School refusal by patients with gender identity disorder

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General Hospital Psychiatry 34 (2012) 299 – 303

School refusal by patients with gender identity disorder Seishi Terada, M.D., Ph.D. a,⁎, Yosuke Matsumoto, M.D., Ph.D. a , Toshiki Sato, M.D., Ph.D. b , Nobuyuki Okabe, M.D. a , Yuki Kishimoto, M.D. a , Yosuke Uchitomi, M.D., Ph.D. a a

Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan b Sato Mental Clinic, Okayama 700-8558, Japan Received 1 September 2011; accepted 14 November 2011

Abstract Objective: The accumulating evidence suggests that school refusal behavior is associated with severe negative outcomes. However, previous research has not addressed school refusal by patients with gender identity disorder (GID). In this study, we tried to clarify the prevalence of school refusal among GID patients and the relationship of school refusal to demographic characteristics. Methods: A total of 579 consecutive Japanese GID patients at the outpatient GID Clinic of Okayama University Hospital between April 1997 and October 2005 were evaluated. Results: The prevalence of school refusal was 29.2% of the total sample. School refusal was more frequent among GID patients with divorced parents than those with intact families. Multiple logistic regression analysis showed that younger age at consultation and divorce of parents were significantly associated with school refusal among the male-to-female GID patients. Conclusion: The rate of school refusal among GID patients is high, and school refusal is closely related with a low level of education and current unemployment. We should pay more attention to GID patients of school age to prevent their school refusal, which results in low educational achievement. © 2012 Elsevier Inc. All rights reserved. Keywords: Gender; Gender identity disorder; School refusal; Transsexualism

1. Introduction Gender identity disorder (GID) is characterized by a strong and persistent identification with the opposite sex and discomfort with one's own sex [1]. Compared with many other psychiatric disorders, GID is rare, with an estimated lifetime prevalence of 0.001%–0.003% [2–4]. But in recent years, there has been a marked increase in patients seeking treatment for GID [5,6]. In 2006 and 2007, a yearly incidence of 1/100,000 in the age bracket of 18–65 was reported [5]. For most GID patients, a strong and persistent identification with the opposite sex and discomfort with one's own sex is a life challenge that often creates distress and carries potential stigmatization [7,8]. Over half of GID patients experience some form of harassment or violence within their ⁎ Corresponding author. Tel.: +81 86 235 7242; fax: +81 86 235 7246. E-mail address: [email protected] (S. Terada). 0163-8343/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2011.11.008

lifetime [9]. About half of the GID patients reported having thought seriously about taking their own lives, and about one quarter reported one or more suicide attempts [8,10]. In many patients with GID, a strong and persistent identification with the opposite sex and discomfort with one's own sex began before the age of 18 [11], and victimization began, on average, at age 13 [12]. Therefore, it is possible that such psychological stress might induce a refusal to attend school. However, there have been no studies of the school refusal behavior of GID patients. In Japan, high prevalence rate of school refusal behavior has been reported for more than 10 years [13,14] and is recognized as a major social problem [13–16]. The reason for the increased attention to school refusal behavior is the accumulating evidence of severe negative outcomes associated with it [17–19]. The aim of the present study was to clarify the lifetime prevalence of school refusal behavior and clinical characteristics of those who exhibited school refusal behavior among GID patients in Japan.

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2. Methods 2.1. GID Clinic The GID Clinic at Okayama University Hospital, the second oldest GID clinic in Japan, was established in Okayama in 1997. During the study period, the GID Clinic at Okayama University Hospital was the only specialized GID clinic in western Japan. It consists of four departments: psychiatry, urology, gynecology, and plastic and reconstructive surgery. The services of the GID Clinic include diagnosis, counseling, genetic testing, hormonal therapy, plastic surgery and coordination of social service resources.

