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. Author manuscript; available in PMC: 2016 Feb 29.
Published in final edited form as: Int J Transgend. 2015;16(1):49–61. doi: 10.1080/15532739.2015.1022680

Adult Attachment and Transgender Identity in the Italian Context: Clinical Implications and Suggestions for Further Research

Anna Lisa Amodeo 1, Roberto Vitelli 2, Cristiano Scandurra 3, Simona Picariello 4, Paolo Valerio 5
PMCID: PMC4770629  NIHMSID: NIHMS752190  PMID: 26937224

Abstract

Introduction

Although attachment theory has been recognized as one of the main reference for the study of the general wellbeing, little research has been focused on the attachment styles of transgender people. Attachment styles are deeply influenced by the earliest relationships with caregivers, which, for gender nonconforming children, are often characterized by parental rejection. Consequently, transgender children and adults likely internalize societal stigma, developing internalized transphobia. The current research was aimed to explore the link between adult attachment and internalized transphobia.

Method

25 male-to-female (MtF) and 23 female-to-male (FtM) transgender people participated in the survey filling in two self-report questionnaires: the Attachment Style Questionnaire and the Transgender Identity Survey. A cluster analysis, T-Test and multiple regression analysis were conducted to explore the link between attachment styles and internalized transphobia.

Results

A greater prevalence of secure attachment styles was detected. Participants with secure attachment styles reported higher levels of positive transgender identity than those with insecure attachment styles. Secure attachment styles significantly affect positive transgender identity, while insecure attachment styles influence internalized transphobia.

Conclusions

A clinical focus on the redefinition of the Internal Working Models of transgender people can inform psychologically-focused interventions, which transgender people can benefit from.

Keywords: adult attachment styles, internalized transphobia, transgender identity, stigma

Primary attachment relationships are crucial in the development of identity, and in the later quality of life and social and emotional adjustment (e.g., Mikulincer, 1995; Lopez, & Brennan, 2000; Shaver, & Mikulincer, 2009). The construction of gender identity takes place within these relationships (Bussey & Bandura, 1999; Bussey, 2011). In the case of transgender people – a population characterized by the crossing of gender binary (Bockting, 1999) –, this process sometimes might be more complex because of stigmatization of their gender non conformity (i.e., Gordon, & Meyer, 2007; Grossman et al., 2005; Koken, Bimbi, & Parsons, 2009).

International scientific research on transgender issues has mainly focused on dimensions associated with enacted stigma (e.g., Kenagy, 2005; Lombardi et al., 2001), mental health (e.g. Clements-Nolle et al., 2001; Heylens et al. 2013; Lawrence & Zucker, 2012), and post-transition adjustment (e.g., Asscheman et al., 2011; Dhejne et al., 2011; Grajfoner, 2009; Leriche, 2008; Schilt & Wiswall, 2008; Smith et al, 2005). So far, these dimensions have been scarcely explored within the Italian context, with the exception of the works by Gerini et al. (2008), who confirm the presence of an high prevalence of enacted stigma, and Prunas et al. (2014), who focus on the defensive mechanisms profile of male-to-female (MtF and female-to-male (FtM) transsexual people seeking Gender Affirmation Surgery (GAS). On the contrary, two interesting Italian studies (Conte, Prunas, & Hartmann, 2008; Vitelli & Riccardi, 2010) have been previously addressed to explore adult attachment dimensions of transgender people. Nevertheless, considering the more general scientific literature, little research has been carried out on the affective relational area. Indeed, as Malpas (2012) stated, “despite their efforts to include interpersonal concerns and loved ones [Bockting, Knudson, & Goldberg 2006; Israel & Tarver, 1997; Korell & Lorah, 2007; Lev, 2004] mental health treatment guidelines often give precedence to diagnostic, assessment and transition issues over transgender people's relational realities. Yet, research shows that committed relationships and the sentiment of belonging are both a priority and a critical source of emotional stability for transgender people” (pp. 71-72). As Meier et al. (2013) have more recently demonstrated, perceived social support from a romantic partner could moderate symptoms of both depression and anxiety (Meier, Sharp, Michonski, Babcock, & Fitzgerald, 2013). At the same time, in the last thirty years, attachment theory has become one of the main references for the study of adult romantic relationships (Strauss, Morry, & Kito, 2012). In particular, attachment styles and, more specifically, Internal Working Models (IWMs) – the internalized representation of the self, of the other and of the possible reciprocal relationships – are considered an important factor in the achievement of a couple's adjustment (Carnelley, Hepper, Hicks, & Turner, 2011; Feeney, 1999; Holland & Roisman, 2010; Sadikaj, Moskowitz, & Zuroff, 2011; Zimmer-Gembeck & Ducat, 2010). Research findings have clearly showed that attachment styles have a direct influence on cognitive, affective and behavioral responses to others (Collins & Read, 1994), influencing expectations and beliefs regarding both the self and the other (Berman, Marcus, & Berman, 1994). As Bowlby (1969/82) explained, in adulthood IWMs shape the perception of partner's availability and consistency, as well as the more or less conscious representation of oneself as someone worthy of attention and care from the partner.

