Personality Disorders and Personality Profiles in a Sample of Transgender Individuals Requesting Gender-Affirming Treatments

Detransition Narratives Trouble the Simple Attribution of Madness in Transantagonistic Contexts: A Qualitative Analysis of 16 Canadians' Experiences

Emerging evidence suggests that transgender individuals are more likely than cisgender peers to receive a diagnosis with a primary mental disorder. Attributions of madness, though, may serve the social function of dismissing and discrediting transgender individual's self-perceptions. The narratives of individuals who stop or reverse an initial gender transition who also identify as living with mental health conditions can sometimes amplify these socio-political discourses about transgender people. Through a critical mental health lens, this article presents a qualitative analysis of 16 individuals who stopped or reversed a gender transition and who also reported a primary mental health condition. Semi-structured, virtual interviews were conducted with people living in Canada. Applying constructivist grounded theory methodology, and following an iterative, inductive approach to analysis, we used the constant comparative method to analyse these 16 in-depth interviews. Results show rich complexity such that participants narrated madness in nuanced and complex ways while disrupting biased attitudes that madness discredited their thoughts and feelings, including prior gender dysphoria. Instead, participants incorporated madness into expanding self-awareness and narrated their thoughts and feelings as valid and worthy. Future research must consider provider's perspectives, though, in treating mad individuals who detransitioned, since alternate gender-affirming care models may better support the identification and wellness of care-seeking individuals who may be identified (in the past, present, or future) as mad.

Romantic relationship obsessive-compulsive doubts, perfectionism, and DSM-5 personality traits in LGB people: a comparison with heterosexual individuals

Introduction

Relationship Obsessive-Compulsive Disorder is characterized by the presence of relationship-centered or partner-focused obsessions and compulsions that determine a great sense of doubt toward the partner or the relationship. Personality characteristics, including perfectionism, are involved in the development of Relationship Obsessive-Compulsive Disorder, and could predispose the individual to excessive doubts and preoccupations regarding the "adequacy of the couple" or the physical appearance of one's partner. Evidence from epidemiological research shows that the LGB community can present a high risk and prevalence of obsessive-compulsive symptoms and recent research demonstrated the usefulness of the DSM-5 personality model in understanding the personality of sexual minorities. However, further research is necessary to deepen our knowledge of the relationship between these variables in the LGB community. The aim of the present study was to compare a group of heterosexual individuals to a group of LGB individuals regarding personality traits, perfectionism, and relationship obsessive-compulsive symptoms.

Methods

A total of 200 participants, 98 in the heterosexual group and 102 in the LGB group, were enrolled in the study and completed a psychological battery comprised of the Obsessive-Compulsive Inventory-Revised, Personality Inventory for DSM-5, Relationship Obsessive-Compulsive Inventory, Partner-Related Obsessive-Compulsive Symptom Inventory, and Multidimensional Perfectionism Scale.

Results

The results show that LGB individuals tend to report greater feelings of doubt regarding the partner's love, more negative emotions (Negative Affect) and Antagonism, and greater perfectionism traits compared to heterosexual individuals.

Conclusion

These findings underline the necessity to consider the implementation of personalized interventions in clinical practice and the importance of initiating early preventive programs in sexual minority communities.

Gender- and Sexuality-Minoritised Adolescents in DBT: A Reflexive Thematic Analysis of Minority-Specific Treatment Targets and Experience

Gender- and sexuality-minoritised (GSM) adolescents are at increased risk of self-harm and suicidal behaviours compared to their cisgender and heterosexual peers. This increased risk is thought to be explained in part by exposure to stigma and societal oppression. Dialectical Behaviour Therapy (DBT) is an evidence-based intervention for self-harm and suicidal behaviour that may have advantages for supporting GSM young people in distress. No study has yet sought to understand what GSM-associated difficulties may be important to consider in DBT for adolescents, or the experiences of GSM young people in a standard DBT programme. Therefore, this study aimed to understand the experiences of GSM young people in DBT and what difficulties and dilemmas associated with their gender and sexuality diversity were thought by them to be important to target in DBT. Qualitative interviews were conducted with 14 GSM young people in a comprehensive DBT programme and were analysed using Reflexive Thematic Analysis. The analysis was supported by two further GSM young people who had finished DBT. The findings were split into three overarching themes (Identity, Impact of Others, and Space for Sexual and Gender Identity in DBT), each with themes within. The identity-based theme included "identity confusion and acceptance"; the relationship-based themes included "cis-Heterosexism" and "community connectedness"; and the space within DBT themes included "negotiating focus and targeting in DBT" and "creating safety in DBT". Findings are discussed in relation to implications and recommendations for therapists working with GSM young people within and outside of DBT.

