A qualitative study on minority stress subjectively experienced by transgender and gender nonconforming people in Italy

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ORIGINAL

ARTICLE

A

qualitative

study

on

minority

stress

subjectively

experienced

by

transgender

and

gender

nonconforming

people

in

Italy

夽

C. Scandurra

a,∗

,

R. Vitelli

a

,

N.M.

Maldonato

a

,

P. Valerio

a

,

V. Bochicchio

b

a

DepartmentofNeuroscience,ReproductiveSciencesandDentistry,UniversityofNaplesFedericoII,Via Pansini5,80131Napoli,Italy

b

DepartmentofHumanisticStudies,UniversityofCalabria,ViaP.Bucci18/C,87036Rende(CS),Italy

Availableonline21May2019

KEYWORDS Transgender; Minoritystress; Health; Coping; Stigma

Summary Agreatamountofquantitativeresearchhaslargelydemonstratedthat transgen-derandgendernonconforming(TGNC)peopleexperiencehighratesofminoritystress,against whichtheyareabletoexerciseresilienceandtouseadaptivestrategiesbufferingthenegative effectsofstressonhealth.Notwithstanding,qualitativeinvestigationsonhowTGNCpeople subjectivelyexperienceminoritystressarestillscarce.Thisstudyaimsatexploringthe sub-jectiveexperiencesofminoritystressthroughafocusgroupwith8ItalianTGNCindividuals (5male-to-female,2female-to-male,and1genderqueer;M=25;SD=5).Narrativeswere ana-lyzedthroughthedeductivethematicanalysis.Theanalysisgeneratedfour maincategories: (1)familyrejection;(2)visibilityofthebody;(3)negativeeffectsoffamilyviolenceonhealth; and(4)integrationofTGNCidentity.Resultsofferanin-depthexplorationofminoritystress processesinTGNCpeople,aswellastheimpactofstressonhealthandadaptivestrategiesto facewithstigma.Suggestionsforclinicalpracticearediscussed.

DOIoforiginalarticle:https://doi.org/10.1016/j.sexol.2019.05.001.

夽 _La _version _en _franc_¸aise _de _cet _article, _publiée _dans _l’édition _imprimée _de _la _revue, _est _disponible _en _ligne, _doi _:

10.1016/j.sexol.2019.05.001.

∗_{Corresponding}_author.

E-mail addresses: cristiano.scandurra@unina.it(C. Scandurra),rvitelli@unina.it(R. Vitelli),nelsonmauro.maldonato@unina.it (N.M. Maldonato),valerio@unina.it(P.Valerio),vincenzo.bochicchio@unical.it(V.Bochicchio).

https://doi.org/10.1016/j.sexol.2019.05.002

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Introduction

Transgenderandgendernonconforming(TGNC)peopleare thosewhosegenderidentityisnotfullycongruentwiththe sexassignedatbirth.TGNCpeoplelivesystematicviolence and oppression throughout their lives due to their gen-dernonconformity(e.g.,Bradfordetal., 2013,Lombardi, 2009), being at risk of developing negative health out-comes, such as anxiety, depression, and suicide ideation orattempts(Bocktingetal.,2013,Bradford etal.,2013). Fromthisperspective,researchersareincreasinglyfocused onunderstandingpsychologicalandsocialprocesses,which lead social stigma to affect mental health of TGNC peo-ple(Amodeoetal.,2015,Scandurraetal.,2017a).Oneof thetheoreticalframeworksaimedatexploringthenegative impactof stigmatizingevents on mental health of minor-itygroupsistheminoritystresstheory(MST;Hendricksand Testa,2012,Meyer,2007).

TheMSTassumesthatminoritypeopleexperiencestress duetopersistentsocialstigmatization.Withinthecontext oftheindividualenvironmentalcircumstances,Meyer(2007) conceptualized both distal and proximal stress processes. Distalprocessesareobjectivestressorsindependentofthe individual,while proximalstressors aredependent onthe individualbecause they arelinked toone’s ownfeelings, thoughts, and actions. Both processes are located on an environmentalcontinuum,inwhichdifferentstressorsact. Fromdistaltoproximalprocesses,thestressorsare:

• stressful objective and chronic events and condi-tions (prejudiceevents, suchasinterpersonal violence, employmentdiscrimination,orproblems inaccessingto healthcaresetting);

• expectations that these events will happen and subse-quentsurveillance(perceivedstigma),and;

• internalizationofnegativesocietalattitudes(internalized stigma).

Inadditiontostressors,theMSTalsohighlightstheroleof protectivefactorsinbufferingtheeffectsofminoritystress onmentalhealth,suchassocialconnectedness,resilience, orgroupcohesion(e.g.,DetrieandLease,2007,Frost,2011, Scandurraetal.,2017d).Thus,stress,resilience,andcoping strategiesinteractandpredictthedevelopmentofmental healthproblems.

MST was originally applied to lesbian, gay, and bisex-ual people, and only recently has been theoretically and empiricallyappliedtoTGNCpeople(Bocktingetal.,2013, HendricksandTesta, 2012, Testa etal.,2015). Itis note-worthythatqualitativeinvestigationsonhowTGNCpeople subjectivelyexperienceminoritystressarestillscarce espe-ciallywithintheItaliancontext.Thus,throughthelensof theMST,aqualitativeresearchwascarriedouttoexplore narrativesof agroup ofItalian TGNCpeopleparticipating inafocusgroup.Beforereportingresults,abrief theoreti-calintroductiontotheTGNCexperienceofminoritystress willbeprovided,aswellasabriefoverviewoftheItalian contextwithinwhichTGNCpopulationlive.