Moreover, several studies have demonstrated the importance that secure adult relationships have in the promotion and maintenance of healthy and adaptive behavior within and across multiple life aspects, such as hope, optimism, positive affect, parenting and caregiving competence, academic and career-related motivation, altruistic behavior, and existential well-being (e.g., see Lopez, 2009). On the other hand, attachment insecurity has been positively correlated with several indices of psychological distress, such as shame, anger, and pathological narcissism (Wagner & Tangney, 1991), negative affect (Simpson, 1990), emotional distress and nervousness (Collins, 1996). Furthermore, insecure attachment dimension has been found to be common among people with a wide variety of mental disorders, ranging from mild distress to severe personality disorders, and even schizophrenia (Mikulincer & Shaver, 2012)1.

IWMs are deeply influenced by the first attachment relationships – i.e. by the availability, responsiveness and nursing capabilities of the primary attachment figures (Ainsworth, Blehar, Waters, & Wall, 1978; Fraley, 2002; Hamilton, 2000; Thompson, 1999; Weinfield, Sroufe, Egeland, & Carlson, 1999; Weinfield, Sroufe, & Egeland, 2000) –, although they may be subsequently modified in the context of close interpersonal relationships (Rothbard & Shaver, 1994) or life events (Hamilton, 2000; Waters, Merrick, Treboux, Crowell, & Albersheim, 2000).

In the case of gender nonconforming children, as already mentioned, the influence of the first attachment relationships on the construction of IWMs could be even more important if we consider that these children may experience parents’ anti-transgender prejudice (Gordon, & Meyer, 2007; Grossman et al., 2005). In other words, sometimes, the immediate family and home may represent the initial context where gender nonconforming children face transphobic behaviors, such as physical and psychological violence, harassment and, at times, removal from the parental home (Gagne & Tewksbury, 1998; Koken, Bimbi, & Parsons, 2009). Factor and Rothblum (1998) provided additional evidence that non-transgender siblings often receive better support from families than their transgender siblings. Gerini et al. (2009), in an Italian sample of transgender people, identified various perpetrators of psychological harassments as sources of emotional distress, i.e., peers (54%), unspecified agents (42%), father (31%) and mother (26%). As a consequence, according to the attachment theory, we can suppose that gender nonconforming children could also be likely to construct internalized negative representations of the “self” and “other”. Indeed, the other could be perceived as a not available and responsive person (IWMs of the other), and the self as not worthy of receiving help from anyone, in particular from caregivers (IWMs of self). Moreover, we can also assume that these children may internalize stigma from the behaviors and attitudes of parents and/or peers, just as in the case of sexual minorities (Herek et al., 2009). In other words, these relational dynamics can facilitate the development of internalized transphobia, which has been defined by Bockting, Knudson, & Goldberg (2006) as “profound shame, guilt, and self-loathing” (p. 46) for their gender variance. According to Bockting (2008; Bockting & Coleman, 2007), this can produce internalizations that affect the subsequent construction of transgender identity. As a consequence, shame, self-hatred, and troubles in conforming to culturally shared models of maleness and femaleness might be developed (Bockting et al., 2006;). In addition, transgender people could choose to hide their transgender identity, or try to pass for a person belonging to the desired gender (Bockting et al., 2006). Finally, transgender people may avoid joining any transgender community, thus fostering negative and alienating feelings towards their own transgender identity (Bockting et al., 2006). Ultimately, both internalized transphobia and insecure attachment styles might have negative effects on the development and/or improvement of resilience strategies. Despite the importance attributed to the attachment system for overall psychological wellbeing and the quality of adult relationships, little research has focused on the attachment of MtF and FtM transgender people. Birkenfeld-Adams (1998) reported a high prevalence of ambivalent attachment styles among gender nonconforming children. Similarly, in adulthood, although some studies have stated that insecure styles are not prevalent (Conte, Prunas, & Hartmann, 2008), research findings by Vitelli and Riccardi (2010) did indicate a higher prevalence of Insecure States of Mind with Reference to Attachment (Dismissing, Entangled and Unresolved/Disorganized) than the averages commonly found in non-clinical samples.