Gender equity in hiring: examining the effectiveness of a personality-based algorithm

Introduction

Gender biases in hiring decisions remain an issue in the workplace. Also, current gender balancing techniques are scientifically poorly supported and lead to undesirable results, sometimes even contributing to activating stereotypes. While hiring algorithms could bring a solution, they are still often regarded as tools amplifying human prejudices. In this sense, talent specialists tend to prefer recommendations from experts, while candidates question the fairness of such tools, in particular, due to a lack of information and control over the standardized assessment. However, there is evidence that building algorithms based on data that is gender-blind, like personality - which has been shown to be mostly similar between genders, and is also predictive of performance, could help in reducing gender biases in hiring. The goal of this study was, therefore, to test the adverse impact of a personality-based algorithm across a large array of occupations.

Method

The study analyzed 208 predictive models designed for 18 employers. These models were tested on a global sample of 273,293 potential candidates for each respective role.

Results

Mean weighted impact ratios of 0.91 (Female-Male) and 0.90 (Male-Female) were observed. We found similar results when analyzing impact ratios for 21 different job categories.

Discussion

Our results suggest that personality-based algorithms could help organizations screen candidates in the early stages of the selection process while mitigating the risks of gender discrimination.

Exploring Gender Diversity in Transgender and Non-Binary Adults Accessing a Specialized Service in Italy

In Italy, studies investigating gender identity and expression in gender non-conforming adults are lacking, as well as data regarding the non-binary population. The present study aimed at dimensionally exploring how transgender and non-binary Italian adults identify and express their gender. The Gender Diversity Questionnaire (GDQ) was administered to a sample of 112 adult subjects aged 18-60 years accessing a gender-specialized service in Rome. The majority of the participants were aged 18-24 years (53.6%), whereas fewer subjects were aged 25-35 years (32%) and 35 years and older (14.3%). Most participants (83.9%) identified themselves as trans binary, while the remaining (16.1%) identified as non-binary. Trans binary participants reported a stable gender identity, whereas non-binary participants reported a more fluid gender identity over time and across contexts. Younger subjects recognized the use of chosen names, pronouns, and clothes as important for their gender expression, whereas older subjects attributed more importance to physical appearance and emotions. Differences regarding gender-affirmative interventions emerged between non-binary and transbinary participants. Findings evidence that gender non-conforming adults accessing gender-specialized services have unique needs and features, thus it is essential to shed light on this population by providing greater visibility and recognition.

The Role of Family Support and Dyadic Adjustment on the Psychological Well-being of Transgender Individuals: An Exploratory Study

Introduction

This study aimed to measure dyadic adjustment, social support, and psychological well-being.

Methods

A research protocol composed of the Dyadic Adjustment Scale, the Outcome Questionnaire 45.2, and the Multidimensional Scale of Perceived Social Support was administered to a sample of 109 Italian transgender individuals.

Results

Higher levels of global psychological distress, symptom severity, and interpersonal relationship distress were associated with lower levels of family support and dyadic adjustment. In addition, transgender women and younger transgender individuals reported higher levels of interpersonal relationship distress.

Conclusions

The results indicate that the support and acceptance of one's partner and family of origin play a crucial role in promoting well-being. It represents an important protective factor with respect to negative psychological health outcomes.

Policy Implications

The findings emphasize the need to develop specific clinical and social practices for transgender individuals and their families. Building family and partner-centered policies and programs is particularly important to enable transgender individuals to avoid paying the emotional and psychological costs associated with rejection and non-acceptance.

