Self-Harm and Suicidality in Children Referred for Gender Dysphoria

doi:10.1016/j.jaac.2016.04.001

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 55, Issue 6, June 2016, Pages 513-520

https://doi.org/10.1016/j.jaac.2016.04.001 Get rights and content

Objective

This study examined rates of self-harm and suicidality (ideation and behavior) in children referred clinically for gender dysphoria compared with their siblings, and referred and nonreferred children from the Child Behavior Checklist (CBCL) standardization sample. Predictors or correlates of self-harm/suicidality were also examined.

Method

The sample consisted of 572 gender-referred children, 425 siblings, 878 referred children, and 903 nonreferred children. Parent report for 2 CBCL items was used to assess self-harm and suicidality. CBCL total behavior problems and a metric of peer relationship problems were also used.

Results

The gender-referred children and the referred children from the standardization sample had significantly higher scores than siblings and nonreferred children in terms of self-harm/suicidality, total behavior problems, and poor peer relations. Based on logistic regression analyses, gender-referred children were 5.1 times more likely than nonreferred children to talk about suicide and 8.6 times more likely to self-harm/attempt suicide, even after overall behavior problems and peer relationship problems were accounted for. In the final models, group, older age, and more total behavior problems, but not poor peer relations, were significantly associated with an increased likelihood of self-harm/suicidality.

Conclusion

By parent report, children with gender dysphoria show an increased rate of self-harm/suicidality as they get older. This risk was not simply an artifact of the presence of behavioral and emotional problems, although these problems were significant correlates of self-harm/suicidality. Clinicians should routinely screen for the presence of suicidal ideation and behavior in children with gender dysphoria, particularly during the second half of childhood.

Section snippets

Participants

The probands consisted of 572 gender-referred children (463 natal boys; 109 natal girls) and 425 of their siblings (239 boys, 186 girls), who ranged in age from 3 to 12 years, and for whom at least 1 parent had completed the CBCL for children 4 to 18 years of age.²⁷ All of the gender-referred children were evaluated in a specialized gender identity service housed within a child and youth mental health program at an academic health science center between 1976 and 2015 (mean year of assessment,

Results

Because the 2001 version of the CBCL did not include data on referred and nonreferred children under the age of 6 years, our comparative analyses described below did not include the data on the gender-referred children and siblings who were under the age of 6 years.

Discussion

Based on parent report, this study examined the prevalence of both suicidal ideation and self-harm/suicidal behavior in a sample of children referred for gender identity concerns and compared these rates to those of their siblings, referred, and nonreferred children. The referred children in the CBCL standardization sample had, on average, a significantly higher suicidality sum score than the gender-referred children, but both groups had a significantly higher score than the siblings of the

References (39)

K.J. Zucker et al.
Traits of separation anxiety in boys with gender identity disorder
J Am Acad Child Adolesc Psychiatry
(1996)
K. Khatchadourian et al.
Clinical management of youth with gender dysphoria in Vancouver
J Pediatr
(2014)
J. Olson et al.
Baseline physiologic and psychosocial characteristics of transgender youth seeking care for gender dysphoria
J Adolesc Health
(2015)
T.M. Achenbach et al.
Are American children’s problems getting worse? A 13-year comparison
J Am Acad Child Adolesc Psychiatry
(1993)
Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.)
(2013)
P.T. Cohen-Kettenis et al.
Demographic characteristics, social competence, and behavior problems in children with gender identity disorder: a cross-national, cross-clinic comparative analysis
J Abnorm Child Psychol
(2003)
T.D. Steensma et al.
Behavioral and emotional problems on the Teacher’s Report Form: a cross-national, cross-clinic comparative analysis of gender dysphoric children and adolescents
J Abnorm Child Psychol
(2014)
J.E. Bates et al.
Gender-deviant boys compared with normal and clinical control boys
J Abnorm Child Psychol
(1979)
K.J. Zucker et al.
Gender Identity Disorder and Psychosexual Problems in Children and Adolescents
(1995)
K.J. Zucker
Gender identity disorder in girls

K.J. Zucker et al.

Models of psychopathology in children and adolescents with gender dysphoria

K.J. Zucker

Psychosocial and erotic development in cross-gender identified children

Can J Psychiatry

(1990)

A.L. de Vries et al.

