Direct and indirect effects of psychological well-being and therapeutic alliance on therapy outcome in eating disorders.

Introduction: Outcome research in eating disorders (EDs) is commonly focused on psychopathological dysfunction. However, Ryff's model of psychological well-being (PWB) has shown promising-yet preliminary-results with ED patients. Additionally, despite substantial evidence highlighting the association between the therapeutic alliance and treatment outcome, findings in ED samples remain unclear. The present study aimed at exploring the direct effect of PWB dimensions and the early therapeutic alliance on ED patients' individual treatment responses, as well as the mediating role played by the early therapeutic alliance in the relationship between PWB dimensions and overall pre-post symptom change. Methods: A sample of N = 165 ED patients assigned female at birth, who were receiving treatment in a residential program, completed the Psychological Well-Being Scale at treatment intake and the Working Alliance Inventory after the first four psychotherapy sessions. Patients also completed the Outcome Questionnaire-45.2 at the same time point and during the week prior to discharge. Results: The PWB dimensions of autonomy, positive relations, and self-acceptance were associated with clinically significant change, while the dimensions of personal growth and self-acceptance were associated with reliable change. The early therapeutic alliance showed both direct and indirect effects on therapy outcome, predicting clinically significant and reliable symptom reduction. It also emerged as a significant mediator in the relationship between all PWB dimensions and overall symptomatic change. Conclusion: The identification of individual, adaptive characteristics in ED patients that might influence their development of an early therapeutic alliance may help therapists to predict relationship ruptures and tailor their interventions to enhance treatment effectiveness.

The intergenerational transmission of attachment during middle childhood in lesbian, gay, and heterosexual parent families through assisted reproduction: The mediating role of reflective functioning.

The present study examined the attachment patterns distribution of 60 lesbian mothers, 50 gay fathers, and 42 heterosexual parents through assisted reproduction and their 76 children, using the Adult Attachment Interview (AAI) and the Friends and Family Interview (FFI), respectively. The study also explored the intergenerational transmission of attachment through reflective functioning (AAI-RF). All families lived in Italy and children were aged 6-12 years (Myears = 8.11, SD = 2.17; 48.68% assigned female at birth). The AAI patterns distribution was similar across family types and did not significantly differ from international and national normative data. Similarly, children's FFI attachment patterns were evenly distributed between family types, and no significant differences emerged in comparison to international and national normative data referring to middle childhood samples. Mediational models revealed that, in all three family types, parents with greater AAI coherence of mind exhibited higher AAI-RF, which, in turn, was associated with increased FFI attachment security in children. Furthermore, parents' AAI coherence of mind directly influenced children's FFI attachment security. The results support and expand hypotheses regarding the intergenerational transmission of attachment in lesbian, gay, and heterosexual parent families through assisted reproduction, while offering unique indications to support these families during middle childhood.

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

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

Disclosure and child exploration of surrogacy origins in gay father families: Fathers' Adult Attachment Interview coherence of mind matters.

OBJECTIVE: The present study aimed at investigating whether gay fathers' coherence of mind within the Adult Attachment Interview (AAI) moderated the influence of parental disclosure on children's exploration of their surrogacy origins during middle childhood and early adolescence. BACKGROUND: Once children of gay fathers are disclosed to about their surrogacy conception, they may start exploring the meanings and implications of their conception. Very little is known about the factors that may enhance such exploration in gay father families. METHOD: A home-visit study was conducted with 60 White, cisgender, gay fathers and their 30 children born through gestational surrogacy, all residing in Italy and with medium to high socioeconomic status. At time 1, when children were aged 6-12 years (M = 8.31, SD = 1.68), fathers were rated for AAI coherence of mind and interviewed about their disclosure of the surrogacy origins to their child. At time 2, approximately 18 months later (M = 9.87, SD = 1.69), children were interviewed about their exploration of their surrogacy origins. RESULTS: In the context of more information disclosed about the child conception, only children whose fathers showed greater AAI coherence of mind explored their surrogacy origins in more depth. CONCLUSION: Gay fathers' ability to show an internally consistent, but not emotionally overwrought, state of mind regarding their own attachment experiences impacted the extent to which their children felt safe and legitimated in sharing their curiosity about their conception.