Gender-Affirming Hormone Therapy for the Trans, Gender Diverse, and Nonbinary Community: Coordinating World Professional Association for Transgender Health and Informed Consent Models of Care

Purpose

Before commencing gender-affirming hormone therapy, people undergo assessments through the World Professional Association for Transgender Health (WPATH) model (typically with a mental health clinician), or an informed consent (IC) model (without a formal mental health assessment). Despite growing demand, these remain poorly coordinated in Australia. We aimed to compare clients attending WPATH and IC services; compare binary and nonbinary clients; and characterize clients with psychiatric diagnoses or longer assessments.

Methods

Cross-sectional audit of clients approved for gender-affirming treatment (March 2017-2019) at a specialist clinic (WPATH model, n=212) or a primary care clinic (IC model, n=265). Sociodemographic, mental health, and clinical data were collected from electronic records, and analyzed with pairwise comparisons and multivariable regression.

Results

WPATH model clients had more psychiatric diagnoses (mean 1.4 vs. 1.1, p<0.001) and longer assessments for hormones (median 5 vs. 2 sessions, p<0.001) than IC model clients. More IC model clients than WPATH model clients were nonbinary (27% vs. 15%, p=0.016). Nonbinary clients had more psychiatric diagnoses (mean 1.7 vs. 1.1, p<0.001) and longer IC assessments (median 3 vs. 2 sessions, p<0.001) than binary clients. Total psychiatric diagnoses were associated with nonbinary identities (β 0.7, p=0.001) and health care cards (β 0.4, p=0.017); depression diagnoses were associated with regional/remote residence (adjusted odds ratio [aOR] 2.2, p=0.011); and anxiety disorders were associated with nonbinary identities (aOR 2.8, p=0.012) and inversely associated with employment (aOR 0.5, p=0.016).

Conclusion

WPATH model clients are more likely to have binary identities, mental health diagnoses, and longer assessments than IC model clients. Better coordination is needed to ensure timely gender-affirming care.

Borderline Personality Disorder Symptoms in a Community Sample of Sexually and Gender Diverse Adults

The current study aimed to identify borderline personality disorder (BPD) symptom disparities in sexually and/or gender diverse adults, determine if BPD symptoms vary across sexual orientation and gender identity, and identify factors related to BPD symptoms in this population. A sample of 218 sexually and gender diverse adults completed measures for BPD symptoms and trauma/stressors. Results suggest that sexually and/or gender diverse adults scored higher on six of the nine diagnostic criteria for BPD and were likely to have a probable BPD diagnosis, although these disparities were not observed across groups. Factors such as age, abuse and neglect and stigmatizing events were associated with more BPD symptoms, although the relationship between stigma and BPD symptoms did not remain when controlling for other factors. Results suggest that sexual orientation and gender identity are important factors when investigating BPD, and stigma may in part account for this disparity, although future research is needed.

Commentary: Bringing together lived experience, clinical and research expertise - a commentary on the May 2022 debate (should CAMH professionals be diagnosing personality disorder in adolescence?)

BACKGROUND

There is a wealth of evidence to suggest that the Borderline Personality Disorder (BPD, or similar Emotionally Unstable Personality Disorder, EUPD) construct is harmful. We provide a commentary on the ideas expressed in the May Debate issue, highlighting both concerns and alternatives.

METHOD

We bring together lived experience, clinical and research expertise. This commentary was written collaboratively drawing on all these sources of evidence.

RESULTS

We outline evidence that the BPD construct is invalid, harmful, not necessary for effective treatment and a potential block to the development and evaluation of alternatives.

CONCLUSIONS

We ask readers to consider these concerns, perspectives and ideas.

Transgender and Gender Diverse Patients in Intensive Mood Disorder Treatment: A Comparative Examination of Clinical Presentation and Treatment Outcomes

