Gender nonconformity as a problem of mentalization

Introduction

The active transformations of society in recent decades have affected such areas as human gender and the gender roles of men and women. It is this fundamental, biologically determined division, which helps navigate reality, predict and streamline people’s lives and activities, is undergoing significant changes, and is on the verge of becoming an inappropriate relic. The phenomena of gender variability are increasingly emerging in society from the underground, are demarginalized and destigmatized. Regarding Western countries, both the medical paradigm and the legal paradigm contribute to gender reassignment for the sake of subjective self-perception. Gender dysphoria is no longer a disorder, but just a feeling of distress from the incongruence of biological sex and internal sensation. For such people, it is proposed to use the terms “gender variable”, “nonconformal”, or “gender expansive” (the term “gender expansive” is used for people whose personality and behavior go beyond the generally accepted ideas about gender and gender representations).

In the article “Why transsexualism isn’t a mental disorder...”, Mendelevich raises the question of what grounds can be taken as the basis for believing that transsexualism is not a mental disorder, and how can it be pathopsychologically characterized. The scientist sees the problem in the fact that it is still not known in what field this phenomenon lies – is it a disorder of thought, consciousness, self-consciousness, or volitional activity? [1] Formally, there is no reason to consider gender incongruence, as gender identity disorders are now called in ICD-11, as a mental pathology. However, the comorbidity of the phenomenon with various mental disorders is high, and often the ideas of gender reassignment are part of a delusional concept in schizophrenia. In addition, the increasing incidence rate of sudden gender dysphoria cases among adolescents, which was pointed out by Littman [2], demonstrates that ideas about gender reassignment occur more frequently in adolescents and young adults, providing more risk factors than exist in puberty. Therefore, modern researchers face an important scientific and ethical task – to destigmatize the phenomenon, while avoiding ignoring scientific facts and providing appropriate therapeutic assistance.

Purpose of the study

This review aims to study and analyze the current trends among Western scientists and mental health professionals regarding issues of gender identity; to study the data of foreign and domestic studies concerning the issues of gender incongruence, gender dysphoria, and their comorbidity with mental disorders, personality disorders, especially with schizophrenia and autism spectrum disorders; to identify promising areas of scientific research in this direction.

Methods

This study used such theoretical research methods as the analysis of scientific literature and publications on the topic. The review of published research was performed according to standard guidelines. Literature search was performed mainly over the past five years among foreign and Russian-language publications in the following electronic databases: Web of Science, Researchgate.net, Google Scholar, Elibrary, and Cyberleninka. The search was conducted according to questions that corresponded to the purpose of the study. English-language queries included such phrases as gender identity disorder, gender identity disorder comorbidity, gender identity disorder schizophrenia, gender identity disorder autism, gender nonconformity. Articles were reviewed for methodological relevance before inclusion in this study.

Results

The prevalence of gender dysphoria among young people is about 1%, and this figure is higher than among adults, which indicates the predominant reversibility of this phenomenon [3]. In general, the group of young patients has not been sufficiently studied, but there is evidence in foreign studies that the majority of persons with gender dysphoria are adolescent girls with recently developed gender dysphoria and concomitant mental and neurocognitive problems [4][5][6][7].

If the comorbidity with mental disorders is so high, it is logical that a psychotherapeutic direction of work with gender-variable individuals should be developed. In the Western world, the problem of gender dysphoria and transgender identity is solved radically, and attempts to “talk about it” are strictly suppressed: conversion therapy is provided to a person planning to reassign gender and is called GICE (gender identity change efforts). According to Western experts in this industry, the therapy of such people should be exclusively gender affirmative, i.e., aimed at asserting themselves in a new role, preparing for hormonal and surgical treatment and adaptation.

