Bullying victimization in variant gender children: Experience in Madrid ́s gender identity unit

It had been reported that transgender people show increased prevalence of stressful childhood experiences. Objective: We describe and analyze the probability of suffering from bullying in gender dysphoria minors, for both genders, as referred to our Gender Identity Unit, at University Hospital “Ramón y Cajal”. Patients and method: Our study has a descriptive design. We took in consideration the variable “self-reported bullying”. If positive, we also asked if they felt it was related to gender dysphoria. Fifty-three consecutive minors were included. Data were collected through a structured clinical interview, 54.7% were female and 45.3% were male. Results: Of 53 children, 52 completed the whole interview. One child was referred to a Mental Health Centre, because of severe psychopathology, and did not complete the interview. From the total of 52 children included, 13 (24.5%) stated bullying and 39 (73.5%) denied. From the 13 children reporting bullying, 12 (92.3%) felt it was related to their gender dysphoria. We found no significant differences (p=0.054) from the two sexes. Conclusions: Our data do not support the idea, reported by other authors, that minors with gender dysphoria suffer from increased bullying rates than nondysphoric minors. Correspondence to: Nuria Asenjo-Araque, Gender Identity Unit, University Hospital Ramón y Cajal, Madrid, Spain, E-mail: mailto:nasenjo@gmail.com


Introduction
Transsexual people have a self-identity as male or female, that do not match their chromosomic gender [1]. If we speak about infancy and adolescence, this is even more complex, being extremely important both early diagnosis and integral treatment of minors in gender dysphoria [2].
Stressful childhood experiences had been reported to be associated with psychiatric symptoms, physical illnesses, alcoholism, and drug abuse. Transgender people show increased prevalence of stressful childhood experiences, when compared with heterosexual controls [3].
Recent Spanish surveys [4] in 21,487 students of secondary school (from 12 to 16 years old), show that 9.3% self-reported being bullied and 6.9% cyberbullying. These data, extrapolated to the overall population of students, results that the number of minors that suffered bullying raise to 111,000, and 82,000 from cyberbullying. Female minors have the worst results: 10.6% manifested self-reported bullying (was 8% in male minors), and 8.5% cyberbullying (was 5.3% in male minors) [4]. These types of negative experiences suffered during infancy and/ or adolescence is crucial for the identity development (Maylon 1982). Unfortunately, as mentioned before, both bullying and cyberbullying are widespread problems throughout schools and teaching centers, and a well-known issue as well as an investigative topic [5]. Bullying, in its different variants, threatens health and psychosocial development of the minor [6]. This kind of intimidation is equivalent to a subtype of aggressive behavior, where the offenders intentionally and continuously attack their victims, who are usually impotent, during a long period of time [7]. This attack may be physical, verbal or relational (malicious rumors or deliberate social exclusion) (Lund 2016). It can also adopt a way, in which the victim perceives that there are no places where they can stay safe, sometimes even facing anonymous attackers. This is cyberbullying [8].
There is a strong evidence supporting that Lesbian, Gay, Bisexual and Transgender (LGBT) population, had a high prevalence of stressful childhood experiences, including bullying [9]. This population is considered to be among the most vulnerable collectives in our society. In gender dysphoria minors, it is especially needed to take this into account, in order to prevent and protect this vulnerable population. Gender dysphoria minors have to deal with complex situations and challenges (usually adverse), where there is an ongoing confrontation of the cultural expectations of gender expression and seeing how to fit in with what is natural for them, based on their gender identity. Trying to find a balance, learning how to cope, questioning but being comfortable with your gender identity and sexual orientation, are paramount for a healthy growth and development [10].
Bearing in mind the prevalence of bullying in the general population, it could be expected that gender dysphoria minors should be more prone to become victims of bullying (and their different forms) than other minors. In our present study, we tried to ascertain the prevalence of bullying in gender dysphoria minors in our Gender Identity Unit (GIU), and to analyze if there is any relationship with gender identity.

Subjects
Our study included 53 minor patients, who met the following inclusion criteria: minors (i.e.: younger than 18) when first attended in our GIU, from May 2007 to April 2016, and of legal age (i.e.: older than 18) in 2016 or before. Of these minors, 29 (54.7%) identified themselves with female gender (but had male chromosomic sex), and 24 (45.3%) identified themselves with male gender (but had female chromosomic sex). Four of them attended our GIU when they were between 12 and 14 years old, while the rest of 49, attended between 15 and 17 years old.