Individuals who are transgender and gender diverse (TGD) are more likely to suffer from and to seek mental health services for mood disorders. Some literature suggests that TGD individuals, because of pervasive and systemic minority stress, may have more complex clinical presentations (i.e., psychiatric conditions and severity of symptoms) and may benefit from empirically based treatments to a lesser degree than their cisgender peers. However, research has yet to examine individuals who are TGD receiving treatment in specialized, intensive mood disorder treatment despite the propensity for them to be diagnosed with and treated for mood disorders. Using a sample of 1,326 adult patients in intensive mood disorder treatment (3.8% TGD), the clinical presentation and treatment outcomes were compared between patients who are TGD and cisgender. Contrary to previous research, TGD patients were largely similar if not healthier than their cisgender counterparts, including similar depression severity, quality of life, emotion dysregulation, and behavioral activation, and less severe rumination at admission. Despite similar to better reported mental health symptoms, TGD patients were diagnosed with more psychiatric conditions overall, including greater prevalence of social anxiety and neurodevelopmental diagnoses. Those who are TGD did not experience attenuated treatment response as predicted. Findings suggest that patients in intensive mood disorder treatment who are TGD may be more resilient than previously assumed, or supports may have increased to buffer effects of stigma on mental health, and emphasize the need to exercise discretion and sensitivity in diagnostic practices to prevent over-diagnosis and pathologizing of TGD individuals.

Characteristics of Transgender Individuals With Emergency Department Visits and Hospitalizations for Mental Health

OBJECTIVE

Transgender individuals experience significant oppression resulting in mental health disparities. Factors associated with their need for acute mental health care are unknown. This study compared characteristics of transgender individuals who presented for acute mental health care with population-based comparison samples.

METHODS

This cross-sectional study examined transgender individuals who had a mental health-related emergency department (ED) visit (N=728) or hospitalization (N=454). Transgender individuals were identified, and their data were linked with health administrative data. The transgender ED and hospitalization samples were each compared with two samples: all individuals in Ontario who had an ED visit or hospitalization (unmatched) and individuals matched on age, region of residence, and mental health care utilization history. Individuals' sociodemographic and clinical factors were compared.

RESULTS

After matching, transgender individuals in the ED sample were more likely than those in the comparison group to be in the lowest neighborhood income quintile (37% versus 27%) and the highest residential instability quintile (47% versus 38%) and to be diagnosed as having a mood (26% versus 19%) or personality disorder (4% versus 1%). Transgender individuals in the hospitalization sample were more likely to be in the lowest neighborhood income quintile (36% versus 27%) and the highest residential instability quintile (45% versus 35%) and to be diagnosed as having a mood (40% versus 35%) or personality disorder (5% versus 2%).

CONCLUSIONS

Transgender individuals who accessed acute mental health care had unique sociodemographic and clinical factors associated with their presentation that persisted after matching. More research into the factors associated with their acute care presentation is warranted, including how experiences of marginalization play a role.

Sex and gender in treatment response to dialectical behaviour therapy: current knowledge, gaps, and future directions

Borderline personality disorder (BPD) is a mental health condition characterized by emotion dysregulation, interpersonal impairment, and high suicidality. Dialectical behaviour therapy (DBT) is the most widely studied psychotherapeutic treatment for BPD. To date, the vast majority of DBT research has focused on cisgender women, with a notable lack of systematic investigation of sex and/or gender differences in treatment response. In order to encourage effective, equitable treatment of BPD, further investigation into treatment targets in this population is critical. Here, we employed a systematic strategy to delineate gaps in the DBT literature pertaining to sex and gender differences and propose directions for future research. Findings demonstrate a significant discrepancy in measurement of sex and gender, particularly among gender-diverse individuals. Exploring DBT treatment response across the full spectrum of genders will facilitate the provision of more tailored, impactful care to all individuals who suffer from BPD.

Key learning aims

(1)

Evaluation of personality disorders in patients with Gender Identity Disorder (GID): An update

Introduction

Gender dysphoria (GD) could cause various mental illnesses, but its main cause is unclear. GD patients also suffer from different personality disorders that increase the risk of side effects among them. The present review study is aimed to investigate the most recent studies on comorbid personality disorders in patients with GD.

Materials and Methods

Online databases were searched using related keywords for collecting any related articles. After precise reviewing the abstract of all collected articles, those with more appropriate content were included in our study.

Findings

The prevalence rate of personality disorders in GD patients has been reported to be from 15% to 80% by different studies. In line with the data from previous studies, it was revealed that borderline personality disorder is one of the most prevalent disorders among GD patients. Available comorbid personality disorders cause a wide range of side effects on the normal function of patients.