Poor peer relations predict parent- and self-reported behavioral and emotional problems of adolescents with gender dysphoria: a cross-national, cross-clinic comparative analysis [published online ahead of print 15 September 2015]

Eur Child Adolescent Psychiatry

(2015)

M. Shiffman et al.

Behavioral and emotional problems as a function of peer relationships in adolescents with gender dysphoria: a comparison with clinical and nonclinical controls

Psychol Sex Orientation Gend Diversity

(2016)

E. Skagerberg et al.

Internalizing and externalizing behaviors in a group of young people with gender dysphoria

Int J Transgenderism

(2013)

K.J. Zucker et al.

Demographics, behavior problems, and psychosexual characteristics of adolescents with gender identity disorder or transvestic fetishism

J Sex Marital Ther

(2012)

Boylan JF. How to save your life: a response to Leelah Alcorn’s suicide note. New York Times. January 6, 2015....

Abeni C. San Diego mourns fourth trans teen lost to suicide this year. Advocate. October 7, 2015. Available at:...

Pesce NL. After Caitlyn Jenner addresses transgender teen suicide, Kyler Prescott's mother shares her son's story. New...

Cited by (89)

Individual Affirming Care: Psychological and Social Approaches to Trans and Gender-Diverse Youth
2023, Child and Adolescent Psychiatric Clinics of North America
Clinical profiles and care of transgender children and adolescents in a specialized consultation in Île-de-France
2023, Neuropsychiatrie de l'Enfance et de l'Adolescence
Il existe très peu de données cliniques françaises sur les modalités de prise en charge médicale des enfants et adolescents transgenres alors que le sujet vient très régulièrement sur le devant de la scène médiatique.
Nous proposons dans cet article de décrire de manière rétrospective l’ensemble des enfants et adolescents reçus depuis 2012 dans la plus importante consultation spécialisée identité de genre enfants et adolescents d’Île-de-France. Outre leurs caractéristiques sociodémographiques, nous étudions la présence ou non d’une incongruence de genre selon les critères de la CIM 11, les vulnérabilités psychiatriques et sociales des sujets et décrivons les principales modalités de prise en charge proposées : la transition sociale, le blocage pubertaire, les transitions hormonales et/ou les rares transitions chirurgicales. Ces trois dernières propositions sont discutées en réunion de concertation pluridisciplinaire (RCP).
Nous avons colligé 239 jeunes âgés de 3 à 20 ans. L’âge moyen auquel les jeunes et leur famille sont vus au premier rendez-vous est de 14,5 ans (± 3,16). Au total, 91 % de l’échantillon présentent une incongruence de genre, 32 % ayant exprimé cette incongruence avant la puberté. Deux-tiers sont des jeunes assignés de sexe féminin à la naissance (p < 0,05). En termes de psychopathologie, les troubles dépressifs et anxieux, ainsi que la suicidalité arrivent largement avant les autres cooccurrences psychiatriques. L’ostracisme et le rejet scolaire sont fréquents. Par rapport à la population adolescente générale, les jeunes de la consultation spécialisée sont beaucoup plus exposés aux discriminations et aux insultes, voire aux agressions sexuelles dans l’espace public, que leurs pairs et l’internalisation de la transphobie par ces jeunes est particulièrement importante. Au total, 40 % des jeunes ont effectué une transition sociale avant le premier rendez-vous et 74 % et 61 % d’entre elles/eux l’on fait au sein de la famille et à l’école (l’âge moyen de la transition sociale à l’école = 15,13 ans). Au total, 35 % des jeunes ont officialisé en mairie le changement de prénom (l’âge moyen = 16,26 ans). La prise de bloqueurs de puberté concerne 11 % des jeunes qui ont atteint la puberté (âge moyen = 13,9 ans, délai moyen avant instauration du traitement = 10 mois). Au total, moins de la moitié des jeunes (44 %) ont reçu un traitement hormonal masculinisant ou féminisant par hormones sexuelles (âge moyen = 16,9 ans, délai moyen avant l’instauration = 14 mois). Au total, 8,7 % des jeunes ayant reçu un traitement hormonal par hormones sexuelles ont réalisé une préservation de fertilité. Les demandes de chirurgie avant 18 ans restent très rares. Les plus fréquentes sont les torsoplasties (20 %) réalisées à l’âge moyen de 18,44 ans et jamais avant 16 ans.
Les résultats de cette cohorte sont proches de ceux rapportés par d’autres centres européens pour ce qui concerne la proportion plus élevée de jeunes assignés de genre féminin à la naissance. En revanche, ils diffèrent avec des chiffres plus bas en termes de recours à des traitements hormonaux. La transition sociale est dans notre centre la demande la plus fréquente mais elle n’est pas systématique. Nous discuterons la place de la parole dans notre accompagnement pour expliquer ces différences.
French clinical data on the medical management of transgender children and adolescents are scarce. Yet, the topic regularly comes to the forefront of the media.
In this article, we propose to retrospectively describe all the children and adolescents received since 2012 in the largest specialized gender identity consultation for children and adolescents in Île-de-France. In addition to their sociodemographic characteristics, we study the presence or not of gender incongruence according to the ICD 11 criteria, the psychiatric and social vulnerabilities, and describe the main management modalities proposed: social transition, puberty blockage, hormonal transitions and/or rare surgical transitions. These last three proposals were discussed in multidisciplinary concertation meetings.
