Transgender Youth’s Psychological Wellbeing, Mental Toughness, and Fear of Negative Appearance Evaluation

ABSTRACT

This study investigates the relationship of variables that play a role in improving the wellbeing of transgender people. It examines the mediating effect of mental toughness on the relationship between fear of negative appearance evaluation and the psychological wellbeing of transgender youth. A total of 271 young transgender individuals aged 13-18 years old were recruited from Gujrat, Lahore and Rawalpindi districts in Pakistan using the snowball sampling technique. Data were collected through a quantitative cross-sectional survey research design after checking the internal consistency of the tools in a pilot study on 30 young transgender participants. The findings revealed mental toughness has a significant mediating role (P<.001) on the relationship between fear of negative appearance evaluation and psychological wellbeing among transgender people youth. Moreover, a significant direct negative effect of fear of negative appearance evaluation appeared on mental toughness and psychological wellbeing. On the other hand, mental toughness appeared to have a positive direct effect on the psychological wellbeing of the young transgender. Hence, the mental toughness of transgender people should be improved to enhance their psychological wellbeing.

Keywords: Transgender youth, Psychological wellbeing, Mental toughness, Fear of negative appearance evaluation.

INTRODUCTION

Fear of negative appearance evaluation (FNAE) has been associated with the threat of being negatively judged and receiving unfavorable feedback from others (Bradford and Petrie, 2008; Goffnett et al., 2023). It has also been defined as the dread of being judged adversely to the extent of hampering one’s psychological wellbeing (PWB) (Bradford and Petrie, 2008; Presnell et al., 2004). It is believed that people experience it infrequently, but some groups fear it to a disabling level, and transgender young people is one such group (Hendricks and Testa, 2012). They receive continuous negative appearance evaluation from others, making their FNAE intense, harming their PWB (Inderbinen et al., 2021; Pinna et al., 2022). As Ryff and Keyes (1995) assert, PWB does not only mean happiness, but refers to the intra and inter-healthy functioning that an individual has to achieve by maintaining a state of balance between the challenging and rewarding events of their life. PWB refers to  “the achievement of one’s full psychological potential” (Carr, 2013).

FNAE has also been observed to affect the mental toughness (MT) of individuals negatively and this negative effect manifests through a lack of confidence, social avoidance, and poor performance (Atasoy et al., 2016). MT has been studied in sports for a couple of decades. However, recently researchers began to study it in other fields of life also. MT has been identified as the ability to manage fear of negative evaluation, high-performance demands, and achieving success in sports and other fields (Anthony et al., 2016; Connaughton et al., 2010; Gucciardi and Gordon, 2012). It is an ability to maintain and regain focus when distracted. While different opinions exist over the definition and general conceptual clarity of MT (Gucciardi, 2017). It is most commonly presented as a set of positive attributes that enable individuals to achieve goals by proceeding through difficult situations (Connaughton et al., 2010; Gucciardi, 2017).

Further, MT has been found to play a significant role in enhancing and improving PWB (Jin and Wang, 2018; Stamp et al., 2015) by reducing the effects of fear of negative evaluation (Gerber et al., 2018; Haghighi and Gerber, 2019). The literature suggests that MT can either moderate (Gerber et al., 2018; Levy et al., 2012) or mediate the other constructs to enhance the wellbeing of the individuals (Benjamin and John, 2021; Gucciardi, 2017; Haghighi and Gerber, 2019). In short, MT is an attribute that enables a person to consistently produce high levels of subjective (e.g., personal goals) or objective performance (collective goals) despite everyday challenges and adverse experiences (Gucciardi, 2017).

