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月至2017年6月间转介到Westmead性别服务机构的70名儿童中有57人参加了关于依恋的结构化访谈，使用的是为学龄儿童和较大青少年设计的版本。
• 有性别痛苦的儿童大多被归为高风险依恋，不同于57名相同年龄和性别的社区儿童。只有8人（14%）表现出典型的、健康的模式。差异之大，绝不可能是偶然。
• 他们也比社区儿童有更多未解决的丧失或创伤。
• 他们的依恋模式和未解决的丧失或创伤的比率，与51名有各种心理健康问题的儿童没有差别。
• 57人中有50人（88%）有其他心理健康诊断，他们的日常功能受损，平均得分约为100分中的55分。
• 被转介性别问题的儿童平均有5.5种艰难的童年经历，如虐待、忽视或家庭破裂，而社区儿童为1.7种。只有35%与亲生父母双方同住，而对照为75%。
• 较低的家庭收入和地位、非传统的家庭结构，以及包括虐待或忽视在内的艰难经历，与高风险依恋有关。

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.