It is a well-established observation that individuals suffering from gender dysphoria (GD) demonstrate an increased prevalence of mental health issues when compared to the general population (1). One theory that explains the link between GD and mental illness is the minority stress model (2,3). Gender-non-conforming and GD youth experience elevated rates of victimization, discrimination, and prejudice. According to the minority stress theory, these adverse experiences are the primary cause of the poorer mental health status of GD individuals.
There are two issues which contradict the minority stress theory. First, evidence shows that mental health issues often precede the onset of gender identity concerns (4-6). Second, long-term studies have not been able to demonstrate lasting mental health benefits of “gender-affirmative” (hormonal and surgical) interventions (7-9). These findings do not support the argument that minority stress is the primary reason for the high co-occurrence of GD and other psychiatric disorders.
An alternative explanatory model for the co-occurrence of GD and other forms of distress and mental illness is that both arise as a result of a complex interplay of biological, relational, and cultural factors (10-14). A new study, led by an Australian team of researchers, investigated one aspect of this complex relationship: early relational experiences. The researchers examined childhood attachment patterns and unresolved trauma/loss in GD youth, comparing them to age- and sex-matched youth with other psychiatric disorders but no GD, as well as to healthy controls (15).
The study found that young people with GD had childhoods characterized by at-risk attachment patterns to caregivers and high rates of unresolved trauma/loss. Further, when the study compared GD youth to the youth referred for other psychiatric disorders but not GD, both groups showed similarly high rates of unresolved trauma/loss and at-risk attachment patterns. In contrast, healthy controls had normative (low risk) attachment patterns and low rates of unresolved childhood trauma or loss.
It is SEGM's view that while the adverse effects of prejudice and discrimination experienced by GD youth are not debatable, the results of this study challenge the role of minority stress as the primary explanatory model for the high rates of mental illness in youth with GD. Instead, the findings suggest that adverse childhood histories and poor attachments may predispose a young person to the onset of GD as well as other psychiatric illness and symptoms of distress. This in turn further challenges the notion that “gender affirmation” (social and medical) is the appropriate first-line treatment for GD youth (22). The study findings make a strong case for a more nuanced and in-depth exploration of children and adolescents’ clinical presentations of GD, with the goal of identifying treatment pathways that prioritize long-term health outcomes.
In January 2021, Frontiers in Psychology published a study from the Children’s Hospital at Westmead and the University of Sydney Medical School which examined the quality of attachment patterns in children and adolescents presenting for care to a gender service (15).
Attachment patterns refer to the ways children interact with their primary caregivers to obtain maximal safety and comfort and are classified into secure and insecure categories (16,17). Attachment patterns form in the first 12 months of life and play an important role in children’s socioemotional development later in life (18). A large body of evidence has established that children with certain insecure attachment patterns are at higher risk of developing psychological and behavioral problems than those who display secure attachment patterns (19,20). Insecure attachment can be a consequence of a wide range of factors, including early or prolonged separation from a caregiver, parental depression, parental or family trauma, problematic interaction patterns between parent and child, or neglect and abuse.
Kozlowska and colleagues (15) assessed 57 GD children and adolescents presenting for care at a newly established gender service. The majority of the GD study subjects had prepubescent onset of GD. This GD group was compared with children with other psychiatric disorders but no GD (n = 51), as well as a group of healthy controls (n = 57). The researchers examined the quality of their attachment patterns, the number of reported adverse childhood events (e.g., instability, parental psychiatric disorders, financial stressors, maltreatment, etc.) and the rates of unresolved loss or trauma.
Various key findings emerged from the analyses:
- 88% of children and adolescents from the GD group had a comorbid mental health diagnosis. Approximately 50% of them had a history of self-harm and reported suicidal ideation; 60% had experienced bullying. Global level of functioning was also affected, with impaired overall health and well-being.
- When compared to healthy controls, youth with GD reported significantly more adverse childhood events and higher rates of unresolved loss/trauma. Moreover, they were mostly classified into at-risk attachment categories, whilst healthy controls mostly displayed normative (low risk) patterns of attachment.
- However, when comparing the GD youth to the group of youth with other psychiatric disorders but no GD, no difference was found between the two with regard to rates of unresolved loss/trauma, adverse childhood events or the quality of attachment patterns.
- GD youth with at-risk patterns of attachment were more likely to come from families with a low socio-economic status, and more likely to have experienced maltreatment (physical abuse, sexual abuse, emotional abuse, neglect, and exposure to domestic violence).
Range of Interpretations
The results of this study may be interpreted in a number of ways.
1. GD predisposes a person to the development of mental illness
Experiences of bullying and peer rejection related to gender identity were common in the study. These experiences may have led to the high levels of mental illness, as proposed by the minority stress model.
2. Baseline mental illness predisposes a person to the development of GD
GD is a secondary phenomenon and a consequence of pre-existing, primary mental health problems. Since the study did not report on the time of onset of mental health issues with respect to the onset of GD, the direction of effect between GD and mental illness cannot be conclusively determined (20).
3. The relationship between GD and mental illness is complex and shaped by early childhood developmental factors
Both GD and mental illness are endpoints of developmental trajectories characterized by a range of adverse developmental experiences. GD and its relationship with other mental health issues is shaped by a complex interaction of early developmental, relational and social factors.
It is SEGM’s position that the findings by Kozlowska et al. (15) support the theory that GD and its connection with mental illness is complex and is shaped by a range of adverse developmental experiences. The study adds to previous studies reporting high rates of at-risk attachment patterns and early traumatic experiences among individuals with GD (10-14). This emerging evidence suggests that multiple and seemingly unrelated factors can converge into specific forms of emotional distress, including GD.
These findings have important implications for clinicians, therapists, and counsellors working with children and adolescents with GD, who frequently exhibit a range of additional emotional and behavioral issues such as depression, anxiety, self-harm, and suicidal ideation:
- GD is only one facet of a complicated clinical presentation in which the determinants of distress are multiple and complex. A narrow approach, which focuses primarily on addressing gender issues, may fail to address the complex causes of the young person’s distress.
- Gender minority stressors are unlikely to be the primary reason for the high levels of psychiatric comorbidity in GD youth. The similarities between youth with GD and other psychiatric populations with regards to their developmental trajectories and their rates of childhood trauma call for a more complex understanding of the relationship between GD and psychological comorbidities.
- This calls for extensive and rigorous psychological exploration and engagement with GD youth before "gender-affirmative" medical interventions are commenced. Since multiple factors contribute to the experience of GD, clinical assessments should be informed by an all-encompassing biopsychosocial perspective that takes into account how these factors interact and come together in each particular case.
We applaud the authors’ effort and call for more inquiry into the topic of childhood and adolescent GD and the relationship between GD and high rates of mental illness.
The study by Kozlowska et al. (15) casts doubt on the validity of the minority stress model as a singular explanation of mental illness in individuals with gender-related distress. The study results challenge the current conceptualization of GD and gender identity as isolated entities that are disconnected from psychosocial factors and developmental pathways.
Consequently, the results dispute the appropriateness of immediate affirmation through social or medical means as the first-line and one-and-only therapeutic approach for treating GD youth. The study findings make a strong case for a more nuanced and in-depth exploration of children and adolescents’ clinical presentations of GD, with the goal of identifying treatment pathways that prioritize long-term health outcomes.
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