MinoritystressinTGNCpeople

Regarding themost distalstressors, theprejudice events, evidenceindicates thatTGNCpeopleexperiencehigh lev-els of violence and discrimination. To this end, Lombardi etal.(2011),inapopulationof402TGNCpeople,reported that 59.9% of the sample suffered from violence and abuse, and that 37.1% suffered from economic discrimi-nation; overall, 47% were assaulted in some way during their life-time. Again, Bradford et al. (2013), in a sam-pleof 350TGNCpeople, reportedthat41% sufferedfrom transgender-relateddiscriminationandthatthemost associ-atedfactorsweregeographiccontext,beingfemale-to-male (FtM), belongingness to an ethnic minority group, low socioeconomic status, younger age at ﬁrst transgender awareness,lackofhealthinsurance,historyofabuse, sub-stanceuse,andlowlevelsofcommunityconnectednessand familysupport.

Previousresearchreportedthatpsychologicalproblems were caused by stressful experiences suffered by TGNC people. For instance, Lombardi (2009), in a sample of 90 TGNC people, reported that transphobic events were associated with depression and anxiety. Bockting et al. (2013), in a sample of 1.093 TGNC individuals, reported thatsocialstigmawasassociatedwithdepression,anxiety, and somatization. Shipherd et al. (2011), in a sample of 97 male-to-female(MtF) TGNCpeople, reportedthat 98% sufferedfromatleastonetraumaticevent,andthat91% suf-feredfrommultipletraumaticevents;amongthem,17.8% reported post-traumatic stress disorder symptoms, while 64%reporteddepressivesymptoms.

Compared to distal stressors, less research has been aimedatassessingtheimpactofproximalstressorsonTGNC health.Tothisend,asregardstheperceivedstigma,Beemyn andRankin(2011)reportedthatmorethanhalfoftheir sam-ple(n=3.474)declaredthattheyhidtheirgenderidentityto avoidintimidation.Similarly,Testaetal.(2012)statedthat TGNCpeopledonotreportviolencetothepoliceanddonot haveaccesstomedicalandmentalhealthservicesduetothe fearofbeingvictimized again.Instead,themostproximal stressor,thatisinternalizedtransphobia,canbedeﬁnedasa discomfortwithone’sownTGNCidentityduetothe internal-izationofsocietalnegativegenderexpectations(Bockting, 2015).Perez-Brumeretal.(2015)reportedthatinternalized transphobiaincreasedthelikelihoodofattemptingsuicide, whileScandurraetal.(2017b)foundapositiveassociation betweeninternalizedtransphobiaandbothanxietyand sui-cideideation.Furthermore,inarecentstudybyScandurra etal. (2018a), it wasfound that internalized transphobia mediated the relationship between prejudice events and negativementalhealthoutcomes,andthatthisrelationship waspositivelybufferedbyhighlevelsofresilience.

As regards the latter point, within the MST, there is evidencethat TGNCindividuals useadaptive strategiesto buffer theeffectsofbothdistalandproximalstressorson health (Pﬂumetal.,2015,Singhetal.,2011,2014, Testa etal., 2014).Forinstance, Singhetal.(2014) found that communityconnectednessandsocialsupportcanreducethe levelsofinternalized transphobia,andPﬂumetal.(2015) foundthatsocialsupportamelioratesthenegativedistress causedbyprejudiceevents.

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DatapresentedinthisparagraphshowthatMSTisa use-fulframeworktounderstandpsycho-socialprocessesleading socialstigmatoaffectTGNCmentalhealth.Recentevidence demonstratedthattheMSTisasuitableframeworkto under-standhowsocialstigmaaffectshealthinItalianTGNCpeople (e.g.,Amodeoetal.,2018b,Scandurraetal.,2017e).

TheItaliancontextforTGNCpeople

TheItaliancontextisnothighlysupportiveforTGNC popula-tion(e.g.,Cussinoetal.,2017).Forinstance,Italyhasonly recentlyestablished,thankstoasentenceoftheCourtof Appealspromulgatein2015,thatthegenderreassignment surgerymustnotbeconsideredaprerequisiteformodifying one’sownlegalgenderstatus,thus removingtheprevious mandatorysterilization.Moreover,Italyhasnotyet promul-gatedananti-discriminationpolicytoprotectTGNCpeople fromsocialstigmaandhatecrimes.Tothisend,aEuropean studybyTurneretal.(2009)aimedatmappinghatecrimes in Europe,in a sample of2.669 TGNCpeople, found that ItalianTGNCindividualsexperiencedthehighestpercentage (51%)oftransphobicverbalcomments.Inthesamevein,ina studyanalyzingthecausesoftransphobicmurdersinEurope between2008and2013,ItalywasclassiﬁedastheEuropean country withthe second highest rate of transphobic hate crimes,afterTurkey(Prunasetal.,2014).

Thefewstudiesthathaveassessedtheeffectof minor-ity stress on the health of Italian TGNC people seem to conﬁrm that such a population is at a risk of experienc-ingstigmatizingepisodeswhich,inturn,canaffectmental health(e.g.,Amodeoetal.,2015,2018b,Scandurraetal., 2017d,2017e).Indeed,Scandurraetal.(2017a),inasample of almost150 Italian adultTGNC people,found thatboth distal (i.e., anti-transgender discrimination)and proximal (i.e., internalized transphobia) stressors were associated withdepression,anxiety,andsuicideideation.Furthermore, intheirstudy,Scandurraetal.(2017a)foundthatsupport fromfamilyandresiliencewereabletobufferthenegative effectofstressorsonhealth.Ontheother hand,negative healthoutcomeshavebeenfoundalsoinasampleofTGNC adolescents(Fisheretal.,2017).

As specifically regards resilience, a study by Amodeo et al. (2018b) aimed at assessing the efficacy of an empowerment-basedgroup training program in increasing resilience levels in a smallgroup of Italian TGNCyouths, highlighted that resilience is a fundamental coping strat-egytofacewithstigmatizing episodes.Summarizingtheir results,Amodeo etal. (2018b)definedresiliencein TGNC individualsas‘‘theabilitytodefineone’sowngender iden-tityandtogeneratethesubjectivesenseofhavingaspecific gender identity, thus self-recognizing and accepting one’s owntransidentity’’(p.13).