The present research has explored the link between adult attachment styles and internalized transphobia within a small sample of Italian transgender people. More specifically, the study has been aimed at: 1) exploring the prevalence of attachment styles; 2) testing whether and what kind of relationship exists between attachment styles and internalized transphobia; 3) whether internalized transphobia can be partly accounted for by insecure attachment styles.

In particular, the rationale of exploring the prevalence of attachment styles was due to the contradiction between the findings obtained in the only two Italian studies on attachment styles in transgender people (Conte, Prunas, & Hartmann, 2008; Vitelli & Riccardi, 2010). Furthermore, because secure attachment is a protective factor (e.g., Prior & Glaser, 2006; Schore, 2001; Sroufe 2005), it was hypothesized that those who present this kind of attachment report also higher scores of positive transgender identity, whereas those who present insecure attachment styles are higher in internalized transphobia. Consequently, as the insecure attachment could represent a factor of vulnerability (Abdul Kadir & Bifulco, 2013; Pielage et al., 2000), a final hypothesis was that transgender people with insecure attachment styles are more likely to present higher levels of internalized transphobia.

Methods

Participants

A small non probability-based sample of Italian transgender people (25 MtF and 23 FtM people) participated in the survey. Their age ranged from 18 to 60 years old with an average age of 36.6 (SD = 10.8), and they were all Italian and Caucasian. Fifteen responders (31%) had undergone GAS, 23 (48%) had not yet, 8 (17%) had no intention to do it, and 2 (4%) indicated they were in doubt about this matter. With regard to the stage of transition, 19 participants (40%) were having exclusively hormonal treatment, 6 (12%) were waiting for the authorization to undergo GAS, 2 (4%) were waiting for legal changes in their names and gender after GAS, 13 (27%) had completed their transition processes and 8 (17%) preferred not to answer. As for the civil status, 21 participants (44%) declared to be single, 9 (19%) were in a stable relationship for an average of 6 years, 13 (27%) had been living with their partners for an average of 4.8 years, only 2 people (4%) were married and 3 participants (6%) preferred not to answer. Thirty-two participants (67%) had received a religious education, while the remaining 16 (33%) had not. They were almost equally divided into those affiliated (n=25) and those non-affiliated (n=23) with an Italian lesbian, gay, bisexual and transgender (LGBT) association. Regarding political preferences, 27 (56.25%) declared they were progressive, 17 (35.42%) moderate, 3 (6.25%) conservative and only 1 (2.08%) preferred not to answer.

Procedure

The survey was disseminated through informatics procedures (e-mail, blogs or social networks) and Italian LGBT associations. The only criteria of inclusion were the self-identification as transgender and the legal age of consent. The first page of the survey presented an informed consent document where participants had to check a box if they wanted to take part in the study. In this document, respondents were explained that they could have quit the survey in any moment. After this, a brief description of the general meaning of transgender identity was provided and participants were asked whether they identified themselves as transgender. This was a conditio sine qua non they were unable to proceed in the study.

The research project was promoted through two widely known Italian websites (Arcigay and Digayproject) and participants filled in the questionnaires on the website www.bullismoomofobico.it of the Antidiscrimination and Culture of Differences Service (www.sinapsi.unina.it) of the University of Naples Federico II. The whole data collection, subsequent analyses and dissemination were protected by a secure gateway to which only the principal investigator had access and no individual could be identified. Furthermore, in order to guarantee the anonymity, the principal investigator deleted the IP addresses of participants before sharing the data with other researchers. The only recognizable reference to responders was the IP address, recorded to prevent people from taking the survey more than once. The study was approved by the Institutional Review Board and the ethics committee of the University of Naples Federico II.