Several studies note the negative effects of FNAE, MT and PWB in young individuals. Lee et al. (2022) conducted a study on the role of FNAE and the PWB of young students in Hong Kong and found a negative association between FNAE and PWB (Atasoy et al., 2016; Gerada, 2020; Howe, 2014). Social appearance anxiety, and perfectionism are negatively associated with lower PWB in youth (Busch et al., 2023; Charania and Krishnaveti, 2021). Similar findings have been reported by others (Sigurvinsdottir et al., 2021), finding FNAE to be positively related to poor PWB in terms of social anxiety and distress. Sharif et al. (2020) found that FNAE has recently emerged as a contributor to negative behaviors as well as affecting PWB. On the other hand, FNAE is found to be positively associated with negative behaviors in young people thus negatively affecting the normal routine life and wellbeing of the individuals (Fathima et al., 2019; Selem et al., 2023). Further, a recent study in Pakistan also reported that FNAE is associated with lower PWB of participants (Shahid et al., 2022).

Similarly, FNAE was reported to be negatively associated with PWB among transgender people (Verbeek et al., 2020). Glynn and van den Berg (2017) found low PWB in terms of high psychological distress and lower self-esteem among transgender people. Further studies reported body shame, gender identity, low body satisfaction, and loneliness (Wittlin et al., 2023) that are linked with FNAE which harms the PWB of young transgender people individuals (Anderssen et al., 2020). Recent studies revealed poor social relationships, poor self-acceptance, low confidence, lack of emotional control, worthlessness, social isolation, body of dissatisfaction, loneliness sense of discrimination, and rejection which are the indicators of low PWB and mainly the outcomes of FNAE (Goodfriend et al., 2023; Hendricks and Testa, 2012; Jones et al., 2022; Mainland et al., 2023).

MT has recently caught the attention of researchers, but most studies focus on athletes (Stamp et al., 2015). MT has been studied in the field of sports psychology for decades and is positively associated with PWB. However, MT has been reported to be negatively linked with FNAE (Benjamin and John, 2021; Stamp et al., 2015). Sportsmen face FNAE frequently, therefore a substantial amount of research focuses on the variables that mediate and moderate their fear to make their performance better (Benjamin and John, 2021; Stamp et al., 2015; Welsh et al., 2023). Based on the findings, the researchers recommended prevention and treatment plans to improve MT to reduce fear and enhance the PWB of sportsmen (Charania and Krishnaveti, 2021; Welsh et al., 2023). However, recent findings suggest that mentally tough individuals cope more effectively with the negative experiences of their lives because they perceive that they are capable of successfully overcoming such psychological pressures (Gucciardi and Gordon, 2012; Levy et al., 2012). Recent research revealed that young transgender people show gender identity and confirmation challenges, FNAE, and poor PWB (Hendricks and Testa, 2012; Verbeek et al., 2020). Moreover, poor coping skills, poor mental strength, and poor wellbeing have been reported among transgender people (Başar et al., 2016; Ruff et al., 2019).

STUDY CONTEXT

In general, young people are very conscious about their appearance (Mainland et al., 2023). They are worried about their facial features, weight, height, body shape, and image. The positive evaluation of their appearance boosts their psycho-social health however the negative appearance evaluation negatively affects their PWB (Atasoy et al., 2016; Lee et al., 2022). In this regard, young transgender people face crucial challenges (Witten and Eyler, 1999). They receive strong negative appearance evaluations from relatives and society. In response to this, they develop a FNAE that adversely affects their PWB (Tebbe and Budge, 2022; Wittlin et al., 2023). Several studies reported poor PWB among transgender people, however limited published literature is available on the promoting factors and aspects of PWB. Recent studies conclude that exploring only the levels and factors of PWB among transgender people will not bring a substantial difference to their lives. These studies recommended identifying the mediating and moderating factors of the PWB of transgender people. Consequently, these findings can be incorporated into the PWB improvement programs for young transgender people at prevention and treatment levels (Inderbinen et al., 2021; Pinna et al., 2022; Tebbe and Budge, 2022).