Notwithstandingtheseﬁndings,toourknowledgeno pre-vious studies have qualitatively investigated how Italian TGNC individuals subjectively experience minority stress andhowtheycopewithit.

The

current

study

Thecurrentstudyaimsatqualitativelyexploringhow minor-ity stress is subjectively experienced in a small group of

Table1 Socio-demographiccharacteristicsofparticipants (n=8).

PseudonymAgeGenderidentiﬁcationSexualorientationGAFa

Denise 30 MtF Straight Yes

Christine 21 Genderqueer Queer No

Rachel 28 MtF Straight Yes

Sophie 25 MtF Straight No

Philip 22 FtM Straight No

Carl 26 FtM Straight No

Allison 20 MtF Straight No

Angela 28 MtF Lesbian No

a _GAF:_Gender_afﬁrmation_surgery;_MtF:_{female-to-female;}

FtM:female-to-male.

ItalianTGNCindividualsparticipatinginafocusgroup.Given the literature on stigma and coping in TGNC people and informedbytheMST,themainquestionswhichguidedthis studywere:

• HowdoTGNCindividuals subjectivelyexperiencesocial stigmatowardsthem?

• Whatimpactdoes thesocialstigmahaveonTGNC indi-viduals’health?

• HowdoTGNCindividualscopewithsocietalstigma?

Method

Participantsandprocedures

Thepresentstudyinvolved8ItalianTGNCparticipants,born andlivinginNaples,acityofSouthernItaly.Consideringthe genderidentification,7ofthemself-identifiedas transgen-der,specifically5MtF and2FtM.Only 1self-identified as genderqueerandwasfemale-assigned-at-birth.As regards thegender affirmation surgery, only2 participants under-wentgenitalsurgery,whileallofthem,withtheexception ofthegenderqueerparticipant,weretakinghormones. Par-ticipantsagedfrom20to30yearsold(M=25;SD=5).Finally, asforsexualorientation,6self-identifiedasheterosexual, 1aslesbianand1asqueer.Socio-demographic characteris-ticsofparticipantsdescribedabovearereportedforclarity inTable1.Inordertoprotecttheidentitiesofparticipants, pseudonymsareusedthroughoutthemanuscript.

Participantswererecruitedthroughtheinvolvementof personalcontactsofthefourthauthorofthecurrentwork, whois well knownwithin the local TGNC community for hislongexperienceintheadvocacyforTGNCrights.Thus, throughasnowball samplingprocedure, potential partici-pantsweresentapresentationletterofthestudy,inwhich objectivesandmethodsweredescribedindetail.Inthe let-ter,inclusioncriteriatotake partinthefocusgroupwere alsoreported,thatwere:

• self-identifyingasaTGNCperson; • beingagedbetween20and30years; • beingbornandlivinginNaples.

Beforebeingincludedinthegroup,participantswho vol-untarilydecidedtotake partin thestudywere invitedto

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ameeting for thepresentation of thestudy.The meeting was conducted by the second and fourth authors of the currentwork. Inthatoccasion, apreliminaryscreening to exclude severe psychiatric disorders was performed with the participants’ informed consent. Following the meth-odsadoptedbyAmodeoetal.(2018b)inastudyaimedat assessingtheefﬁcacyofagrouptrainingprogramin increas-ingresiliencelevelsinTGNCyouths,thecurrentscreening containedquestionsaboutperceivedwell-being(e.g.,‘‘All thingsconsidered,howsatisﬁedareyouwithyourlifeasa wholenowadays?’’),symptomsof depression(e.g.,‘‘Have youeverhadaspelloffeelingdownordepressed?’’),and suicidalthoughts (e.g., ‘‘Haveyou ever seriously thought ofending your ownlife?’’). Allparticipants attendingthe meetingwererecruited,asthescreeningshowednosevere psychiatricdisorders.

Thefocusgroupwasnotconductedbythesameauthors who managed the initial meeting, in particular because theywerewellknowntosomeoftheparticipants.Thus,to avoidpotentialinterferencesontheresearchprocess(e.g., influenceofthepreviousknowledgeonanswers,social desir-ability, etc.), the focus group wasconducted by the first authorof thecurrent work whodidnotknow any partici-pantsandhadacertifiedexperienceinTGNCissuesandin conductingfocusgroups.Duringthefocusgroup,all parti-cipants wereinformed again about the aimsof the study andtheresearcher presentedhimselfasbothpsychologist and expert in research on TGNC issues. In the informed consent, the importance of answering honestly, the non-existence of right answers, the right for each participant toleave thegroupat anytime,andtheanonymizationof the participants’ identity in case of scientific publication werestressed.Allparticipantsgaveconsenttoreporttheir narrativesinascientificmanuscript.

AlldatawerecollectedinaccordanceoftheGeneralData ProtectionRegulation679/2016andthestudywasdesigned torespect allprinciples of the Declaration of Helsinki on EthicalPrinciplesforMedicalResearchInvolvingHuman Sub-jects.Collecteddatawerestoredinadatabaseaccessible onlytotheprincipalinvestigator,theﬁrstauthorofthe cur-rent article, who masked participants’ identities through pseudonymsbeforesharingdatawithotherresearchers.

Focusgroup

Onesemi-structuredfocusgrouplastingtwohourswas con-ductedbythefirstauthorofthecurrentwork,asexpertin groupconduction andTGNCresearchissues.It was audio-recorded with the informed consent of participants and transcribed verbatim. The focus group was conducted so that all participants hadthe opportunity toexpress their thoughts.As wewereinterestedinexploringsocialstigma processes towards one’s own TGNC identity and coping mechanismsusedtofacewithit—i.e.,dimensionsoccurring withincollectiveandsocialsystems(Brown,2010,Scandurra etal.,2017c)—focusgroupwasconsideredmoresuitable thanindividualinterviews.Indeed,assuggestedbyHughes andDuMont(2002),contrarytoin-depthinterviews, focus groupsspecificallyprovideinsightsaboutbothpsychological andsocialprocessesthatoccurinspecificculturalgroups, sheddinglightontheirsocialrealities.