Instruments

The Transgender Identity Survey (TIS) (Bockting, 2010) is a self-administered questionnaire consisting of 26 items on a 7 points Likert scale, that assesses the incorporation of one's transgender identity into the overall self-identity. The scale is constituted by 4 components, which refer to distinct aspects of transgender identity: 1) Pride (α = .85), which constitutes the only positive dimension, protecting transgender persons from social stigma and facilitating the coming out process; 2) Alienation (α = .71) from other transgender persons, characterized by personal feelings of embarrassment in the presence of other transgender people, by the deny of the benefits of peers’ support and, finally, by isolation; 3) Passing (α = .87) is the attempt to avoid being perceived as a transgender person, thus hiding one's own gender identity; 4) Shame (α = .86) refers to shameful feelings experienced towards one's own social condition and identity. The total scale has demonstrated good internal consistency (α = .91). The scale has been recoded so that a higher score on the Pride subscale indicates a more positive transgender identity and lower levels of internalized transphobia; on the contrary, a higher score on Alienation, Passing and Shame indicates a negative transgender identity and higher levels of internalized transphobia. The TIS was translated into Italian, independently, by two clinical psychologists with an excellent proficiency both in English and Italian and every disagreement was discussed, until a final agreement was achieved. The final version adopted for use in the present study involved a native language speaker for the back-translation (Behling & Law, 2000).

The Attachment Style Questionnaire (ASQ) (the Italian version has been translated and validated by Fossati et al., 2003) is a 40-items questionnaire, which required participants to rate relational aspects of themselves and significant others on a 6-point Likert scale. The items deal with relationships in general and yields 5 subscales: 1) Confidence (secure attachment style; α = .60); 2) Discomfort with closeness (avoidant attachment style; α = .68); 3) Relationships as secondary (dismissing attachment style; α = .75); 4) Need for approval (preoccupied/fearful attachment style; α = .80); 5) Preoccupation with relationships (anxious/ambivalent attachment style; α = .80). This instrument focuses on distinctive and explicit patterns of relating to specific partners that are representative of different adult attachment styles. In fact, the items capture some of the common themes in attachment theory, such as trust, dependence, and self-reliance. For the Italian validation, the authors tested the existence of two latent factors which represent the main dimensions of attachment, or rather Anxiety and Avoidance (Fossati et al., 2003). ASQ subscales can be explained through these latent factors. Respectively, Discomfort with closeness and Relationships as secondary reflect Avoidance; Need for approval, Preoccupation with relationships and low Confidence reflect Anxiety (Fossati et al., 2003). In the current study, authors preferred to work with two macro-categories, different from anxiety and avoidance, namely secure and insecure attachment styles. These latter ones, indeed, account for both positive and negative aspects of attachment, rather than only for its insecure dimensions, as in the case of anxiety and avoidance.

Results

In order to assess the prevalence of secure and insecure attachment styles, participants were categorized into clusters based on the scores obtained from the ASQ subscales through a cluster analysis. Prior to cluster analysis, univariate and multivariate outliers were detected following the recommendations of Tabachnick & Fidell (2007). No scores greater or lower than ±3.29 were identified. A two-step process to create attachment styles clusters was conducted. In the first step, a hierarchical cluster analysis was realized using Ward's method and squared Euclidian distances (Steinley & Brusco, 2007) and revealed two main clusters. In the second step, K-means cluster analysis was used to test the mean differences in attachment dimensions between the two clusters. The means comparison, measured through a t-test analysis for two-independent samples between the obtained clusters, was statistically significant for all of the attachment styles (Table 1). Specifically, participants with secure attachment styles had higher average scores in Confidence (M = 4.50, SD = 0.09) than those with insecure attachment styles (M = 3.66, SD = 0.14), t(46) = −5.40, p = <.001, d = −1.59. On the contrary, participants with insecure attachment styles had higher average scores in Discomfort with Closeness (M = 4.33, SD = 0.15) than those with secure attachment styles (M = 3.52, SD = 0.11), t(46) = 4.43, p = <.001, d = 1.31. Insecure attachment cluster reported also higher means in Relationship as Secondary (M = 2.92, SD = 0.24) than secure attachment cluster (M = 2.28, SD = 0.14), t(46) = 2.46, p = .018, d = 0.72. Insecure attachment cluster reported higher means in Need for Approval (M = 3.83, SD = 0.18) than secure one (M = 2.19, SD = 0.13), t(46) = 7.79, p = <.001, d = 2.29. Finally, participants with insecure attachment styles had higher average scores in Preoccupation with Relationships (M = 4.01, SD = 0.18), than those with insecure ones (M = 3.28, SD = 0.20), t(46) = 2.59, p = <.001, d = .076. As the clusters were represented by a small number of people, it is meaningful that the Cohen's d (Cohen, 1988) values indicating the effect size of the mean differences ranged from medium to high. The two clusters did not revealed statistically significant differences in any demographic characteristic (age, sex, marital status, sex reassignment surgery, religious education, political belief, affiliation with LGBT association). For this reason, these are not included in the following multiple linear regressions analyses reported below.