This study attempts to bridge this gap by considering the theoretical grounds that describe the nature of life stressors and the consequences faced by transgender people. As a social minority group, they experience negative evaluation, rejection, victimization, and discrimination due mainly to the incongruence between their gender identity and gender expression (Busch et al., 2023; Hendricks and Testa, 2012; Witten and Eyler, 1999). This continuous negative feedback develops internalized trans negativity. In response to this internalized trans-negativity, they tend to hide their real gender identity which further leads to poor PWB. In this scenario they need to enhance their MT to grow positively with good psychological health by being resistant to FNAE (Inderbinen et al., 2021; Pinna et al., 2022).

Keeping in view the above-mentioned theoretical scenario this study has been conducted to examine the mediating role of FNAE and PWB among transgender people young people. Further, to the best of the author’s knowledge, this is the first study conducted to examine the relationship between FNAE, MT, and PWB among young transgender people in Pakistan.

MAIN OBJECTIVE

To assess the mediating effect of MT on the relationship between FNAE and the PWB of young transgender participants.

HYPOTHESES

H1: MT mediates the role of the relationship between FNAE and PWB.

H2: FNAE has a direct and negative effect on the PWB and MT of young transgender people.

H3: MT has a direct positive effect on PWB.

METHODOLOGY

This section provides the data and methods to conduct the study. It also insights into the techniques and tools of data collection used to conduct the study.

RESEARCH DESIGN

In this quantitative correlational cross-sectional survey design the following tools were used to collect data.

Population and Sample: A total of N (271) young transgender people aged 13 to 18 years were recruited from Gujrat, Lahore, and Rawalpindi districts of Pakistan by employing snowball sampling techniques. Only young transgender people who could read and write Urdu were included in the study. However, individuals with psychiatric illnesses were excluded. The demographic characteristics of the sample are presented in table 1.

Table 1

Descriptive statistics of participants (N = 271).

Ethical Consideration: This study was performed in line with the principles of APA Approval granted by the Departmental Ethics Research Committee of the university (Date. 9/05/2023/No. PSY/UOG/23/4107). After explaining the nature and aim of the research, written consent was taken from the participants and they were given complete right to withdraw participation at any time without any penalty. For participants, confidentiality was ensured as their names were not published with their responses. Further, the tools for data collection were used after obtaining permission from the respective authors.

Demographic Form: The demographic data of the participants was recorded on a self-developed demographic form. This data was tabulated and presented in table 1.

PWB Scale: The Urdu version of a brief version of the PWB scale, which consists of 16 items and a points rating scale (strongly disagree = 1, strongly disagree = 7) was used for data collection with the permission of the authors (Ryff and Keyes, 1995). The scale was translated by Bhatti and Akram (2020) using the back translation method. They conducted a study on the PWB and mental health among women with menopause and the internal consistency of the scale was reported as 0.704. The measure consists of six dimensions: autonomy, positive relationships with others, personal mastery, a feeling of purpose and meaning in life, and personal growth and development. The total score was obtained by summing up the scores on six dimensions. An individual with a higher total score represents a higher level of PWB. Prior studies reported good internal consistency of the scale ranging from 0.81 to 0.88. The alpha reliability for the scale in the current study is 0.86.

FNAE Scale: The Urdu (translated) version of the FNAE scale, a six-item self-report originally developed by Lundgren et al. (2004), was administered to participants. In this study the scale was translated again with the back translation method. Firstly, a panel of three bilingual experts (three PhDs in Psychology) were requested to translate the scale from English to Urdu. The best words/phrases were first selected by two senior members of a relevant field. Then the three bilingual experts were requested to perform the back translation. Then the two scales (original and back-translated) were compared and evaluated by the aforementioned two senior members. The translated Urdu version was pre-tested on a sample of N (30) adolescents to estimate the content clarity of the scale. The internal consistency of the scale turned to be 0.78. Moreover, the translated scale was administered on 10 adolescents to evaluate the content and improve conceptual clarity. The participants did not point out any problem. Further, t is a five-point Likert scale with responses ranging from “not at all” (1) to “extremely” (5). The item scores were summed to obtain a total score for the FNAES. In the current study, Cronbach alpha reliability of the translated Urdu version of FNAES is 0.94.