In this study, informed by the MST, the focus group included4semi-structuredquestions,asfollows:

• distalstressors(‘‘Whatkindofstressors,suchas discrim-ination,violence,abuse,didyouexperienceinyourlife duetoyourgendernonconformity?’’);

• proximalstressors(‘‘Howdoyouthinktheseexperiences inﬂuencedtheperceptionyouhaveofyourselfasaTGNC person?’’);

• effectofstressors onhealth(‘‘What effectdoyoufeel thattheseexperienceshavehadonyourwell-beingasa TGNCperson?)and;

• copingstrategies(‘‘Howdidyoucopewiththese experi-ences?’’).

Questions were the product of a reﬂexive comparison betweenall researchersinvolved inthestudy.Beyondthe semi-structured questions, we had to ask other questions fordifferentreasons,suchastobringoutlatentdiscourses, toguaranteethesameparticipationtoallparticipants,or to obtain more and detailed informationabout a speciﬁc discourse.

Dataanalysis

Aswewereinterestedinqualitativelyexploringtheeffect of social stigmaon TGNCparticipants’ health and coping strategies using a clear theoretical framework, i.e. MST, data were analyzed through a deductive thematic analy-sis,thathelpstheinterpretationofidentifiablethemesand patterns of behavior (Braunand Clarke, 2006). According toBraunandClarke(2006),theanalysisofthefocusgroup transcriptsconsistedoffivemainstages,eachofthem per-formed by two independentraters (the first and the last authorsofthiswork)toguaranteevalidity.Theydiscussed tofindagreementondivergences anddifferences ineach stage.

Inthefirststage,aninitialdetailedreadingofthe materi-alsservedtofamiliarizewithdata.Inthisstage,researchers tooknotesabouttheirinitialthoughtsandhighlighted con-ceptsorphrasesconsideredassignificantorinterestingon the basis of MST.In the second stage,the transcript was re-readseveraltimessothatitwaspossibletogenerate ini-tialcodes, thatservetoidentifya featureof thedata.In thethirdstage,initialcodesweretransformedinto poten-tialthemes.Thus,differentcodeswerecombinedtocreate an overarching theme. In the fourth stage, themes were refinedandevaluatedonthebasisof theirinternal homo-geneity(i.e.,thedatacollatedwithineachtheme adhere togetherin ameaningfulway)andexternalheterogeneity (i.e.,thereareclearandidentifiabledifferencesacross indi-vidual themes). Inthe fifth stage, themeswere clustered intocategoriestowhichanamewasattributed.Subthemes werealsoidentified.

Results

Thedeductivethematicanalysisallowedtoclusterthemes identiﬁed into4 main categories, asreported in Table 2. Theresultsarepresentedwithextractsfromthedatasetto supporteachcategory.

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Table2 Themesandrelatedsubthemesidentiﬁedthroughthedeductivethematicanalysis.

Theme Subthemes

1.Familyrejection a.Familyrejectionandpain b.Familyrejectionandgenderism 2.Visibilityofthebody a.Persecutorybody

b.Bodyandintimacy 3.Negativeeffectsoffamilyviolenceonhealth a.Violenceandsexualhealth

b.Violenceanddepressivesymptoms 4.IntegrationofTGNCidentity a.Pride

b.Communityconnectedness

Familyrejection

Most of participants told different stigmatizing episodes (e.g.,verbalor physical abuse,difficulty infindinga job, etc.), that were experienced in diverse contexts (e.g., school,workplace,healthcaresystems,etc.). Notwithstand-ing,inrethinkingaboutthem,allparticipantsagreed that themostsignificantstigmatizingepisodeswerethose expe-riencedwithinthefamilyoforigin,inparticularwhenthey werechildren.Forexample,Denise(30yo,MtF),hadthisto say:

Iwasviolatedasachild everytimeIwasforcedtodo something.Ididn’t likeitbutIhadtobehave asboy.I feltabused.Iwasborntransgenderanditwasterrible. Ilovedtohavelongnails,butmyterribleneighbortold mymother‘‘Whytheselongnails?He’snotagirl,he’sa boy!’’.Andmymotherviolentlyhitmetoeducateme.I gavetheBarbiedolltomysister,butjustbecauseIcould haveuseditinsecret.So,Imissedthechancetoplaywith otherchildren.Ifeltasenseofloneliness,emptinessand sadness.Ilacked apieceandthispieceis stilllacking! Isuffered fromevery kind ofviolence. Isuffered from harassment.Isufferedfromeverything.Icouldlivemy lifeonlyinmyfantasy.Thedollswereinmymind,Iwas femaleinmymind,everythingwasinmymindandonly inmyloneliness.

This is a clear statement about the ﬁrst subtheme,or ratherthepainTGCNindividualsmayliveifthe familyof originisrejectingtowardstheirowngendernonconformity (e.g.,Kokenetal.,2009).Theimpossibilityforgender non-conforming children to share their thoughts and feelings about the gender nonconformity itself, or their needs to berecognizedasagendernonconformingchild,might cre-ate,as in the case of Denise, a great senseof loneliness (Bochicchio et al., 2019), leading the child tofeel to be freeofexpressinghis/herselfonlyinthementalworld.

Asecondsubthemeidentiﬁedinthedatasetistheaction ofgenderism withinfamily.Genderismis an ideology that perpetuatesthenegativeevaluationofpeoplewhodonot identifyascisgender;suchanideologyleadstobelievethat nonbinarypeople are anomalies (Hill,2003).To this end, Rachel(28yo,MtF)stated:

Mymotherdidn’tallowmetowearskirtsbefore under-goingsurgery,becausepeoplewouldhavethoughtthatI hadsomethingdanglingundermyskirtanditwas frus-tratingfor her.Iworeaskirtfortheﬁrsttimeacouple

ofyearsago.Ihadstartedtothinkthatmyproblemwas mylegs.