We collected 239 youths aged 3 to 20 years. The mean age at which youth and their families were seen at the first appointment was 14.5 years (± 3.16). In all, 91% of the sample had gender incongruence, with 32% expressing gender incongruence before puberty. Two-thirds were youth assigned female at birth (P < 0.05). In terms of psychopathology, depressive and anxiety disorders, as well as suicidality, came well ahead of other psychiatric co-occurrences. School ostracism and rejection were common. Compared to the general adolescent population, the young people in the specialized consultation are much more exposed to discrimination and insults, and even sexual aggression in the public space, than their peers, and the internalization of transphobia by these young people is particularly important. In all, 40% of the young people made a social transition before the first consultation and 74% and 61% of them did so within the family and at school (the average age of social transition at school = 15.13 years). In all, 35% of the young people made the name change official at the town hall (the average age = 16.26 years). Puberty blockers were used by 11% of the youths who had reached puberty (mean age = 13.9 years, mean time to initiation = 10 months). In total, fewer than half of the youths (44%) received masculinizing or feminizing sex hormone treatment (mean age = 16.9 years, mean time to initiation = 14 months). In all, 8.7% of the young people who received sex hormone treatment underwent fertility preservation. Requests for surgery before the age of 18 remain very rare. The most frequent are torsoplasties (20%) performed at a mean age of 18.44 years and never before 16 years.
The results of this cohort are close to those reported by other European centers in terms of the higher proportion of young people assigned female at birth. However, they differ with a lower proportion of hormonal treatment. Social transition is the most frequent request in our center, but it is not systematic. We wonder whether the place of narration while in our care may explain these differences.
Suicide risk of transgender adolescents
2023, Medecine et Droit
Young people from the Missions locales de Paris and the risk of suicide. Preliminary results of a controlled trial of a psychotherapeutic follow-up suicide prevention (MLADO) proposal
2023, Bulletin de l'Academie Nationale de Medecine
En France, et vu sa fréquence, la prévention du suicide est devenue un enjeu de santé publique. La Mission locale de Paris (MLP) est une association ayant une délégation de service. Elle est financée par l’État, la région Île-de-France et le département de Paris. La MLP a pour objectif d’accompagner les jeunes dans leur insertion professionnelle et sociale. Les jeunes en insertion ont environ deux fois plus de risque d’avoir fait une tentative de suicide que les jeunes actifs.
La recherche MLADO, essai randomisé et contrôlé, a visé à évaluer l’efficacité de la proposition d’un suivi psychologique hebdomadaire pour un an pour les adolescents et jeunes adultes des Missions locales de Paris, ayant un score égal ou supérieur à 8 à l’Adolescent Depression Rating Scale (ADRS/EDA), ou avec un score supérieur au seuil Child Trauma Questionnaire (CTQ/ETE).
Cent soixante-cinq jeunes suivis sur les cinq sites participants de la MLP se sont rendus à un entretien en vue de leur inclusion et leur randomisation dans MLADO. Parmi les 128 inclus, 20,3 % avaient déjà fait une tentative de suicide. Aucune tentative de suicide n’a été enregistrée pendant toute la période de suivi, dans les deux groupes, et malgré l’isolement dû au Covid-19 pendant la dernière partie de l’étude. Le score à l’ADRS a chuté dès le 3^e mois de suivi, dans les deux groupes mais ne s’est régularisé qu’au bout d’un an de suivi dans le groupe contrôle.
Aller au-devant de ces jeunes vulnérables en leur proposant une évaluation et l’entrée dans un suivi psychologique en ville, sans coût ni délai pour eux, est une démarche bien acceptée, et qui se montre efficace pour diminuer leur dépression et le risque de suicide. L’ADRS/EDA et la CTQ/ETE dans leurs versions françaises sont de bons outils de dialogue, qui peuvent permettre l’entrée dans une démarche de soin.
Considering its frequency, adolescent and young adult suicidal behavior has become in France a major public health issue. The Mission locale de Paris (MLP) is a publicly financed structure aiming at helping young people in distress to achieve a better social and professional insertion.
Since youths without activity have a twofold increased risk of suicidal behavior, we designed MLADO, a controlled and randomized trial to assess the efficacy of offering a weekly psychological follow-up for youths from the Paris MLP with a score at 8 and over on the Adolescent Depression Rating Scale or with a score over threshold at the Child Trauma Questionnaire. This psychological follow-up by a professional was paid for a year.
One hundred and sixty five youths, followed up at the five participating MLP agencies, went for an interview for inclusion into MLADO. Among the 128 included, 20.3% had an antecedent of suicidal behavior but no suicidal attempts or even self-harm was observed in the two groups during follow-up. The ADRS score dropped sharply in both groups after the 3^rd month of follow up, but it took a year of follow-up for this score to be normalized in the control group.
