Trans-identified youth are an extremely vulnerable population given the prevalence of mental health and neurodevelopmental co-occurring conditions. Here’s what we know about a few mental health conditions and their interplay with gender distress.
- Autistic children are extremely likely to experience gender-distress
- Children with ADHD are extremely likely to experience gender-distress
- Trans-identified young people are more likely to have anxiety and depressive disorders
- Adolescents referred for gender dysphoria have a substantial co-occurring history of psychosocial and psychological vulnerability
A study by clinicians who worked at the UK’s Tavistock GIDS clinic noted that 48% of children and young people seen at GIDS scored in the mild to severe range for a Social Responsiveness Scale measure, a quantitative approach to assess autistic behaviours. Other research published in the BMJ found that 35% of young people referred to GIDS presented with moderate to severe autistic traits.
A significant amount of Canadian research has been undertaken to better understand the link between autism and gender dysphoria. Studies have found that children and young people with gender dysphoria (GD) also express intense and obsessional interests more than expected. This is particularly the case with pre-pubertal male children. The study leveraged data based on the Child Behaviour Checklist, which is used to assess behavioural traits in school-aged children, and asks specific questions to assess a wide range of behaviours. Item 9 asks “Can’t get his/her mind off certain thoughts; obsessions (describe):” The study authors noted:
“A gender-related theme was significantly more common for gender-referred boys than male siblings on Item 9 only. A gender-related theme was not significantly more common for gender-referred girls compared to their female siblings on either item. The findings for Item 9 support the idea that children with GD show an elevation in obsessional interests. For gender-referred boys in particular, gender-related themes constituted more than half of the examples provided by their mothers.”
The study concludes that intense/obsessional interests in children with gender dysphoria (GD) may be one of the factors underlying the purported link between GD and ASD.
The study concludes that intense/obsessional interests in children with gender dysphoria (GD) may be one of the factors underlying the purported link between GD and ASD.Study
A more recent Canadian study proved that there is a link between autism and gender dysphoria. The study compared children aged 4-12 referred for gender dysphoria with a control group of children who had been referred for other issues. 21.3% of children in the gender dysphoria group had a diagnosis of ASD vs 0% in the control group. Further, 21.7% of the children in the gender dysphoria group met the criteria for ASD traits based on the Social Communication Questionnaire vs 3.3% in the control group. The results of this study conclusively proved that there is a link between GD and ASD, although the nature of this link is not yet understood.
The study authors note; “It is unlikely that gender dysphoria predisposes a child to develop ASD.” In contrast, they say, “it has been suggested that at least some characteristics of ASD (e.g., the propensity to develop intense interests or obsessions) could predispose a child to develop gender dysphoria if the contents of such interests/obsessions become focused on gender-related behaviors and cognitions.”
“It is unlikely that gender dysphoria predisposes a child to develop ASD.” In contrast, they say, “it has been suggested that at least some characteristics of ASD (e.g., the propensity to develop intense interests or obsessions) could predispose a child to develop gender dysphoria if the contents of such interests/obsessions become focused on gender-related behaviors and cognitions.”Canadian research study
Children who have ADHD experience emotions differently than others and often have difficulty managing their behaviour and emotions to fit into typical social expectations in general. This can be particularly noticeable in classroom activities, during sports, or when interacting with others in a structured environment. The experience of gender variance in children with ADHD was found to be related to elevated emotional symptoms in a study of children. Study participants who had ADHD were 6.6 times more likely to express gender variance than the children in the study who did not have ADHD.
Anxiety and Depressive Disorders
A study that compared the medical records of 1333 trans-identified children and adolescents between the ages of 3 and 17 years old with a similar cohort of non-trans-identified children and adolescents showed that 49% of males and 62% of females had depressive disorders. The study reported that common diagnoses for trans-identified children and adolescents were attention deficit disorders (transfeminine 15%; transmasculine 16%) and depressive disorders (transfeminine 49%; transmasculine 62%), respectively. For all diagnostic categories, prevalence was several times higher among trans-identified youth than in matched reference groups.
General psychosocial and psychological vulnerability
A Canadian study of 50 consecutive referrals of adolescents with a diagnosis of GD found significant psychological vulnerability based on 15 different factors. Over half of this group had six or more of the vulnerability factors. These factors were significantly correlated with behavioral and emotional problems on the Youth Self-Report Form and the Child Behavior Checklist and point to the need for a comprehensive assessment that does more than simply evaluate whether a minimal bar of gender dysphoria is present.
“The findings supported the clinical impression that a large percentage of adolescents referred for gender dysphoria have a substantial co-occurring history of psychosocial and psychological vulnerability, thus supporting a “proof of principle” for the importance of a comprehensive psychologic/psychiatric assessment that goes beyond an evaluation of gender dysphoria per se.”
The study authors note that this psychological vulnerability is often being overlooked as more and more children are offered medical transition options such as puberty blockers and cross-sex hormones.
Yet Canadian Gender Clinics are Phasing Out Mental Health Assessments
Traditional mental health assessments are being systematically phased out at the same time as new research is emerging that illuminates the complex inter-relationship between psychological vulnerability and gender distress. This is because pro-transition advocates say mental health assessments are “stigmatizing” and a “barrier to care”.
For minor children, however, mental health assessments need not pathologize one’s experience of gender identity or gender-related distress. Young people seeking help and support for gender-related issues deserve comprehensive mental health care that helps them understand the various factors at play within their relational and psychological makeup and how these are influencing their current experience of gender. There is ample evidence to support the need to screen gender-distressed youth for mental health issues and trauma in order to create an informed approach to care that will support their best interests in the long term. This appears to be sorely lacking in Canada as medicalization of young people is increasingly being done for identity rights reasons rather than supported by objective and evidence-based healthcare.
It’s the experience of Canadian parents that it is extremely difficult to access mental health services for trans-identified youth other than “affirmation-only therapy,” which fully supports the process of social and medical transitioning. Gender clinics often tell the media that “comprehensive assessments” are happening, but when the majority of young people are being offered puberty blockers at their first visit, it’s clear that the term “assessment” has a very different meaning from what most would expect. A recent study on youth experiences at Canadian gender clinics found that 62% of children are offered off-label puberty blockers at their first visit, and the most common reason it’s not a higher majority is “the clinic protocol of not prescribing at first visit”.
Gender Exploratory Assessment Models Exist Elsewhere
In the UK, the pediatric gender service that had adopted the poorly understood “affirmation” protocol was investigated and is being shut down due to safety concerns. The new service specification requires a multi-disciplinary approach so that a young person seeking gender transition is able to fully understand multiple aspects of their developing identity, including possible external influences on their mental health. This will enable them to gain a fulsome understanding of themselves prior to undertaking life-changing medical interventions. This type of approach, where the assessment model will be standardized and then the treatment pathways adapted to the individual needs of the client in order to prioritize mental well-being is the only responsible model of care that has thus far been articulated.
Of particular concern is an emerging trend in some research to position mental health issues experienced by trans-identified youth to be the result of “minority stress,” often without exploring whether or not mental-health comorbidities are a factor in the study observations. These kinds of “conclusions” help support an identity rights narrative, but ignoring the potential impact of mental health co-morbidites is not helpful to support the long-term well-being of this vulnerable population of young people.