This statementshedslight onthe shamethat aparent mayfeelifason oradaughterdoes notmatchthesocial binarygenderexpectations.Thelastsentence(i.e.,‘‘Ihad startedtothinkthatmyproblemwasmylegs’’)showsthat feelings of shame coming from a genderist belief might be internalized. Furthermore, the social pressure coming from genderism seems to lead to perceive surgery as a solutionwhichenablesTGNCindividualstoconformtothe binaryviewof gender, preventinga more subjective self-identiﬁcation development which, as known (e.g., Vitelli etal.,2017),mightbeverydiverseandoftenunhookfrom the genitalsurgery. As a further evidence of this ‘‘social cage,’’itisinterestinghowAllison(20yo,MtF)answeredto theRachel’snarrative:

Beyondthepersonal distress, you havetoadd the dis-tresslivedinyourfamily.It’sveryheavy,orbetterextremely heavy.Thistotallyimpactsyourbehaviors,attitudes...this makesyourlifeahell,acage!

Visibilityofthebody

Intalkingabout proximalstressors (i.e.,perceived stigma and internalized transphobia), narratives of participants wereorganizedaroundtheroleoftheirbody.Assuggested by Vitelli (2014, 2015, 2017, 2018), the body represents thesymbolic andmaterialplacewhere theTGNCidentity expressesitselftoothers.Indeed,mostTGNCpeopleneed to change their body in order to adapt it to the image theyhaveofthemselves.Thebody-imageofTGNC individ-ualsrepresentsthe interface between subjective internal identiﬁcationsandsocialnormsrelatedtofemininityor mas-culinity,andthismakesthelookoftheOtherverysigniﬁcant for TGNC people. Nevertheless, if, on the one hand, the other’sgazeisimportantfortheidentitystabilizingprocess, ontheother hand, the other is established asaconstant sourceofthreat.AsSophie(25yo,MtF)hadtosay:

Societytendstoidealize.Thus,ifyouarearealmanora realwoman,itwillbemorewelcomingjustbecauseyour bodygivesyoutheshapesocietywants.That’sthereason whyatransgenderpersonwhodoesnotmatchthisbinary conceptionofbodiesisconstantlytargeted.Continuous, inquisitivelooks!Ieverydayliveinquisitiononmyskin.

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Thisstatementclearlyshowsthatone’sownbodymight become persecutory for some TGNC individuals who feel themselvesconstantlylookedbyothers.Thismighthavea heavypriceinpsychological terms,asitcan causeshame andself-hatredifinternalized,orratherinternalized trans-phobia(e.g.,Bockting,2015,Scandurraetal.,2018a).The discomfort that the internalization of societal normative genderexpectations, inother termstheinternalization of thelookoftheOther,iswellshownbyCarl(26yo,FtM)in hisnarrative:

IlovesoccerandI’vealwayshadtheseasonticket.Now, onmycard it’swritten C. [femalename],but my pic-tureshowsaboywithbear.Ialsosaved40Eurosonthe subscriptionfor women reduction.Iknew that Iwould havechangedmyIDsattheendofthechampionshipand Iaskedtopaythe wholeprice, theonefor men.They didn’tallowmebecauseIhadtorespectthelaw.Ihad manyproblemstohaveaccesstwice.Theﬁrsttime,after sometalk,Imanagedentering.Thesecondtime,instead, Isufferedsomuch.Ihadthesameproblem.Theydidn’t letme in.People in thequeue keptonlooking at me. FullofangerIscreamed:‘‘Ifyouwantaprove,putyour handinmyslip!’’.So,hetoldmetowaitandwentaway, goingonlookingatme.Iscreamedagain‘‘HaveItotake offmy pants?Don’t you have enough?’’. These people takeoffyourclotheswiththeireyes.Youcannothavean ideaoftheviolenceIsawinthoseeyes.Thoseeyeskill youbecausetheymakeyouashamedofyourself.Ihated myselfandmyidentityinthatmoment.

Arelatedsubthemeidentiﬁedinthedatasetisthe rela-tionship between the body and intimacy. Being the body visible,mostTGNCindividualsareimmediatelyrecognizable asTGNCand thismay cause stressand discomfort(Radix etal.,2017). Indeed,visible TGNCindividuals experience higherratesofdiscriminationcomparedtothosewhopass for cisgender person (Grant et al., 2010, Reisner et al., 2015). Even when TGNC individuals are not immediately visible because theypass for cisgender person, theymay avoid overt discrimination, but may experience high lev-elsofanxietyduetothefearofdisclosure(Sevelius,2013, Vitelli,2017).Asigniﬁcantstatementabouttherelationship betweenbodyandintimacywasbyAngela(28yo,MtF):

Ican’t have an intimacy about my life. Ican’t have a spaceandatimetodecidetowhomandwhenrevealmy identity.Isimplymusttodiscloseittoeverybody, differ-entlyfromagaymalewhocanhavehistimeandchoose todisclose himselftoaparentﬁrst,toabrotherlater, andsoon.Atransgenderpersonhasnotthispossibility, becauseshe/hehastofacewithsomaticchanges.Bodyis central,fundamentalandvisible.Itstealsyourintimacy. Iwouldhavelikedtomakeapeacefulpath,inharmony withmytime.Butithasn’tbeenpossible,becausebody doesn’tleaveyouprivacy.