From symptoms to subjective and bodily experiences: the contribution of the Psychodynamic Diagnostic Manual (PDM-2) to diagnosis and treatment monitoring in eating disorders.

PURPOSE: Atheoretical and descriptive conceptualizations of eating disorders (EDs) have faced substantial criticism due to their limited ability to assess patients' subjective characteristics and experiences, as needed to determine the most appropriate treatment options. The present article provides an overview of the clinical and empirical literature supporting the potential contribution of the Psychodynamic Diagnostic Manual (PDM-2) to both diagnostic assessment and treatment monitoring. METHODS: Following a discussion of the most relevant shortcomings of current diagnostic models of EDs and a description of the rationale and structure of the PDM-2, evidence supporting the core PDM-2 dimensions of ED patients' subjective experiences (i.e., affective states, cognitive processes, relational patterns, somatic/bodily experiences and states) are examined, alongside their relevance to ED diagnosis and treatment. RESULTS: Overall, the reviewed studies support the diagnostic importance of these patterns of subjective experiences in EDs, highlighting their potential role as either predisposing or maintaining factors to target in psychotherapy. A growing body of multidisciplinary evidence also shows that bodily and somatic experiences are central to the diagnosis and clinical management of ED patients. Moreover, there is evidence that a PDM-based assessment may enable closer monitoring of patient progress during treatment, with regard to both subjective experiences and symptom patterns. CONCLUSIONS: The study suggests that current diagnostic frameworks for EDs would benefit from the addition of a person-centered perspective that considers not only symptoms, but also patients' full range of functioning-including their deep and surface-level emotional, cognitive, interpersonal, and social patterns-to improve patient-tailored interventions. LEVEL OF EVIDENCE: Level V, narrative review.

Non-Binary Clients' Experiences of Psychotherapy: Uncomfortable and Affirmative Approaches.

Non-binary people may face specific challenges in psychological settings. Psychotherapists often display a lack of preparation for non-binary gender identities, resulting in overt or subtle forms of prejudice that compromise the therapeutic alliance. The present study aimed to provide data on non-binary clients' positive and negative experiences within therapeutic relationships. Twenty-five interviews were conducted with non-binary people in the age range of 19-35. Using codebook thematic analysis, the researchers identified three main themes: (1) the self of the psychotherapist, consisting of the impact of the therapist's personal (i.e., sexual identity) and professional (i.e., competence) characteristics on the therapeutic experience; (2) the practice of the psychotherapist, emerging as affirmative (validation and microaffirmations) or negative (gender identity change efforts, manifest aggressions, and microaggressions) approaches toward non-binary identities; (3) the therapeutic relationship, referring to the alliance, rupture, and reparation based on the therapists' openness toward non-binary identities. To provide a safer setting for non-binary clients, psychotherapists should incorporate issues related to gender minority identities in their training, acknowledge clinical errors when they occur and adopt an active predisposition to learn through the client's experience, giving value to their unique contribution.

Gender Identity and Non-Binary Presentations in Adolescents Attending Two Specialized Services in Italy.

BACKGROUND: Recently, the variability and heterogeneity of gender presentations in transgender youths have gained significant attention worldwide. Alongside this, specialized gender services have reported an increase in referrals of youths reporting non-binary identities. In Italy, studies investigating gender identity and expression in gender non-conforming youths are lacking, as are data regarding the non-binary population. AIM: The present study aimed at dimensionally exploring how transgender and non-binary Italian adolescents identify and express their gender. OUTCOMES: Gender expression in trans binary youths and non-binary youths. METHODS: The Gender Diversity Questionnaire (GDQ; Twist & de Graaf, 2019) was used to investigate gender identity, gender fluidity, and gender expression in a sample of 125 adolescent patients from the Gender Identity Development Service (SAIFIP) in Rome and the Gender Incongruence Unit of the Careggi Hospital in Florence, between April 2019-June 2021. RESULTS: The majority of participants (74.4%) identified as trans* binary and the remaining (25.6%) participants identified as non-binary. Trans binary participants reported a stable gender identity, whereas non-binary participants reported a more fluid gender identity across time and contexts. Almost all participants rated external appearance as important to their gender expression, yet trans binary participants attributed more importance to the body in this respect. Body discomfort and pubertal stage emerged as the most influential factors in participants' experiences of gender. Participants who were assigned male at birth expressed significantly more desire for puberty blockers, whereas those who were assigned female at birth had a stronger desire to engage in breast/chest surgery. Non-binary participants sought different medical interventions relative to trans binary participants. CLINICAL IMPLICATIONS: These results may be useful for clinicians working with transgender youths as they provide awareness regarding the features of young people who identify within and outside of binary constructions of gender. STRENGTHS & LIMITATIONS: This study provides useful data in gaining insight into understanding the variety of experiences and challenges of gender non-conforming youths. However as the sample was recruited from specialized services, it may not represent the entire gender non-conforming population in Italy. CONCLUSION: The results describe the range of gender identities and expressions among gender non-conforming youths attending gender specialized services in Italy, thereby improving our understanding of the variety of identities experienced and the specific medical needs of both trans binary and non-binary adolescents. Mirabella M, Piras I, Fortunato A, et al. Gender Identity and Non-Binary Presentations in Adolescents Attending Two Specialized Services in Italy. J Sex Med 2022;19:1035-1048.