Table 1.

Means Comparison Between Two Attachment-Style Clusters in ASQ Subscales Among Transgender Adults Participants (n = 48)

Attachment styles
Insecure attachment (N=20) Secure attachment (N=28)
M SD M SD t df
Confidence 3.66 0.14 4.50 0.09 −5.40*** 46
Discomfort with Closeness 4.33 0.15 3.52 0.11 4.43*** 46
Relationship as secondary 2.92 0.24 2.28 0.14 2.46* 46
Need for Approval 3.83 0.18 2.19 0.13 7.79*** 46
Preoccupation with Relationships 4.01 0.18 3.28 0.20 2.59* 46
Open in a new tab
*

p < .05

***

p < .001

Note. M = Means. SD = Standard Deviation.

The scores of all attachment subscales range from 1 (Completely disagree) to 6 (Completely agree).

Furthermore, findings failed to support what was expected. Indeed, secure attachment styles were more prevalent than insecure attachment styles.

Results from bivariate correlation analysis between attachment styles and total TIS (Positive Transgender Identity) revealed significant and positive associations with Confidence, r(46) = .31, p = .03, and significant and negative associations with Need for approval, r(46) = −.40, p = .004, and Preoccupation with relationship, r(46) = −.34, p = .02.

The results from a comparison of means through a t-test analysis for two-independent samples in TIS subscales (Table 2) between participants with secure (M = 4.75, SD = 0.98) and insecure attachment styles (M = 3.98, SD = 0.93), revealed that participants with secure attachment styles report higher levels of positive Transgender Identity, t(46) = −2.76, p = .009, d = −0.81. On the contrary, participants with insecure attachment styles (M = 4.75, SD = 1.32) reported higher average scores in Passing than those with secure attachment styles (M = 3.77, SD = 1.52), t(46) = 2.37, p = .025, d = 0.69. Similarly, insecure attachment cluster had higher average scores in Shame (M = 3.43, SD = 1.46),than the secure one (M = 2.53, SD = 1.22), t(46) = 2.24, p = .025, d = 0.66.

Table 2.

Mean Comparisons between Two Attachment-Style Clusters in Transgender Identity Dimensions Among Transgender Adults Participants (n = 48)

Attachment styles
Insecure attachment (N=20) Secure attachment (N=28)
M SD M SD t df
Alienation 3.88 0.99 3.33 1.76 1.26 46
Passing 4.75 1.32 3.77 1.52 2.37* 46
Pride 3.97 1.46 4.64 1.35 1.61 46
Shame 3.43 1.46 2.53 1.22 2.24* 46
Positive Transgender Identity 3.98 0.93 4.75 0.98 −2.76** 46
Open in a new tab
*

p < .05

**

p < .01

Note. M = Means. SD = Standard Deviation.

The scores of all Transgender Identity Survey subscales range from 1 (Completely disagree) to 7 (Completely agree). Higher scores in Pride indicate a more positive transgender identity and lower levels of internalized transphobia; on the contrary, higher scores in Alienation, Passing and Shame indicate a negative transgender identity and higher levels of internalized transphobia.