Negativeeffectsoffamilyviolenceonhealth

Thisthemewasconnected,butdifferentiated,totheﬁrst one(i.e.,‘‘familyrejection’’).Indeed,inaskingaboutthe effects of stressors on health, all participants answered thinkingabouttheirmostsigniﬁcantstigmatizingepisodes,

thatwerethoseexperiencingwithintheirfamilyoforigin. Theﬁrstsubthemeidentiﬁedwasthenegativeeffectof fam-ily violence on sexual health. Many participants asserted thatthefamilyrejectionaffectedhowtheyexperiencetheir bodyinsexualrelationships.Theeffectofsuchviolenceon sexual health is well shown by Rachel (28yo,MtF) in her narrative:

Just3yearsagoIfeltproudofshowingmybodyonthe beachandIpublishedonFacebooksomepicturesofme. Iwondered wheretheneed tohidemybodyfrommen comesfrom.Today,Ianswerthatitcomesfromtheabuse IsufferedfromwhenIwasachild,whenIwasforcedby myparentstoplaykaratebecauseitwouldhave made memoremasculine... Isawallthosedicksinthelocker room...Isawdickseverywhereandformeitwasa vio-lence. That’s the reason why I’ve many difﬁculties in beingeventouchedbyaman.Icouldhavesexfortheﬁrst timeonly3yearsago.Forme,havingsexualintercourse wasterrible.Malehandsonmybodywereanabusefor me.

This statement clearly shows that rejecting one’s own gender nonconformity may have detrimental effect on health and well-being. Notwithstanding that, as reported inpreviousresearch(e.g.,Amodeoetal.,2018a,Scandurra etal.,2019a,2018a)prejudiceeventshaveanegativeeffect on health through the action of proximal stressors, such asinternalized stigma.Itseemed tousthatthe narrative reportedaboveclearlyillustratesucha mediation mecha-nism,asfamilyviolence negativelyaffectedsexualhealth throughtheaction ofbodyshame, thatisassociatedwith internalizedstigma(GreeneandBritton,2012,Wisemanand Moradi,2010)andthatseemstobecausedbyviolence.

Asecondsubthemewasidentiﬁedinthedevelopmentof depressivesymptomsasaresultofthefamilyrejection,as wellexplainedbyPhilip(22yo,FtM).

Myfatheralwaystoldme

‘‘youarenotaboy,youareagirlandyoumustbehave likethat’’.Ilovedmalegames,likefootball,robots,and soon.Myfatherdidnotallowmetoplaywiththesegames andIdidnotunderstandwhy.Isimplylikedthem.So,for years,IthoughtIwasnotworthyofhislove.Ifeltdown.I sawmyfriends’fathers...theywerenotlikemine.They lovedtheirchildren.IfeltlikeIwasmissingapiece.I’ve alwayswonderedifitwasthisthatpushedmetoeatuntil becomingoverweight.AndthemoreIate,themoreother classmates,especiallyduringthemiddleschoolperiod, made funofme. Ididnot sleepatnightwhen Iwasa child.Iwasreallybad!

Thisstatementclearlydealswiththedepressivefeelings thatmaybedevelopedwhenchildrenarenotrecognizedby parentsintheirneedsanddesires.Itisprobablythat eat-ingproblemsrepresentedanexpressionoracorrelateofa depressivemood. Itis noteworthytohighlight the vicious circleonwhich Philipsheds light:familyviolence seemed tocausedepressivesymptomsthat,maybe,wereexpressed througheatingproblemswhich,in turn,caused other vio-lence(i.e., bullying inschool). This seemstoconﬁrm the detrimentaleffectthatfamilyviolencemayhaveonchildren and,inachainreaction,onadolescents.

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IntegrationofTGNCidentity

In talking about strategies to cope with stigmatizing episodes, the discourses of participants were organized aroundtheprocessofTGNCidentityintegrationwithintheir Self,inparticulararoundpridefeelingsandcommunity con-nectedness,thatwerethetwosubthemesidentiﬁed.

TGNC identitydevelopment representsa verycomplex processconstitutedbydifferentstages(e.g.,Devor,2004, Lev,2004).Thisprocessisnotlinearandcanassumespecific characteristics,leadingtodifferentoutcomes.BothDevor (2004)andLev(2004)assignedacentralroletopride feel-ingstoward TGNCidentity,specificallyinthelatterstages of their TGNC identity development models. Lev (2004) affirmedthatprideisadimensionwhichindicates asense ofidentityintegration,andthisiswellexplainedbyAngela (28yo,MtF):

I bring always my condition, my body, with myself, together withmystory. Making people proud of them-selvesisnecessary,becausetheydonothavetoreject what theyare... they have to love their body even if itnegativelyimpactedtheirstory.MostMtFtransgender people rejectthemselves. They have to ﬁght for what theyare.Theyhavetoﬁghtinsociety,tomakeitaware oftheiridentity.Today,whenImeetnewpeople,Idon’t mind anymore to disclose my identity, because others havetounderstandthatwearesimilar,butalsodifferent. Weareallhumanbeings.

Anotherstatementwhichclearlydealswithpride dimen-sionisthatbyChristine(21yo,genderqueer):

My sisterdidn’t want tocall me withmy new gender-neutralname.Shewentoncallingme withmyoriginal femalename.ButIhadthecouragetotellherandmy dad‘‘callmeC.[newname]...thisismyrealidentity’’. Ifeltveryproudofmyself.I’mveryproudofmyidentity! The identity integration process seems to be strongly facilitatedbythecommunityconnectedness(i.e.,the sec-ondsubthemeindividuated),asreportedbySophie(25yo, MtF):

In the past, Ifelt my transgender condition as similar toahandicapped one.Ifeltlike lackinga part ofme, asifIhadnot anarm. Today,Ifeeldifferent...Ihave understoodthatIhavebotharms.AndIhaveunderstood this sinceI had the couragetoseek help from a local association. Icameintocontactwithother peoplelike meandwebecamefriends.Now,Ifeelawhole! Thisstatementshedslightontheprotectiveroleofpeer groupswhichcanbeseenasaformoffamilialsupportthat most participants did not receive during their childhood. Indeed,usingthe metaphor bySophie,peers seem toact asalacking arm,allowingtofeeloneselfmoreintegrated and,asaresult,increasingthelevelsofself-acceptance.