Is It Autism? A Critical Commentary on the Co-Occurrence of Gender Dysphoria and Autism Spectrum Disorder.

An increasing amount of literature revealed a link between GD and ASD. Both GD and ASD are complex and heterogeneous conditions characterized by a large variety of presentations. Studies have reported that individuals with GD tend to have higher prevalence rates of autistic traits in comparison to the general population. The purpose of this commentary is to provide, through the description of a clinical case, our reading and a possible interpretation of the correlation of these two conditions in light of the several methodological limitations found in literature. We hypothesize that the traits often classified as autistic could be more accurately related to the distress and discomfort evoked by GD. The autistic traits of individuals with GD as forms of psychological defenses and coping mechanisms aimed at dealing with socio-relational and identity problems are discussed.

Psychological Well-Being of Trans* People in Italy During the COVID-19 Pandemic: Critical Issues and Personal Experiences.

Introduction: The COVID-19 pandemic represents risk to physical health and psychological well-being. Specifically, it causes concerns among minoritized communities, such as transgender/non-binary individuals. The study investigates the experience of this group in Italy during the pandemic and identifies risk factors that exerted negative impacts on psychological well-being and physical health. Methods: The study developed an online questionnaire to investigate psychological status, access to medical health services, and factors such as predictors of risk outcomes among transgender/non-binary people during lockdown restrictions. Responses were collected (n = 256) on April 2020. Descriptive analysis, univariate analysis of variance, and t-test were conducted. Results: The respondents confirmed several issues, such as worries about the future (58.2%), negative emotions (46.9%), and self-uncertainty (52.7%) during the pandemic. Difficulties in undertaking hormone therapy and access to health facilities were reported. Living with family members represented a significant stressor for psychological well-being, whereas lack of support from LGBT + communities was reported. Subjects undergoing psychological therapy during the pandemic reported increases in depression, anxiety, somatization, and lack of privacy in the household. Conclusions: The study findings provide a framework for critical aspects experienced by transgender/non-binary individuals during the pandemic. Specifically, the study provides evidence of the vulnerability of this population underlined by multiple difficulties. Policy Implications: The study findings provide an overview of the experience of transgender and non-binary people during the pandemic, insights regarding risk factors, and aspects that require adequate attention and care. Supplementary Information: The online version contains supplementary material available at 10.1007/s13178-021-00633-3.

Defensive Functioning of Individuals Diagnosed With Gender Dysphoria at the Beginning of Their Hormonal Treatment.

Defense mechanisms are relevant indicators of psychological functioning and vulnerability to psychopathology. Their evaluation can unveil individuals' unconscious strategies for mediating reactions to emotional conflict and external stressors. At the beginning of their journey toward gender reassignment, individuals diagnosed with gender dysphoria (GD) may experience conflict and stressful experiences that trigger a wide range of defense mechanisms. Mature defenses may strengthen these individuals as they travel along this important path, while neurotic and immature defenses may exacerbate their body dissatisfaction (BD) and hinder their processing of change. Only a few studies have investigated self-reported defensive functioning in transgender people, finding a higher frequency of maladaptive defense mechanisms relative to controls. The present study was the first to apply an in-depth clinician-rated tool to assess the entire hierarchy of defense mechanisms within a sample of transgender people. Defensive functioning and personality organization were assessed in 36 individuals diagnosed with GD (14 trans women, 22 trans men, mean age 23.47 years), using the Defense Mechanisms Rating Scales (Perry, 1990) and the Shedler-Westen Assessment Procedure-200 (Shedler et al., 2014). Body uneasiness was assessed using the Body Uneasiness Test (BUT; Cuzzolaro et al., 2006). The findings showed that defensive functioning correlated positively with healthy personality functioning and negatively with BD. Compared to cisgender controls, participants with GD who presented greater defensive functioning were found to be more immature and to demonstrate significant differences in many levels of functioning. The clinical implications of the results suggest that psychological interventions aimed at improving defensive functioning in individuals with GD will be important in helping them manage the challenges posed by their gender transition.