Conclusion

The majority of studies carried out on the comorbidity of personality disorders have revealed that the possibility of personality disorders in GD patients is high. Anyway, further studies are required to understand the exact effect of psychological care on personality disorders in these patients.

Mental health in transgender individuals: a systematic review

Several lines of evidence indicate the prevalence of mental health disorders in Transgender (TG) individuals is higher than that of cisgender individuals or the general population. In this systematic review, we aim to propose a summary of some of the most significant research investigating mental health disorders' prevalence among this population. We performed a double-blind systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting (PRISMA) on PUBMED/MEDLINE and SCOPUS, specifically using peer-reviewed articles examining the mental health status of transgender (TG) individuals. This review did not exclude any research based on publication date. The last search was performed in February 2022. The employed search strategy led to the selection of 165 peer-reviewed articles. The majority of these papers presented a cross-sectional design with self-reported diagnoses and symptoms, signaling a significant prevalence of mental health disorders amongst TG Individuals. Of the reviewed articles, 72 examined the prevalence of mood and anxiety disorders; 8 examined eating disorders; 43 examined the prevalence of suicidal or self-harm ideation or behaviors; 5 papers examined the prevalence of trauma and stress-related disorders; 10 examined the frequency of personality disorders; 44 examined substance use disorders; and 9 papers examined the prevalence of autism spectrum disorder. Finally, 22 studies reported on the prevalence of TG individuals diagnosed with co-morbid mental health disorders or unspecified mental disorders. Our findings coincide with existing research, which indicates TG individuals do experience a higher prevalence of mental health disorders than that of the general population or cisgender individuals. However, further research is needed to address the existing gaps in knowledge.

Clinical Presentation and Treatment Trajectory of Gender Minority Patients With Obsessive-Compulsive Disorder

Gender minorities experience unique minority stressors that increase risk for psychiatric disorders. Notably, gender minorities are four and six times more likely than their cisgender female and male peers, respectively, to be treated for or diagnosed with obsessive-compulsive disorder (OCD). Despite higher rates of OCD, more psychiatric comorbidities, and minority stressors, little is known about the clinical presentation and treatment outcomes of gender minorities with OCD. Using a sample of 974 patients in specialty treatment programs for OCD, the current study found that gender minorities reported more severe contamination symptoms and greater incidence of comorbid substance use/addiction, trauma/stressor-related, personality, and other/miscellaneous disorders compared to cisgender male and female patients. Despite significantly longer lengths of stay, gender minorities reported less symptom improvement across treatment compared to cisgender male and female patients. Findings underscore the need for continued research to improve the effectiveness and individualization of treatment for gender minorities with OCD.

Epidemiology of personality disorders in individuals with gender dysphoria

PURPOSE OF REVIEW

Prevalence estimates of personality disorders (PD) in individuals with gender dysphoria (GD) are variable and heterogeneous, as psychiatric comorbidity and long-term follow-up data from gender-diverse samples are still limited. This review aims to assess prevalence rates across age groups and discuss potential reasons for variability in PD prevalence estimates among transgender people.

RECENT FINDINGS

International epidemiological data from several countries indicate that the best available estimates of the prevalence of any PD diagnosis in transgender youth are around 20% for adolescents and tend to increase to nearly 50% in trans-adults. The paucity of available data on personality dysfunction in children and adolescents with GD precluded us from definitive conclusions on the trends of emerging PDs in this population. Estimates of PD prevalence in transgender and gender-diverse people seem to be highly affected by methodological characteristics of the studies with no universally agreed reference standards for this population.

SUMMARY

The review of epidemiological studies on PD among gender-diverse people highlights the need for using more standardized study methodologies to make findings comparable. Nevertheless, international epidemiological data seem to support the link association between the development of PD and GD.