Discussion

The purposeofthis workwastoqualitativelyanalyze the subjectiveexperiencesofminoritystressinagroupofItalian TGNCindividualsthroughthelensoftheMST.Thedeductive

thematicanalysisgeneratedfourthemes:familyrejection, visibilityofthebody,negativeeffectsoffamilyviolenceon health,andintegrationofTGNCidentity.

Although differentiated, the themes which have been presentedseparatelyshouldbeseenasinterrelated dimen-sionsofapsycho-socialprocess—i.e.,theminoritystress — which postulates that stress mediates the relationship between social status and health of sexual and gender minoritygroups(Hatzenbuehler,2009).InthecaseofTGNC people,theminoritysocialstatusisrepresentedbygender nonconformityitself.

The ﬁrst theme individuated (i.e., family rejection) showedthatgendernonconformityisstigmatizedveryearly, oftenduringchildhood.Thisisinlinewithpreviousstudies, which highlighted that non-TGNC siblings receive greater supportthan TGNCones(FactorandRothblum, 2007)and that mothers and fathers are among the main perpetu-ators of psychological harassment (Gerini et al., 2009). Furthermore,scientiﬁcliteraturehighlightsdifferentmeans throughwhich familystigma can be manifested, that are physical,verbalandsexualassault,orlessovertmeans,such aslack of emotional support(Factorand Rothblum,2007; GrossmanandD’Augelli,2006),asinthecaseofparticipants ofthe current study.Family rejection resulted tobealso stronglyassociatedwithgenderismthat,asreportedabove, isan ideology whichperpetuatesa negativeevaluationof gendernonconformity.AssuggestedbyHillandWilloughby (2005),‘‘genderismisbothasourceofsocialoppressionand psychologicalshame,suchthatitcanbeimposedona per-son,but alsothatapersonmayinternalizethesebeliefs’’ (p.534).Thisisinlinewithwhatparticipantsofthecurrent studyreported.Indeed,participantsclearlyexpressedthat theirgender nonconformitycausedshamefeelingsintheir parentsandthattheyendedupfeelingashamedof them-selves,internalizingthosebeliefs.Inthiscomplexprocess, itseemsthattheonlysolutiontoadaptoneselftothe nor-mativegenderexpectationsistoundergogenitalsurgery,in ordertosolvethegendernonconformityitself.

The second theme individuated (i.e., visibility of the body)seems tobea direct derivativeof the ﬁrst theme, becausethebodyofTGNCindividualsisnotconformingto thesocietalexpectationsaboutfemininityandmasculinity. Indeed,bodyisintheforegroundforTGNCpeople(Amodeo etal.,2018b),astheyexperiencean incongruitybetween thegiven bodyand the bodythey wouldhave for feeling themselves(Lemma,2013).TheincongruityTGNC individu-alssufferfromleadsotherstoconstantly lookatthem,in particularattheirbody,andthismayleadTGNCpeopleto livetheirownbodyinapersecutoryway(Vitelli,2015).As Lemma(2013)suggested,thisprocessmaystartveryearly, inchildhood,aperiodinwhichtheotherslookingatthebody aretheparents.Thus,‘‘inquisitivelooks’’,asreportedby oneparticipantof thecurrentstudy,maybeinternalized, causingshameandself-hatred(i.e.,internalized transpho-bia),aswellasaperceptiontobeconstantlyvisibletoothers (i.e.,perceivedstigma),regardlessofwhetheroneistruly visibleornot.Thisisprobablythereasonwhyparticipants ofthecurrentstudyfeltthattheirintimacywasviolated.

The latter point — the relationship between body and intimacy—issomehowrelatedtothethirdtheme individ-uated(i.e.,negativeeffectsoffamilyviolenceonhealth). Indeed,participantsexpressedtwomainhealthdimensions

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they felt to be affected by family violence (i.e., sexual health anddepressivesymptoms).Analyzing narratives, it seemedtousthatthiseffectwasnotdirect,butmediated byproximalstressors,inparticularbyinternalized transpho-bia.Thisisinlinewitharecenttheoreticalframeworkwhich representsanextensionoftheMST,thatisthepsychological mediationframework(PMF;Hatzenbuehler,2009).ThePMF, recentlyappliedquantitativelytobothTGNC(e.g.,Breslow etal.,2015,Scandurraetal.,2018a,Testaetal.,2017)and lesbian/gay(e.g.,Amodeoetal.,2018a,Liaoetal.,2015, Schwartzetal.,2016)population,shedslighton psycholog-icalpathways linking stigma-related stressors to negative health outcomes,assuming that proximalstressors of the MSTact asmediatorsbetween distalstressorsandhealth. Itseemstousthatparticipantsofthecurrentstudy specif-icallyhighlightedtheroleofinternalized transphobiaasa mediatorbetweenfamilyrejectionandhealth,in particu-lardepressivesymptomsandsexualhealth.Asregardsthe effectof violenceondepressivesymptoms,previous stud-iesalready foundthisrelationship (e.g.,Scandurraetal., 2017a, Testa et al., 2015). As for the effect of violence onsexualhealth,we arenotawareof studiesspeciﬁcally focusedonthisassociation.Thisresultseemstobestrictly interrelatedtothevisibilityofthebody,asthebody repre-sentsone of the ﬁelds in which sexuality is experienced. Indeed, as reported above, the body may become per-secutory for TGNC individuals, as they are often visible andrecognizable.ThismayleadsomeTGNCindividualsto developinternalizedtransphobiawhich,inturn,mayaffect positive relationships with others, even in sexual terms. Thus,itisplausibletohypothesizeanassociationbetween social stigma,visibilityof the body, and sexuality. Future studiesshouldexplorebothqualitativelyandquantitatively thishypothesis.