The problems of the patient's family members are reported to be important predictors of school refusal [21]. Divorce of parents is recognized as a stressful event in childhood and youth. Therefore, we examined the prevalence of parental divorce among GID patients. Only parental divorce before the patient reached the age of 18 was included in this study. School refusal behavior is reported to be associated with poor academic achievement [18] and poor social skills [19]. In this study, the level of education and whether the patient had a job or not were examined. Finally, the age at onset of GID was defined as the age at which the patient's first well-defined discomfort with his or her sexual identity was perceived.

2.2. Ethics 2.5. Statistics (data analysis) This study was approved by the Internal Ethical Committee of Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences. After a complete description of the study to the subjects, written informed consent was obtained before their inclusion in the study. 2.3. Subjects A total of 603 consecutive Japanese patients consulted the outpatient GID Clinic of Okayama University Hospital between April 1, 1997, and October 31, 2005. All patients were comprehensively evaluated independently by at least two senior psychiatrists with a special interest in this area, and 579 of 603 patients fulfilled the criteria for GID according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [1]. Of 579 patients, 349 (60.3%) were the female-to-male (FTM) type (a biological female who feels a strong identification with male), and 230 (39.7%) were the maleto-female (MTF) type (a biological male who feels a strong identification with female). The mean age at first examination was 26.5±6.1 years for the FTM type and 32.0±10.2 years for the MTF type.

Statistical analysis was conducted using SPSS 18.0J (SPSS Inc., Chicago, IL, USA). The difference in the proportion of MTF and FTM GID patients among groups was evaluated using the χ 2 test. Group differences in school refusal behavior were compared by the χ 2 test. The significance level was set at Pb.05. To identify which variables were significantly correlated with school refusal behavior, we used multiple logistic regression using school refusal behavior as a dependent variable. Independent variables were age at consultation, age at onset and divorce of parents. The final multiple logistic regression model was obtained after the forward selection method of independent variables using the likelihood-ratio test with Pb.10. The strength of the relationship between independent variables and school refusal behavior was expressed by means of odds ratio with 95% confidence interval and P value. Almost all categorical variables differed significantly between MTF and FTM. Therefore, it seems likely that different risk factors would be relevant for school refusal behavior within the respective groups. As a consequence, logistic regression analyses were conducted separately for MTF and FTM.

2.4. School refusal behavior and other clinical data School refusal behavior is defined by the criteria of the Ministry of Education, Culture, Sports, Science and Technology of Japan (MECSST) as refusal by a student to attend school for psychological, emotional, physical or social reasons, and as being absent from school for more than 30 days per year for reasons other than sickness or economic causes [20]. In Japan, most reliable data on school refusal behavior were collected using the criteria of MECSST. Therefore, in this study, the lifetime presence or absence of school refusal behavior was investigated by asking the following question: “Have you ever refused to attend school and been absent from school for more than 30 days per year for reasons other than sickness or economic causes?”

3. Results 3.1. Demographic characteristics of GID patients Demographic characteristics of the patients are shown in Table 1. Almost all FTM-type GID patients (324/349, 92.8%) started to feel discomfort with their sexual identity before graduation from elementary school. In contrast, about half the MTF-type GID patients (101/230, 43.9%) started to feel discomfort with their sexual identity after graduation from elementary school. Almost all variables differed between the MTF and FTM GID patients with the exception of school refusal behavior and divorce of parents. The prevalence of school refusal was high in both MTF and FTM GID patients (MTF, 27%; FTM, 31%).

S. Terada et al. / General Hospital Psychiatry 34 (2012) 299–303 Table 1 Demographic characteristics of patients with GID Variables

MTF

n 230 Age (years): n (%) ≤24 62 (27) 25–29 37 (16) 30–34 49 (21) ≥35 82 (36) 32.0±10.2 Mean age a Age at onset: n (%) Before elementary school 63 (28) Lower grades of 33 (14) elementary school Higher grades of 33 (14) elementary school Junior high school 50 (22) Senior high school and 51 (22) thereafter Stage of therapy at first examination: n (%) No therapy 109 (48) Hormonal therapy without 88 (38) genital surgery With genital surgery 33 (14) Divorce of parents: n (%) Positive 33 (14) Negative 197 (86) Level of education: n (%) University or higher 85 (37) High school 120 (52) Junior high school 25 (11) Job: n (%) Present 143 (62) Absent 87 (38) School refusal: n (%) Positive 62 (27) Negative 168 (73)