Gender Identity Milestones, Minority Stress and Mental Health in Three Generational Cohorts of Italian Binary and Nonbinary Transgender People

Transgender and gender nonconforming (TGNC) people experience high rates of minority stress and associated risk for negative health outcomes. However, during the last years, significant positive socio-cultural changes have happened, and younger cohorts of TGNC individuals are having diverse experiences compared to older cohorts. By integrating the minority stress theory and the life course perspective, this cross-sectional, web-based study aimed to explore in 197 Italian TGNC people aged 18 to 54 years (M = 29.82, SD = 9.64) whether the average ages of gender identity milestones (i.e., first insights about being TGNC, self-labeling as a TGNC person, and coming out), minority stress, and mental health vary among three generational cohorts (i.e., Generation Z, Millennials, and Generation X). Compared with older cohorts, younger participants: (a) were more likely to be in the trans-masculine spectrum; (b) self-labeled as TGNC and came out earlier; (c) had more negative expectations and lower levels of disclosure; and (d) had higher levels of mental health problems. No generational differences related to first insights about being TGNC and distal minority stressors were found. Furthermore, compared with binary individuals, participants with a non-binary identity: (a) reported later ages for the gender identity milestones; (b) had higher negative expectations; and (c) had higher levels of mental health problems. Overall, our findings indicated that changes in the social environments have a limited impact on stigmatization processes and mental health of Italian TGNC people.

Negative Affectivity, Authoritarianism, and Anxiety of Infection Explain Early Maladjusted Behavior During the COVID-19 Outbreak

During the first phase of the COVID-19 outbreak, Italy experienced problems of public order and maladjusted behavior. This study assessed the role of negative affectivity, right-wing authoritarianism, and anxiety of COVID-19 infection in explaining a variety of the maladjusted behaviors (i.e., “China-phobic” discrimination, panic buying) observed with an Italian sample. Specifically, we examined the effect of Negative Affectivity and Right-Wing Authoritarianism on maladjusted behaviors, and the moderating role of anxiety of infection. Seven hundred and fifty-seven Italian participants completed an online survey between March 3rd to the 7th 2020, which was immediately before the lockdown. A moderated-mediation model was tested using a structural equation modeling approach. Results indicated that both Negative Affectivity and Right-Wing Authoritarianism were positively associated with COVID-19-related maladjusted behavior, and that Right-Wing Authoritarianism mediated the relationship between Negative Affectivity and maladjusted behavior. Furthermore, the effect of Right-Wing Authoritarianism on maladjusted behavior was greater for those with high anxiety of infection, and the indirect effect of Negative Affectivity on maladjusted behavior through Right-Wing Authoritarianism was moderated by infection anxiety. Findings highlight potential psychological paths that may inform communication strategies and public health initiatives aimed at promoting healthy behavior during an outbreak.

Endocrine Management of Transgender Adults: A Clinical Approach

The attention to transgender medicine has changed over the last decade and the interest is most likely going to increase in the future due to the fact that gender-affirming treatments are now being requested by an increasing number of transgender people. Even if gender-affirming hormone therapy (GAHT) is based on a multidisciplinary approach, this review is going to focus on the procedures adopted by the endocrinologist in an out-clinic setting once an adult patient is referred by another specialist for ‘gender affirming’ therapy. Before commencing this latter treatment, several background information on unmet needs regarding medical and surgical outcomes should be investigated. We summarized our endocrinological clinical and therapeutic approaches to adult transgender individuals before and during GAHT based on a non-systematic review. Moreover, the possible relationships between GAHT, gender-related pharmacology, and COVID-19 are also reported.

Minority Stress and Mental Health in Italian Bisexual People

Bisexual people are a strongly stigmatized population experiencing health disparities caused by social stigmatization. The predominant framework helping to understand these health disparities and the impact of stigma on mental health of social groups belonging to a sexual minority identity constitutes the minority stress theory. In Italy, studies assessing this model in bisexual populations are very limited. Within this framework, the current study aimed at assessing in 381 Italian bisexual individuals (62 men and 319 women) the effects of anti-bisexual discrimination, proximal stressors (i.e., anticipated binegativity, internalized binegativity, and outness), and resilience on psychological distress. The results suggested that only anti-bisexual discrimination and internalized binegativity were positively associated with psychological distress, and that resilience was negatively associated with mental health issues. Furthermore, the results suggested that internalized binegativity mediated the relationship between anti-bisexual discrimination and mental health problems. No moderating effect of resilience was found. This is the first study to have thoroughly applied minority stress in Italian bisexual people, providing Italian clinicians and researchers with an outline of the associations between minority stress, stigma, resilience, and psychological distress within this population.