Asregardsthelasttheme(i.e.,integrationofTGNC iden-tity), our results indicated that TGNC individuals tend to copewithstigmathroughbothinternal(i.e.,pridefeelings) and external (i.e., community connectedness) resources. TheseresourcesleadTGNCindividualstointegratetheirown TGNCidentitywithintheirSelf,promotingaprocessof self-affirmation and self-acceptancethat, on the basis of the MST,maybufferthenegativeeffectsofviolenceonhealth. Assuggestedbytwoveryknowntheoreticalmodels,prideis thelatterstageoftheTGNCidentitydevelopmentprocess (Devor,2004,Lev,2004).Specifically,Devor(2004)intended pride both in politically and personally terms, while Lev (2004)reportedthatprideisadimensionindicatingasense ofidentityintegration.Bothauthorsconsidered prideasa dimensionabletobuffertheeffectsthatshameandsocial stigmamayhaveonhealth.Onthesameline,participants ofthecurrentstudyexpressedthatprideallowedthemto feelcomfortableindisclosingtheirTGNCidentitytoothers, andthismaybeinterpretedasabufferingresourceinthe faceofshameandpersecutoryfeelings.Ontheotherhand, participantsofthecurrentstudyhighlightedthe fundamen-talroleofpeersandcommunityconnectednessinpromoting aprocessofidentityintegration.Thisisinlinewithprevious studieswhichhighlightedthatfamilyasaprimarysupport networkisofteninaccessibletoTGNCpeopleand,forthis, theyoften find a supportsource within TGNC community itself(e.g.,Carrolletal.,2002).

Limitations

Themainlimitationofthecurrentstudyconcernsthelocal level ofparticipants, whowererecruitedin auniquecity of the SouthernItaly.This cannot allow togeneralizeour resultstotheItaliancontext.Furthermore,duetothesmall numberofparticipants,wecannotexplorethedifferences onhowMtF,FtM,andgenderqueerparticipantssubjectively experienceminoritystress.Futurestudiesshouldconsider exploring such potentialdifferences through focusgroups that are homogenous with respect to gender identities. Notwithstanding,theexplorativeandqualitativenatureof thestudyallowslookingattheselimitsasrelative.

Implicationsforclinicalpractice

Thisstudyhasimportantimplicationsforclinicianswhowork withTGNCindividuals.The MST,indeed,wasdevelopedto understand thosedimensions relatedtothementalhealth ofsexualandgenderminoritiesthataredependentonsocial contextsandontheinternalizationofsocietalattitudes.As suggestedbyHendricksandTesta(2012),itisnecessarythat clinicians,withincounselingand/orpsychotherapy interven-tions, assess deeply the different dimensions of minority stress.

The results of the current study shed light on subjec-tiveexperiencesofminoritystresswhichTGNCindividuals maydoduringtheirlifecourse.Thedetrimentaleffectthat familyrejectionmayhave onhealththroughtheaction of internalized transphobia should lead clinicians toaddress theirpsychologicalinterventionstomitigatethe psycholog-icaldistresscomingfromthenegativeself-imagewhichmay result from stigmatization. As we showed, stigmatization may affect sexualhealth leading tofeelingof shame and self-hatred,aswellascausedepressivesymptoms.Applying thePMF,an efﬁcientclinical workshouldbe addressedto proximalstressors,astheylinkviolencetonegativehealth outcomes.Thus,clinicallyworkingoninternalized transpho-bia,onthefearofdisclosingone’sownTGNCidentity,onthe persecutoryfeelingsaboutone’sownbody,mayresultina reliefand,inturn,maypromoteanidentityintegration pro-cessthatbufferstheeffectsofstigmaonhealth(Scandurra etal.,2019b).

Atthesametime,giventhecomplexityofclinically work-ing onsuchdeeply encysteddimensions, clinicians should payattentiontothoseaspectslinkedtosocialsupportand resilience. To this end, Meyer (2007) highlighted the efﬁ-cacyofthegroupandcommunitydimensioninbufferingthe effects ofstressors onmentalhealth. This is undoubtedly alsotrueforTGNCpeople.Thus,cliniciansshouldconsider using, beyond an individual approach, a group approach, asthe group has thepotential tofacilitate mirroring and empowerment processes (Amodeo et al., 2017, Esposito etal.,2017,2018,Scandurraetal.,2018b).

Bothatindividualandgrouplevel,itisfundamentalthat cliniciansprovideafﬁrmativecounselingandpsychotherapy interventions which are respectful and supportive of the identity and life experiences of TGNC people (Korell and Lorah,2007).Currently,TGNCpeoplemayencounterother sources of stigmawithin mental health services, and this

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representsa powerful andcommon barrier for this popu-lation (AmericanPsychological and Association, 2015). As suggestedbyMcCannandSharek(2016),TGNCpeoplemeet speciﬁc mental health needs, encountering distinct chal-lenges due to their gender expression and identity, such asaccesstoappropriateservicesandtreatments,andthe responsivenessofproviders,aswellastheprovisionof fam-ilysupport.Mentalhealthprovidersshouldbeawareofthis, havingtheethicalobligationofprovidingacompetentand informedanswertotheirclients.

Conclusions

Thepresentstudymightbeconsideredaqualitative explo-rationintotheminoritystresssubjectivelyexperiencedbya groupofTGNCindividuals.OurstudyshowsthatTGNC indi-viduals,although representing a resilientcommunity able tofacewithsocietalstigma,stillexperiencerejectiondue totheirgendernonconformity,andthisrejectionstartsvery early,duringchildhood.Earlyexperiencesofrejectionseem to set in motion the complex process of minority stress which, starting from distal stressors, may come toaffect mental health and well-being. This should leadto imple-mentpsycho-socialinterventions,aswellassocialpolicies, aimedatchangingthenegativesocio-culturalviewson gen-dernonconformity,promotingalessgenderistculturalview and helping families in supporting gender nonconforming childrenintheiridentitydevelopmentalpaths.

Disclosure

of

interest

Theauthorsdeclarethattheyhavenocompetinginterest.

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