Gender Diverse Children and Adolescents in Italy: A Qualitative Study on Specialized Centers' Model of Care and Network.

In recent years, Italy, similar to many other countries, has witnessed an increase in children and adolescents presenting gender incongruence. This trend has led to the development and implementation of specialized centers providing care and support for these youths and their families. The present study aimed at investigating the functioning of agencies specialized in working with transgender and gender non-conforming youths in the Italian territory. Professionals in these agencies were interviewed about their perspectives on their agency's functioning, networks with other services, and work with trans* youths and their families. A semi-structured interview was developed and administered to professionals in specialized centers and associations dedicated to trans * youths, and deductive thematic analysis was applied to the transcripts. Eight professionals were interviewed: six working in specialized centers and two working in associations. The qualitative analyses of transcripts revealed four main themes, pertaining to service referrals, assessment protocols and intervention models, psychological support for youths and families, and agency shortcomings. The study explored the functioning of Italian agencies specialized in caring for transgender and gender non-conforming youths, from the perspective of professionals working in these agencies. While several positive aspects of the work emerged, the study highlighted a lack of uniformity across the Italian territory and the need for better networks between agencies and other medical professionals.

The Body I Live in. Perceptions and Meanings of Body Dissatisfaction in Young Transgender Adults: A Qualitative Study.

Body dissatisfaction in individuals with Gender Incongruence (GI) represents a primary source of suffering. Several studies have highlighted how this suffering has psychological, physical, and biological implications. This work aims to explore experiences related to body dissatisfaction and investigate the issues associated with living in a body perceived as incongruent for individuals with GI. Thirty-six individuals, aged between 18 and 30 years old and at stage T0 of hormone treatment, participated in the study. Body dissatisfaction and experiences related to it were investigated using the Clinical Diagnostic Interview. The Consensual Qualitative Research methodology was applied to the transcripts of the interviews. Several themes emerged: experiences with GI development, experiences with puberty and bodily changes, perception of one's body, psychological problems and complex behavioral patterns related to body dissatisfaction. Results pointed out the complexity implied in the relationship with one's body for individuals with GI, highlighting specific aspects of body dissatisfaction among these individuals (e.g., eating disorders, sexual difficulties, social withdrawal). This study underlines the need for a deeper understanding of some aspects of GI to better define guidelines for a correct assessment of it. In this way it will be easier to avoid negative outcomes for the psychological and general health of transgender people.

Caring for gender diverse children and adolescents in Italy: A mixed-method investigation of clinicians' knowledge and approach to clinical practice.

INTRODUCTION: In today's Italy, gender diversity has assumed a remarkable resonance and visibility in both scientific and popular literature, which has facilitated the development of studies regarding treatments and support for children and adolescents with gender-related issues. AIM: the aim of this study was to conduct a preliminary evaluation of how Italian clinicians (psychologists and pediatricians) perceive gender variant children and adolescents, evaluating their approach to clinical practice. METHODS: An online questionnaire directed to clinicians regarding their experience with, and perceptions of, gender variant children and adolescents was used for the first part of the research. In the second part of this study, Consensual Qualitative Research (CQR) methodology was applied to semi-structured interviews aimed at investigating clinicians' approach to clinical practice. RESULTS: Professionals reported 374 cases, including 200 children (aged 2-11 years) and 174 adolescents (aged 12-19 years); a total of 10 interviews were conducted with professionals. CONCLUSION: This study highlights the increase of gender variant children and adolescents seen by professionals, but also the poor awareness of Italian professionals about gender diversity and their care, as well as an absence of a network model of intervention.