D'Angelo et al. analyze in their research the problem of displacement of conversion therapy by affirmative psychotherapy [8]. They dispute the 2020 study by Turban et al. [9], which examined the impact of attempts to change gender identity on the mental health of transgender people. Turban et al. concluded that efforts to change gender identity were harmful to mental health and should be avoided in children, adolescents, and adults. The findings of the research were widely covered by the media, and demands were made to legally ban GICE. D'Angelo et al. note that they state a growing number of people who reassigned their gender in their teens and now regret “not having received exploratory psychotherapy that would have helped them understand their suffering and desire to reassign gender before they underwent irreversible medical or surgical treatment, feeling trapped in ‘Gender No-Man's Land’”. According to the results of research by D'Angelo et al., many therapists continue to affirm transgender identity even when patients have doubts about the correctness of the decision, attributing them to internalized transphobia and encouraging them to continue medical interventions. The authors of the research conclude that for many years, there have been no systematic studies on the role that psychotherapy can play in improving the condition of gender dysphoria, especially among young people. “Promoting ‘affirmation’ approaches that pave the way for the medical interventions is ethically questionable. We believe that exploratory psychotherapy, which is neither ‘affirmation’ nor ‘conversion’, should be the first line treatment for all young people with gender dysphoria”, D'Angelo et al. state [8].

Despite the destigmatization and depathologization of gender incongruence, research continues on the comorbidity of gender dysphoria, gender incongruence, and personality disorders. International epidemiological data from several countries show that among transgender youth, the prevalence of personality disorders is about 20% for adolescents and tends to increase to almost 50% in transgender adults [10]. Perrotta presented a study aimed at defining a correlation between gender dysphoria and personality disorders. In a sample of 255 subjects aged 18 to 72 years who reported presumed transsexuality in either transitional or terminal state, 97.5% were shown by the Perrotta Integrative Clinical Interview PICI-1 (TA version) to have at least five dysfunctional personality traits from the cluster B (borderline, hysterical, narcissistic, antisocial, sadistic and masochistic disorders), and 56.55% had at least three dysfunctional features among disorders of cluster A (anxiety, obsessive, depressive, phobic and somatic disorders) [11].

Thus, the comorbidity of gender nonconforming conditions and pathological personality traits, as well as mental disorders, attracted the attention of researchers, and this area continues to develop, leaving, however, the following question open: are mental disorders a substrate for gender nonconformity or are they caused by stigma trauma?

The problems of gender variability and transsexuality combined with schizophrenic and autism spectrum disorders are also highlighted. In the context of the first problem, these are not crazy ideas of gender reassignment, but a specific thought process that prevents integration. Rajkumar [12] considers these three phenomena as etiologically and phenomenologically related, although the mechanisms of each of them and their relationship with each other still need to be investigated. It should be noted that today there are more and more data on the really high incidence rate of gender nonconformity and gender dysphoria in people from these two spectrums and, conversely, on the high incidence rate of autistic, schizoid, and schizotypal traits in gender nonconforming people. The increase in the number of people who want to reassign their gender, noted in the study by Dyachenko et al., occurs precisely at the expense of people with schizophrenia spectrum disorders, and this indicator is due to the “social pathomorphosis of schizophrenia spectrum disorders” [13].

Researchers from the University of Cambridge, based on data on almost 642 thousand people, have found that autism, autism-related traits, and other mental disorders are more common in transgender people and people with nonbinary gender than in cisgender people [14]. Similar data are indicated in a number of other studies [15][16][17].

At the same time, a number of Western mental health professionals do not consider ASD to be a contraindication to gender reassignment, indicating only that adolescents with gender dysphoria combined with ASD “need special care and clinical knowledge during gender affirmation” [18].

In contrast to the above-mentioned trends, the study by Kallitsounaki et al. aimed to prove the relationship between the feeling of gender nonconformity, dysphoria, the presence of autistic features (including nonclinical manifestations), and the level of mentalization [19].