Taking a proactive stance towards vulnerable youths seems acceptable, with the proposition of an assessment and orientation towards a psychological treatment, with a qualified psychologist in town, without any delay nor at any cost for them. This is also effective in reducing depression and suicidal risk. Both the ADRS and the CTQ appear to be good dialogue boxes, allowing for a dialogue about their present mental health and about their past, and helping them to seek help.
Prevalence of suicidal ideation and self-harm behaviours in children aged 12 years and younger: a systematic review and meta-analysis
2022, The Lancet Psychiatry
Citation Excerpt :
No information was given in our included studies regarding the severity of suicide attempts and whether hospital care was required. All four studies on self-harm13,27,28,33 relied on parental report only, perhaps understating the true prevalence of self-harm. For NSSI, one study based on the Adolescent Brain Cognitive Development (also known as ABCD) cohort reported a prevalence of 9% in children aged 9–10 years,17 whereas another study from a small convenience sample reported a prevalence of 44·5%,35 suggesting that the prevalence of NSSI can vary considerably depending on how questions are formulated.
Suicide in children is a pressing public health concern. The increasing number of deaths by suicide and emergency visits for suicidal ideation and self-harm in children might not be fully representative; it is likely that many more children are in distress but do not seek out help. We conducted a systematic review and meta-analysis of existing studies to quantify the prevalence of suicidal ideation and self-harm behaviours among children in the community aged 12 years and younger.
In this systematic review and meta-analysis, we searched PsycINFO, MEDLINE, and Web of Science via OVID from database inception to Feb 28, 2022, for articles published in French or English that reported estimates of prevalence of suicidal ideation (including suicide planning) and self-harm behaviours (namely, self-harm, suicide attempts, and non-suicidal self-injury) in children aged 12 years and younger. Reference lists were also searched; case studies, qualitative studies, and health-care visit studies were excluded. The outcomes were suicidal ideation, suicide plan or attempts, and self-harm. We used a random-effects model to calculate the overall pooled prevalence of suicidal ideation and self-harm behaviours for all timeframes combined and for ever versus the past 12 months for suicidal ideation. We used the Joanna Briggs Institute Critical Appraisal tool to evaluate the risk of bias in each study. This study is registered with PROSPERO, CRD42020179041.
28 articles, encompassing 30 studies overall, met the inclusion criteria, aggregating findings from 98 044 children (of whom 46 980 [50·5%] were girls and 46 136 [49·5%] were boys; six articles did not report sex or gender) aged 6–12 years. The pooled prevalence estimate was 7·5% (95% CI 5·9–9·6) for suicidal ideation from 28 studies and 2·2% (2·0–2·5) for suicide planning from three studies. The pooled prevalence was 1·4% (0·4–4·7) for self-harm from four studies, 1·3% (1·0–1·9) for suicide attempt from six studies, and 21·9% (6·2–54·5) for non-suicidal self-injury from two studies. The prevalence of suicidal ideation was higher in studies that included child-reported outcomes (10·9% [95% CI 8·1–14·5] for child only and 10·4% [6·8–15·5] for child and parent combined) than for parent-only reported outcomes (4·7% [3·4–6·6]; p=0·0004). The prevalence of suicidal ideation and self-harm behaviours was similar in boys and girls (suicidal ideation, 7·9% [95% CI 5·2–12·0] for boys vs 6·4% [3·7–10·7] for girls; self-harm behaviours, 3·5% [1·6–7·2] for boys vs 3·0% [1·4–6·4%] for girls). Detailed ethnicity data were not available. High heterogeneity was identified across estimates (I²>90%), which was not well explained by the characteristics of the studies.
A high number of children in the general population can experience suicidal ideation and self-harm behaviours, thus underlining the need for more research on childhood suicide, including developmentally appropriate preventive strategies, such as youth-nominated support teams or dialectical behavioural therapy.
Canada Research Chair in Youth Mental Health and Suicide Prevention.
Suicide among LGBTQIA+ youth: A review of the treatment literature
2022, Aggression and Violent Behavior
Suicide is a serious public health problem among adolescent and young adults. Indeed, 12.1% of adolescents contemplate suicide, 4.0% make a plan, and 4.1% make an attempt (Nock et al., 2013). LGBTQIA+ youth (i.e., lesbian, gay, bisexual, transgender, questioning/queer, intersex and/or asexual adolescents and young adults) are particularly vulnerable to suicide (CDC, 2016; Liu & Mustanksi, 2012; Peters et al., 2019). While many LGBTQIA+ youth are healthy and resilient (Ream & Savin-Williams, 2005) they often report higher rates of both suicidal ideation and behavior than their heterosexual (Haas et al., 2011) and cisgender (James et al., 2016) peers. The purpose of this paper is to provide a structured review the state of suicide treatment research for LGBTQIA+ youth and offer recommendations for future directions.