MT Scale for Adolescents (MTS-A): The Urdu (translated) MTS-A assesses the MT of adolescents. There are six sub-scores: emotion control, challenge, commitment, interpersonal confidence, control of life, and confidence in abilities (McGeown et al., 2018). These sub-scores add to make a total score. The higher scores indicate higher levels of MT. Internal consistency estimates for this scale ranged from 0.73 to 0.79 in previous studies. In this study, the internal consistency was 0.89. The scale was translated using the same back translation method. First, a panel of five bilingual experts with PhDs in Psychology translated the scale from English to Urdu. Then a committee comprised of three other experts selected the best words/phrases of the items by mutual agreement. After finalization the back translation was done by different two bilingual experts. At the end, the two scales (original and back-translated) were compared and evaluated. Further, the Urdu version was tried out on 15 adolescents to estimate the conceptual and content clarity of the translated version. The internal consistency has been 0.758 and no problems were reported in the scale.

Pilot Study: The suitability of the above-mentioned translating tools was checked by administering them to 30 young transgender adolescents (13 to 18 years old) in the current study. The sample was selected through the snowball technique. Only young transgender individuals who can read and write Urdu were included in pilot study. They filled out the questionnaires without any difficulty. The data were entered into the SPSS package and internal consistency was estimated which at 0.788, 0.745, and 0.768 for the FNAE, PWB, and MT respectively.

RESULTS

This section provides the results of the primary data and data analysis presented in tabulated form.

Descriptive Quantitative Results: After the collection of data, it was entered into SPSS IBM version 26. Descriptive statistics was run to calculate the frequencies and percentages of demographic characteristics of the participants, whereas hypotheses were tested by administering mediation analysis with the help of Process Hayes version 4 on SPSS. The results of the study are tabulated and interpreted.

Hayes Process version 4 was employed to test all hypotheses. Results are in table 2 and figure 1.

Table 2

Mediation analysis.

H1 was that MT mediated the relationship between FNAE and PWB. The results indicated an indirect effect of MT on PWB of -0.386 (P<.000) supporting H1. It means that the indirect effect of FNAE (-0.387) through MT on PWB is almost half of the direct effect which shows that MT lowers the negative effect of FNAE on PWB. However, a significant direct effect of FNAE also appeared in the presence of the mediator, MT which shows the competitive partial mediation of MT. Figure 1 shows the results clearly.

Figure 1

Summary of coefficients for mediation analysis.

Figure 1 represents Path A, a significant direct negative effect of FNAE on MT (B= - 0.857, SE=.013, P<.001). Furthermore, Path C shows a significant direct negative effect of FNAE on PWB (-0.804, SE = .049, P<0.001). Thus, H2 is also proven. On the other hand, Path B shows a significant direct positive effect of MT on PWB (B = .45, SE = 0.55, P<.001). Therefore, H3 is also supported.

DISCUSSION           

The findings of the present study indicate that MT has a significant mediating role in the relationship between FNAE and PWB among young transgender individuals. The results also indicate that FNAE strongly but negatively affects the PWB and MT of young transgender people. The fear of being rejected due to one’s gender identity makes transgender youth avoid social situations (Kamath, 2023; Rohilla et al., 2016; Rood et al., 2017). They hide themselves from others due to other’s non-acceptance of attitudes toward their gender, and they live their lives in isolation. This isolation further causes a lack of confidence, poor consistency, poor communication skills, and poor concentration and decision-making abilities. In their loneliness, they adopt negative coping strategies such as substance use. Further, they become the victim of stress, anxiety, depression, and other psychological disorders. Their self-esteem becomes low and they cannot perform their daily life activities in their academic, social, and professional lives in an effective way (Tebbe and Budge, 2022; Wittlin et al., 2023). The transgender youth internalize the negative beliefs of others and with time they tend to think about themselves negatively. In other words, with time, the non-acceptance attitude toward their gender becomes congruent with that of other people and they tend to perceive themselves as worthless and a burden on society. This negative thinking leads them to minority stress and affects their PWB negatively (Devís-Devís et al., 2017; Rodríguez-Madera et al., 2017).