The results from a multiple linear regression analysis of secure and insecure attachment clusters on the TIS subscales and on the total TIS indicated that the belongingness to the insecure attachment cluster was a significant predictor of Passing, β = −.323, t (47) = −2.315, p < .05 and Shame β = −.323, t (47) = −2.316, p <.05. Specifically, insecure attachment cluster explained a significant proportion of variance of Passing, R2 = .104, F(1, 47) = 5.361, p < .05, 95% CI [−1.824, −.127], f2 = 0.12, and Shame, R2 = .104, F(1, 47) = 5.362, p < .05, 95% CI [−1.683, −.118], f2 = 0.12. On the other hand, the belongingness to the secure attachment cluster was a significant predictor of the positive transgender identity (total TIS), β = .374, t (47) = 2.736, p < .01, explaining a significant proportion of variance of the positive transgender identity, R2 = .140, F(1, 47) = 7.486, p < .01, 95% CI [.204, 1.341], f2 = 0.16. Pride and Alienation were not significantly predicted by the two different clusters of attachment.

Discussion

In considering the results obtained, we should keep in mind that the size and the unique composition of the sample, who volunteered for the present study, limit the generalizability of the results to the whole Italian transgender population. Notwithstanding, the results serve as a catalyst for further reflections and research.

Contrary to authors’ expectations and to the results previously obtained by one of the authors through the Adult Attachment Interview (Vitelli & Riccardi, 2010), the current study has revealed a higher prevalence of secure attachment styles among Italian transgender individuals. Therefore, to some extent, the current findings seem to be in line with those which emerged from a previous study on another Italian sample, where different evaluation measures were used (Conte et al., 2008). The authors of the present study believe that their findings differ from those obtained by Vitelli & Riccardi (2010) mainly because in the latter study participants were a clinical sample, differently from the current research. In addition, the two samples were recruited with different modalities, namely face-to-face versus online, respectively. Furthermore, the differences between the two measures which have been employed – respectively, Adult Attachment Interview and Attachment Style Questionnaire2 – should not be overlooked.

In any case, the most salient and important finding obtained in the present study is the association between transgender identity and adult attachment styles: specifically, people with secure attachment styles are more likely to have a positive transgender identity than those with insecure attachment styles. On the contrary, transgender people with insecure attachment styles are more likely to have a greater investment in passing for the gender of their choice and to feel ashamed of their own identity. These findings can cast new light on the defined purposes of psychological counseling with transgender people. Actually, in our experience, people who have come to our attention at the Gender Dysphoria Psychological Service (operating at the Federico II University Hospital since 1997) have rarely arrived with an independent questioning of their existential experience, despite the frequent presence of dramatic life incidents which had occurred in their lives (Vitelli, & Riccardi 2010). Rather, they have been referred by other professionals in the medical/legal system: judges, endocrinologists and/or urologists. Indeed, psychiatrists and clinical psychologists today ply their trade as official technical consultants or experts, essentially performing a merely diagnostic function. In this way, they are substantially perceived as “gatekeepers” of hormones and surgery (Speer, & Parsons 2006). Vice versa, the psychological clinical encounter may be seen as a valuable opportunity for helping transgender people to improve their quality of life in a more general sense, and in particular their ability to engage in adult romantic relationships, beyond any pathologizing instance. Although within our sample the majority of people have shown a secure attachment style, and previous researches have studied specific resilience strategies developed by transgender people in response to societal stigma (Singh et al., 2011; Singh, Meng, & Hansen, 2014), this is not always the case. For this reason, clinical work should assess attachment styles as a standard part of treatment planning, and should be primarily aimed to increase a person's sense of security. In other words, following Shaver and Mikulincer (2009), clients should be helped to experience “a sense that the world is a safe place, that one can rely on others for protections and support, and that one can confidently explore the environment and engage in social and nonsocial tasks and activities without fear of damage” (p. 20). Furthermore, as our findings suggest, psychological intervention, designed to improve the secure attachment dimension, could indirectly and positively affect the negative transgender identity, in particular minimizing the Passing and Shame dimensions. As previously said, in adulthood, a secure attachment style is considered an important factor in the achievement of couple's adjustment and well-being (Carnelley, Hepper, Hicks, & Turner, 2011; Feeney, 1999; Holland & Roisman, 2010; Sadikaj, Moskowitz, & Zuroff, 2011; Zimmer-Gembeck & Ducat, 2010). At the same time, adults who lack the capacity for secure attachment frequently also are poor in skills for an adequate social functioning, such as the ability to recruit supportive friendships (Mallinckrodt & Wei, 2005). In this sense, our findings suggest that transgender people with insecure attachment invest in passing and tend to develop shame toward their own transgender identity. Since investment in passing has been considered as an indication of concealment and, thus, as a dimension limiting identity affirmation (Bockting et al., 2013), these people could have difficulty to access benefits of a supportive community. Indeed, as Singh et al. (2011; 2014) and Testa, Jimenez, & Rankin (2014) stated, a connection with a supportive community, as well as with groups of alike transgender people, is very sound to establish a more positive identity and to improve resilience strategies. Therefore, individual and group psychotherapeutic work aimed at re-shaping IWMs3 could directly or indirectly facilitate access to support groups, help to limit internalized transphobia, reinforce a more positive self-image and improve resilience. As Bockting et al. (2013) have recently found, resilience represents an ameliorating factor able to buffer the negative impact of social stigma on mental health. From this point of view, psychological interventions could be directed also onto the development or reinforcement of individual resources to cope with transphobia experienced in different life contexts.