FTM

Table 2 Comparison of GID patients with and without school refusal X2

P

Variables

School refusal

349

b.001 141.782

b.001

28 (8) 18 (5) 7 (2)

217 (62) 96 (28)

12.320

.002

36 (10) 61 (18) 288 (82)

0.999

71 (20) 230 (66) 48 (14)

19.438

247 (71) 102 (29)

4.663

107 (31) 242 (69)

0.920

.318

b.001

.031

.338

a Mean age, independent-sample t test (t value=−8.136, degrees of freedom=577).

3.2. Demographic characteristics of patients with school refusal Table 2 shows that the prevalence rate of school refusal behavior was high in all age groups. However, the mean age at first examination was 27.1±8.1 years for patients with school refusal and 29.3±8.5 years for patients without school refusal (P=.004; independent-sample t test, t value −2.866, degrees of freedom 577). There were no significant differences in the prevalence rate of school refusal behavior among groups divided by age at onset of GID and stage of therapy. Divorce of parents was more frequent among GID patients with school refusal (25%) than those without school refusal (13%). School refusal behavior was more common among GID patients with a lower level of education. Forty-five percent of subjects those who exhibited school refusal behavior had suffered from unemployment, whereas 28% of GID patients without school refusal had been unemployed. Among both MTF and FTM subgroups, the relationship of school refusal

X2

P

−

+

150 (43) 105 (30) 52 (15) 42 (12) 26.5±6.1 245 (70) 51 (15)

301

n 169 Age (years): n (%) ≤24 69 (41) 25–29 44 (26) 30–34 25 (15) ≥35 31 (18) Mean age 27.1±8.1 Age at onset: n (%) Before elementary school 91 (54) Lower grades of 24 (14) elementary school Higher grades of 18 (11) elementary school Junior high school 20 (12) Senior high school and 16 (9) thereafter Stage of therapy at first examination: n (%) No therapy 106 (63) Hormonal therapy without 48 (28) genital surgery With genital surgery 15 (9) Divorce of parents: n (%) Positive 42 (25) Negative 127 (75) Level of education: n (%) University or higher 23 (14) High school 89 (52) Junior high school 57 (34) Job: n (%) Present 93 (55) Absent 76 (45)

410 143 (34) 98 (24) 76 (19) 93 (23) 29.3±8.5 217 (53) 60 (15)

.004 0.111

.999

4.455

.108

52 (13) 358 (87)

13.032

b.001

133 (32) 261 (64) 16 (4)

102.576

b.001

297 (72) 113 (28)

16.497

b.001

43 (10) 48 (12) 42 (10)

220 (54) 136 (33) 54 (13)

behavior to a low level of education and present unemployment was significant (data not shown). 3.3. Logistic regression analysis for school refusal Table 3 displays the results of the multiple logistic regression analysis for school refusal behavior. Among MTF GID patients, younger age at consultation and divorce of parents were significantly associated with school refusal behavior. Among FTM GID patients, no independent variables were significantly associated with school refusal behavior.

Table 3 Multiple logistic regression analysis of factors affecting school refusal Variable

B

SD

Wald P

OD

95% CI

MTF Age at consultation −0.046 0.017 7.747 .005 0.96 0.92, 0.99 Divorce of parents −1.192 0.395 9.105 .003 3.33 1.52, 7.14 Constant 1.419 0.603 5.546 .019 SD, standard error; OD, odds ratio; CI, confidence interval of odds ratio. −2 log likelihood=249.051; model χ 2=19.049 (P=.000). Prediction equation: p=1/[1+exp(−1×score)]. Score=−0.046×age−1.192×divorce of parents+1.419. Divorce of parents: negative=0, positive=1.