View all citing articles on Scopus

: This article is discussed in an editorial by Dr. Walter O. Bockting on page 441.

: Dr. VanderLaan was supported by a Canadian Institutes of Health Research postdoctoral fellowship.

: Disclosure: Drs. VanderLaan, Wasserman, Zucker, and Mss. Aitken and Stojanovski report no biomedical financial interests or potential conflicts of interest.

View full text

New researchSelf-Harm and Suicidality in Children Referred for Gender Dysphoria

Objective

Method

Results

Conclusion

Section snippets

Participants

Results

Discussion

J Am Acad Child Adolesc Psychiatry

J Pediatr

J Adolesc Health

J Am Acad Child Adolesc Psychiatry

Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.)

Demographic characteristics, social competence, and behavior problems in children with gender identity disorder: a cross-national, cross-clinic comparative analysis

J Abnorm Child Psychol

Behavioral and emotional problems on the Teacher’s Report Form: a cross-national, cross-clinic comparative analysis of gender dysphoric children and adolescents

J Abnorm Child Psychol

Gender-deviant boys compared with normal and clinical control boys

J Abnorm Child Psychol

Gender Identity Disorder and Psychosexual Problems in Children and Adolescents

Gender identity disorder in girls

Models of psychopathology in children and adolescents with gender dysphoria

Psychosocial and erotic development in cross-gender identified children

Can J Psychiatry

Poor peer relations predict parent- and self-reported behavioral and emotional problems of adolescents with gender dysphoria: a cross-national, cross-clinic comparative analysis [published online ahead of print 15 September 2015]

Eur Child Adolescent Psychiatry

Behavioral and emotional problems as a function of peer relationships in adolescents with gender dysphoria: a comparison with clinical and nonclinical controls

Psychol Sex Orientation Gend Diversity

Internalizing and externalizing behaviors in a group of young people with gender dysphoria

Int J Transgenderism

Demographics, behavior problems, and psychosexual characteristics of adolescents with gender identity disorder or transvestic fetishism

J Sex Marital Ther

New research
Self-Harm and Suicidality in Children Referred for Gender Dysphoria