Kozlowska et al, 2021

Attachment Patterns in Children and Adolescents With Gender Dysphoria

Background and Introduction

The researchers investigate attachment patterns, adverse events, and unresolved trauma in children and adolescents with gender dysphoria (GD). Drawing on child development literature and empirical studies, the researchers theorise that adverse childhood experiences (ACE) contribute to insecure attachment patterns and GD.

According to attachment theory children respond to insecurity by developing a habitual strategy for protecting themselves. Dysfunctional attachment patterns include:

  • compulsively compliant,
  • compulsively caregiving,
  • punitive,
  • aggressive, and
  • feigned helplessness.

Adverse events can alter brain structure and function and can influence the child’s self-concept. The researchers hypothesise that children and adolescents with GD would have more insecure attachment and more unresolved loss and trauma.


To test their hypothesis, the researchers recruited three groups of participants:

  1. Fifty-seven children and adolescents with GD aged 8-15. 24 male and 33 female.
  2. A clinical group of 51 children with mixed psychiatric diagnoses ages 5-12. 29 male and 22 female.
  3. A non-clinical group of 57 age-matched controls without GD or psychiatric diagnoses aged 9-16. 24 male and 33 female.

The researchers interviewed participants and their family members and assessed attachment patterns, the severity of distress with sex characteristics, socio-economic status, and other mental health measures.

Results and Discussion

Children with GD had a statistically significant 5.5 ACEs compared to 1.7 in the non-clinical group. Common ACEs in the GD group were family conflict (67%), Loss via separation from a loved one or a close friend (60%), bullying (60%), and maternal mental illness (53%). Eleven GD children had been physically abused, and 6 had been sexually abused.

54% of the GD group had unresolved loss and trauma compared to 16% in the non-clinical group. 48 out of 57 had moderate or high risk attachment patterns compared to only 10 out of 57 in the non-clinical group.

The researchers position the increase in GD children within the broader increase in childhood distress and psychiatric issues. They note how much of the literature on GD adolescents present psychiatric co-morbidities as a consequence of bullying and stigmatization experienced by GD adolescents. The researchers also found bullying or peer issues related to gender identity in 8 of the GD group. However most ACEs were unrelated to prior trans-identification.

…because resilience is related to a history of supportive care…at-risk attachment is a risk factor for developing distress, difficulties with adaptation, and psychiatric disorders generally…and also, as is now coming into focus, for gender dysphoria.

Whilst distress pertaining to gender or to bullying or stigmatization in relation to gender is often highlighted in the published literature…the children also experienced high levels of distress…pertaining to family conflict, lack of protection by the attachment figure, loss events, maltreatment, domestic violence, and rejection or abandonment by attachment figures.

The results indicate that ACEs contribute to GD. A simplistic ‘innate’ neurobiological model of GD does not account for childhood development. The results support psychotherapeutic interventions.

…treatment interventions with these children require a comprehensive biopsychosocial assessment with the child and the family, followed by therapeutic interventions that address, insofar as possible, the breadth of factors that are interconnected with each particular child’s clinical presentation. Included in this context are efforts to increase the child’s sense of acceptance by, and safety with, family and peers.


adverse childhood eventsgender dysphoriamental healththerapy