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4. Discussion 4.1. School refusal among GID patients The lifetime prevalence of youths who refuse to attend school at some point in their lives is 5%–28% [21]. However, the definition of school refusal behavior in those reports varied [21,22], and the prevalence rate of school refusal behavior is quite different in various subgroups [22]. Therefore, we need to examine the rate of school refusal behavior among Japanese youth according to the criteria of the MECSST. In Japan, the proportion of all students refusing to attend school (elementary and junior high school) according to the MECSST criteria increased gradually from 0.47% in 1991 to 1.23% in 2001, and thereafter, the rate remained almost unchanged (1.18% in 2002 to 1.18% in 2008) [13]. The MECSST has published the rate for high school students for only 5 years (2005–2009), and it decreased gradually (1.66% in 2005 to 1.55% in 2009) [14]. Taking these total prevalence rates into consideration, the prevalence rate of school refusal behavior among GID patients (MTF, 27%; FTM, 31%) was very high. 4.2. Other clinical characteristics of GID patients with school refusal behavior Parental divorce is reported to be a contextual risk factor for school refusal behavior, and 39% of youths with school refusal behavior lived with a single parent [23]. In Japan, it is reported that 14% of children with school refusal behavior are from one-parent homes [16]. In this study, parental divorce was significantly correlated with school refusal behavior among MTF GID patients. Younger age at first consultation was also significantly associated with school refusal behavior among only MTF GID patients. MTF and FTM GID patients were quite different. Among FTM patients, only 7% of the subjects started to feel discomfort with their sexual identity during junior and senior high school [11]. On the other hand, 44% of the MTF-type GID patients started to feel discomfort with their sexual identity during junior and senior high school [11]. Boys with gender atypicality reported significantly more victimization than girls with gender atypicality [12]. Another study reported gender-related abuse (psychological and physical) to be a major health problem, especially among MTF GID patients and particularly during adolescence [24]. These data suggest the possibility that MTF GID adolescents might be more vulnerable to external causes of distress, such as parental divorce, than FTM GID patients. The younger age at first consultation of MTF GID patients suggests that the prevalence rate of school refusal has increased only among MTF GID patients in recent years and that the prevalence rate of school refusal by FTM GID patients did not change. We cannot suggest a reason why younger age at first consultation by MTF GID patients is

related to school refusal at the present. Further studies on gender harassment during adolescent may shed the light on the mechanism. Long-term sequelae of school refusal behavior include academic underachievement, employment difficulties and increased risk for psychiatric illness [25,26]. In this study, school refusal behavior is significantly correlated with the level of education and present unemployment among both MTF and FTM GID patients. However, we performed only univariate analysis and cannot conclude at present that school refusal behavior caused later academic underachievement and employment difficulties among GID patients. In the future, a study using multivariate analysis in which the level of education or present unemployment is regarded as a dependent variable is needed. 4.3. Limitation of this study Several limitations of this study have to be considered. Firstly, this study is a clinic-based study rather than a field study. Therefore, the sample is large, but not necessarily representative of all GID individuals. As stated above, in this study, 60.3% were FTM GID patients, and 39.7% were the MTF type. This proportion is not common in studies on GID. Secondly, the data were based on retrospective selfreporting of school refusal behavior and thus may be subject to underreporting and biased recall. The temporal contexts of school refusal behavior and parental divorce were not clarified. We did not collect information from third-party informants to validate the respondents' reports. Thirdly, the harassment during school age among GID patients was not evaluated. Fourthly, school refusal behavior should be considered a heterogeneous and multicausal syndrome [27]. It may be caused, for example, by an attempt to avoid specific fears provoked by the school environment, avoidance of aversive social situations or separation anxiety [27]. However, in this study, we did not clarify the reason for and age at school refusal behavior. In a future study, subtypes of school refusal behavior should be considered separately. Despite these limitations, this is the first report to clarify the prevalence of and risk factors for school refusal behavior among GID patients outside North America and Western Europe.

Acknowledgment We thank Ms. Ogino and Ms. Kanamori for their skillful assistance in this study. This study is partly supported by a grant from the Zikei Institute of Psychiatry.

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