Measures, design and procedures
Data collection was conducted using our clinical structured interview (Interview of Psychological evaluation to patients with identity gender disorder) [11]. From these results, we made a selection of those who could give us information about being bullied (in any of its variants). For those minors who answered affirmatively, we took into consideration if that bullying was related or not with their gender dysphoria, i.e. related with the process of change towards their gender identity.
Descriptive design, descriptive data, variable of interest were taken from 53 minor patients attended in our GIU. These patients were referred from their primary care physician or pediatrician. First, the head of the GIU makes an initial assessment. If pertinent, a new appointment is given with one of the clinical psychologists and the structured interview could be conducted to collect data [12].
Descriptive analysis were performed to investigate the frequency and percentage of minors in each of the variables evaluated (gender identity perceived, bullying history, relationship between bullying and gender dysphoria). To assess the relationship among variables, we used the Chi-square test (χ 2 ).

Results
Of the total of 53 minors, 52 (98.11%) completed the interview; one minor was discarded from the study because it was considered that he had to be evaluated previously in a Mental Health Centre, due to severe psychopathology background. The results (see Table 1) show that from 52 minors who completed the interview in our GIU, 13 (24.5%) stated they had suffered from some kind of bullying, and 39 (73.5%) stated they had never suffered these negative experiences.
From the 13 gender dysphoric minors that suffered from bullying, 12 (92.3%) thought it was related to their gender dysphoria condition.
No significant statistical relationship was found between the gender they felt (regardless if male or female) and suffering bullying (p= 0.054), nor in the cases with previous history of bullying according to the identity gender they felt (p= 0.569).

Discussion
Current available evidence regarding victimization experiences from LGTB people is a quite recent focus of research. Although plenty of data show that bullying has a higher prevalence in gender dysphoria minors, our results from the present study do not support the previous evidence. We ignore the exact cause of this. Might be because Spain, and more precisely Madrid, is very tolerant and "trans-friendly" [13].
Stressful childhood experiences have gained increased attention along the years. It looks like the exposure to a previous stressful situation during childhood increases the risk of further exposures to other stressful or traumatic experiences, up to 80% or even beyond [3]. Great part of the evidence states that bullying in a gender dysphoria minor, is more frequent and is more often associated with psychosocial aspects compromised in adult life, compared with the general population [6,14,15].
Oppositely, to what has traditionally been suggested in the literature, there is another study [16], in which the authors found that in the 27 studied school classes in the Netherlands, the gender-referred children were not more often bullied than other children, despite their gender nonconforming behavior.
It is of capital importance, an adequate transmission by the professionals who attend this population in schools, and other places where they spend great part of their daily time. Some studies [15], suggest that youth-led interventions in peer networks, and the modelling of anti-bullying behaviours by colleagues of their same age, is much more powerful than modelling from adults. Therefore, a proper education to people working, spending time and getting along with them, could revert the obnoxious influence that many adverse situations have on them. In the background of the "Affirmative Therapy", we work with this gender dysphoria children and adolescents. From this approach, one of the primary objectives is to provide these minors with the corrective experiences to prevent the consequences of partial socialization.
The conceptual framework of Affirmative Therapy is born from a model of minority stress, which recognizes the negative psychological effects associated with discrimination, rejection, and even hiding self's identity, in the health and well-being of LGTB people. This should be the result of their belonging to a stigmatized social category (Johnson 2012). In our GIU, we provide active support to these minors during the process of affirmation of the gender identity felt, with the aim of assuming their sexual identity in a healthy way, and can develop an active and effective coping style to deal against social stigma and associated conflicts.
Some findings [9] show that the combination of different sources of support received by minors LGBT, is related with better mental health. It is crucial that they can obtain the support of teachers and other significant people, as well as being in contact with other young people in their same situation. For this reason, it is necessary to bear in mind not only the risk factors, but also the protective factors. A metaanalysis conducted in 2016 [6] revises the studies based in schools where school organizations for young LGTBQ (LGTBQueer) aim to improve the environment for sexual minorities. These findings suggest that the presence of these groups is associated with significant lower self-reported levels of victimization, showing evidence that constitute an important protective factor of bullying for gender dysphoria minors.
Taking into account all these data, the results obtained in our study look to be inconclusive. Although these data must be analysed with caution, given the size of the sample. Nonetheless, we should finally explain that in the last couple of years, surely due to a more open minded society, informational TV and radio programs (probably among many other reasons), the minors attended in our GIU, were sent at younger age and increased number. In the near future, we will try to ascertain that, even the number of bullied children and adolescents is not bigger than in other minors, if the severity of that bullying is more damaging or equivalent.

Statement contributorship
N. Asenjo-Araque, conceived the work, assisted in the study design, selected articles for inclusion, supervised the project and helped both with data extraction and writing the paper. M. C. Escolar-Gutiérrez, assisted in both the study design and statistical method, helped both with data extraction and writing the paper. A. Pascual-Sánchez, assisted in both the study design and statistical method, helped both with data extraction and writing the paper. D Ly-Pen, wrote the protocole, selected articles for inclusion, supervised the project and helped writing the paper. A Becerra, conceived the work, wrote the protocol, assisted in the study design, and helped in supervising the project and writing the paper. All the authors have revised and all have participated actively in the elaboration and approved the final draft.