Gender Dysphoria in Kids Linked to High Risk for Self-harm

Pauline Anderson

June 23, 2016

Gender-nonconforming children and adolescents are at increased risk for self-harm and suicide, a new study shows.

This increased vulnerability is not just due to social stigma, according to the authors, who recommend that children who present with gender dysphoria be routinely screened for self-harm and suicidal ideation as well as for general behavioral and emotional problems.

The study, led by Madison Aitken, was published in the June issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

Researchers used reports from the Child Behavior Checklist (CBCL), completed by parents, to assess 572 children aged 3 to 12 years who were referred to a specialized gender identity service from 1976 to 2015.

They compared these children with three control groups: 425 of the children's siblings, 878 children referred for other clinical reasons, and 903 nonreferred children.

As metrics of suicidality, investigators used CBCL items 18 ("deliberately harms self or attempts suicide") and 91 ("talks about killing self"). Both items are rated on a scale of 0 to 2, with 0 being "not true," 1 being "somewhat or sometimes true," and 2 being "very true or often true." An overall suicidality index was determined using the sum of the two items.

As a metric of poor peer relations, they used CBCL items 25 ("doesn't get along with other kids"), 38 ("gets teased a lot"), and 48 ("not liked by other kids").

For behavioral problems, researchers calculated sum scores of all items from the CBCL, minus the two suicidality items.

The study showed that the referred group had, on average, significantly more behavioral problems in general than the other three groups. The gender-referred group had significantly more behavioral problems than the siblings and the nonreferred group, and the siblings had more behavioral problems than the nonreferred group (for all, P < .05).

Both the referred group and the gender-referred group had, on average, poorer peer relations than both the sibling and the nonreferred groups (for all, P < .05).

For item 91 ("talks about killing self"), the referred group had the highest percentage (22.7%), followed by the gender-referred group (19.1%), the sibling group (5.8%), and the nonreferred group (1.7%). A similar pattern was observed for item 18 ("deliberately harms self or attempts suicide"), with 18.6%, 6.5%, 2.2%, and 0.2%, respectively.

On calculating an overall suicidality index, the researchers found that the referred group had, on average, a significantly higher score than the other three groups, and the gender-referred group had a significantly higher score than the siblings and the nonreferred group (for all, P < .05), who did not differ significantly from each other.

One reason referred children had higher mean sum scores on the suicidality index and more behavioral and emotional problems compared with gender-referred children may be that some were inpatients whereas all the gender-referred children were outpatients.

In the gender-referred group, for suicidal ideation, a linear relationship was demonstrated with regard to age. Although there was relatively little such ideation in the very young children, 33.3% of 10-year-old gender-referred children were rated by parents as expressing suicidal ideation. At age 11 years, 17.2% were rated as engaging in self-harm or suicide attempts.

In regression models that controlled for general behavioral problems, having poor peer relations was not a significant predictor of suicidal ideation and behavior.

"Thus, we cannot argue that social ostracism of gender-referred children was a unique correlate of suicidality," the authors write.

Because the data covered a period of 40 years, the researchers questioned whether greater societal acceptance of gender-variant children in recent years could "cloud" the data. But they pointed out that the suicidality metric showed a correlation of almost 0 with year of assessment.

This suggests "that whatever secular change has taken place, it does not appear to have an impact on parent report of self-harm/suicidality in this particular clinical population."

Clinicians Can Help

Commenting on the findings for Medscape Medical News, Gabrielle Shapiro, MD, associate clinical professor of psychiatry, Mount Sinai Hospital, New York City, who specializes in child and adolescent psychiatry, noted that in general, the incidence of depression and suicidal ideation is relatively high among gender-dysphoric youth.

"I agree with the study and think that it's very important for both pediatricians and any primary care provider, including physician extenders, like nurse practitioners, etc, to screen for suicidality in gender dysphoric youth."

In an accompanying editorial, Walter O. Bockting, PhD, Program for the Study of LGBT Health, Division of Gender, Sexuality, and Health, New York State Psychiatric Institute, New York City, said the findings "point toward the need for a more holistic and integrated approach to transgender health."

Gender dysphoria, says Dr Bockting, appears to be inherently distressing. He emphasizes the need for an individual approach to treatment.

"Even when meeting criteria for a formal DSM-5 diagnosis of gender dysphoria, (early) social and medical transition (through hormones and surgery) is not routinely indicated; rather, each individual and his or her psychosocial context is unique and is best served by an individualized treatment plan that addresses barriers to the development of each person's full potential, contributing to a greater appreciation of the spectrum of diversity in gender identity and expression," Dr Bockting writes.

Mental health professionals, he adds, can play a key role in facilitating such development, alleviating gender dysphoria and creating a supportive family and social environment.

Dr Bockting notes that the role of the healthcare professional in the care of gender-dysphoric patients has come under attack. One reason for this is that nonconformity in gender identity has been "depathologized," with more people adopting the opinion that gender dysphoria is not a mental disorder.

Another reason is that interventions to alleviate gender dysphoria for the most part can be accessed only after evaluation and recommendations from mental health professions. This, says Dr Bockting, "is often perceived as undermining the patient's autonomy."

The authors have disclosed no relevant financial relationships.

J Am Acad Child Adolesc Psychiatry. 2016;55:513-20. Abstract, Editorial

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