In order to develop effective psychological interventions, future research should be designed to investigate the effects that negative transgender identity, or rather internalized transphobia, has on wellbeing. Furthermore, a further issue to be addressed by future studies should be the development of intervention models which might allow early prevention of stigma and transphobia, working on primary and secondary socialization contexts of gender non conforming children and youths, such as families and educational agencies.

Overall, the current findings suggest the need for further explorative investigation on larger samples to verify the specific patterns of adult attachment styles in the Italian transgender population. In addition, a variety of valid, and reliable measures of adult attachment should be adopted.

Concluding remarks

Internalized transphobia and negative transgender identity derive often from primary relationships with attachment figures, as well as with peers and significant others. These relational models could produce negative self-images, which in turn could affect future adults relationships. The contribution of this study lies in establishing a link between internalized transphobia and negative transgender identity, and in deducing some clinical and preventive psychological implications.

Indeed, authors believe that working on the IWMs of transgender people, their self-image and self-esteem can increase, thus reinforcing also the positive transgender identity. This is also possible through an individual or group psychotherapy addressed to reshape IWMs.

Finally, as previously stated, within a preventive framework, a psychological support addressed to parents of gender nonconforming children, educational institutions, and all their proximal contexts could result efficient.

Limitations

As already mentioned, the study was a cross-sectional design with a relatively small and non random, volunteer sample. Thus, the findings have a limited external validity, i.e., the results are not widely generalizable. Moreover, the TIS by Bockting has never been validated in Italy, although the results from the current sample demonstrated a good internal reliability. An important limitation of the study is the absence of data about parental acceptance/rejection. We can suppose that parents of gender nonconforming children rejected them because they did not match gender binary and this experience of rejection may be partly responsible for both insecure attachment styles and negative transgender identity. Departing from this hypothesis, a future longitudinal and qualitative work could provide this datum.

Acknowledgment

All the authors are particularly grateful for the assistance given by Prof. Emeritus Harold Cook at Columbia University in revising the whole manuscript.

Funding

The project described was supported by the Summer Institute in LGBT Population Health, under Award Number R25HD064426 from the Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NICHD or the National Institutes of Health.

Footnotes

1

As Mikulincer & Shaver (2012) stated, “attachment insecurity can therefore be viewed as a general vulnerability to mental disorders, with the particular symptomatology depending on genetic, developmental, and environmental factors” (p.12).

2

In attachment literature there is still no agreement on the degrees of association between the various measures of adult attachment (e.g., see Shaver, Belsky, & Brennan, 2000; Shaver & Mikulincer, 2004, 2009).

3

For a review of Attachment theory in clinical work, see Slade, 1999; Wallin, 2007.

Contributor Information

Anna Lisa Amodeo, Department of Humanistic Studies, University of Naples Federico II, Napoli, Italy.

Roberto Vitelli, Department of Neurosciences and Reproductive and Odontostomatologic Sciences, University of Naples Federico II, Napoli, Italy.

Cristiano Scandurra, Department of Humanistic Studies, University of Naples Federico II, Napoli, Italy.

Simona Picariello, Department of Humanistic Studies, University of Naples Federico II, Napoli, Italy.

Paolo Valerio, Department of Neurosciences and Reproductive and Odontostomatologic Sciences.

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