today.
Early clues need checking: The link with family income was not predicted in advance, and the authors say it needs repeating. The possible predictors (age, IQ, family income, family type) were also linked to each other.
A long, disputed debate: Studies like this from this clinic and others have been criticised on method and ethics (Temple Newhook et al., 2018) and defended by Zucker (2018, Int J Transgenderism). Readers should weigh both. The senior author ran the clinic whose patients were studied.

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Summary

Key findings

Abstract

Conclusion