Mentalization, being a relatively new concept developed by Peter Fonagy and Anthony Bateman, is emotional sensitivity and the cognitive ability to represent the mental state of oneself and other people, but it is not fully identical with empathy, reflection, self-awareness, and self-understanding, although it implies all these notions. The lack of mentalization does not allow interpreting and integrating the events of subjective and objective reality due to the inability to establish a connection by means of finding personal meaning, which allows defining the underdevelopment of self-consciousness, self-understanding, and subjectivity.

One of the most important functions of mentalization is to provide a connection between the biological and the mental, making available for symbolization an indefinite bodily excitation, and express it into a perceived need. In addition, it is the ability to mentalize that allows creating an imaginary reality and distinguishing it from reality, which becomes important when fantasies or delusional ideas encourage, without interpretation and transformation, to objectify, bodily or behaviorally, one’s internal mental experiences, as well as affectively significant experience. This is exactly what can be observed with gender dysphoria: if there is a feeling of discomfort from one’s body, then it is necessary to change it [20][21].

According to Sokolova, with a deficit of mentalization, “an unconscious substitution of the mental picture of the inner world with impulsive actions, hypochondriacal and narcissistic fixations, autistic pseudomentalization and manipulation” occurs. The loss of dialogue with the Other “is internalized into internal ‘muteness’ which means not only the loss of understanding of others, but the interruption of a meaningful internal and ‘articulated’ dialogue with oneself, the loss of self-understanding” [22].

The process of mentalization and its relationship with other mental phenomena is today a promising object of research. In 2020, the study by Kallitsounaki et al. revealed a significant association between autistic traits and gender dysphoria or recollection of cross-gender behavior. In the next study, Kallitsounaki et al. decided to replicate the results for validity and expand the previous findings about the role of mentalization in the relationship between autistic traits and gender dysphoria feelings, as well as demonstrate that mentalization fully mediated this relationship. The results of the study provide an explanation for the increased prevalence of gender incongruence among autistic people: weak mentalization equals more actualized gender dysphoria. It is also important that high mentalization significantly attenuates the association between autistic traits and feelings of gender dysphoria. Therefore, weak mentalization can contribute to “increased fluidity of gender identity”, the opposite of which is gender constancy – the understanding that gender is an invariant human property that remains stable over time and associates with superficial changes in appearance [19].

Fonagy emphasizes the importance of ontogenetically early attachment relations (object relations) for the construct of mentalization: attachment disturbance and destructive experience negatively affect this ability [23]. These factors are also significant in the occurrence of schizophrenia spectrum disorders. Laing formulated this as ontological insecurity – the non-embodiment of the mental Self in the body, the inability to structure and restructure the existential experience, to understand oneself through the Other [24]. In one of the few domestic studies, results were obtained indicating the presence of disorders in the form of pseudomentalization and a specific understanding induced by a decrease in the level of mentalization in individuals with schizotypal disorders [25].

Ball Cooper et al. conducted the first study of the applicability of mentalization theory to an alternative (dimensional) model of personality disorders. The study results demonstrated that participants with high levels of attachment avoidance and lower mentalization abilities rated their affectivity as more negative than subjects with similar levels of attachment avoidance but higher mentalization abilities, which indicated therapeutic opportunities for developing mentalization in relation to individuals with borderline personality disorders [26].

Conclusion

The phenomena of “gender incongruence” and “gender dysphoria” go beyond the framework of a genetically determined notion requiring only affirmation or a psychiatric disorder requiring differential diagnosis and treatment, which poses the task of even more in-depth study of their psychological, subject-existential aspects, especially when these phenomena develop in adolescents and young adults. Formal criteria do not allow classifying gender incongruence that is not in the context of psychotic disorders as the psychopathology that leads to suffering and requires treatment or is destructive to others. However, the high comorbidity of this phenomenon with mental disorders and personality disorders, confirmed by the study, reveals a certain common mechanism for them, which, according to the authors, is mentalization and the phenomena of self-consciousness and self-understanding included in this concept.