The results showed that fear of negative evaluation lowers the PWB of the young transgender participants which is also in line with the findings of previous research (Goodfriend et al., 2023; Lundgren et al., 2004; Rohilla et al., 2016). PWB is related to the overall functioning of the individual (Carr, 2013; Ryff and Keyes, 1995). A person has to achieve and maintain a state of balance between the challenging and rewarding events of his life to have good PWB. This balance helps a person to establish good intra-and interpersonal healthy functioning which promotes a positive attitude toward oneself and others. This positive attitude contributes to the self as well as others’ development. This healthy functioning results in a meaningful and purposeful life. A person with good PWB can make choices in life independently, make decisions without any social pressure, and manage the environmental factors in a way to makes the things beneficial to himself and for the society. They continue working to improve their own and others’ lives regardless of past unfavorable experiences (Ryff and Keyes, 1995).

Previous studies show transgender individuals have low PWB in terms of self-acceptance, confidence, decision-making, clear goals, commitment, concentration, focus, and impaired interpersonal relationships (Gosling et al., 2022; Jones et al., 2022). Furthermore, discontentment with one’s body image inhibits one’s social relations. Unprotected attachment, nervous love attachment, lack of trust in people, and social anxiety are all connected to a high chance of failure and deficit experiences (Chavanduka et al., 2021). Fear of negative evaluation is one of the significant psychological factors that negatively influences the lives of people. It creates feelings of anxiety, nervousness, and low self-worth (Chavanduka et al., 2021). The previous research concluded that this makes people have poor positive relationships with others. They lack meaningful and purposeful lives. They avoid interacting with others due to feelings of rejection and discrimination which impair their relationships with others. Because of avoidance, they become lonely and isolated which hampers their abilities to make decisions and act purposefully. As a result, they become the victim of many mental health issues and poor PWB (Lee et al., 2022; Pinna et al., 2022).

The findings of the present study show that FNAE also negatively affects the MT of transgender adolescents. FNAE develops from beliefs that people have defects in their bodies and fears that others will not accept their gender identity. This is developed from the opinions and reactions of others to their gender identity and gender expression (Hendricks and Testa, 2012). Young transgender people should be mentally tough enough to stop thinking this way, accept themselves and not see their bodies as having flaws (Başar et al., 2016; Goffnett et al., 2023; Sares-Jäske et al., 2023). FNAE makes their relationships poor, harms decision-making ability, lowers motivation, and reduces focus, making their lives worthless. Hence FNAE not only negatively affects transgender people’s beliefs about themselves, it also harms their PWB. According to Alegria (2011), FNAE makes a person less confident in facing and solving life’s challenges.

The results of the present study indicate that MT positively affects PWB, which is consistent with previous research (Benjamin and John, 2021; Stamp et al., 2015; Welsh et al., 2023). In other words, people who are persistent and motivated in achieving their goals, and remain focused on the task at hand, exhibit good PWB. Further, they have confidence in themselves. They believe in their abilities to overcome obstacles. Moreover, they perform better under pressure and have good emotional control (Goffnett et al., 2023; Sares-Jäske et al., 2023). In short, people who show the above-mentioned characteristics are mentally strong, and in consequence, they grow from even adverse situations (Chavanduka et al., 2021; Goffnett et al., 2023).

However, the findings of this study, its partial mediation, indicate that there could be other factors that can play a role in enhancing the PWB of young transgender people in relationship to FNAE and PWB. Those factors may be related to demographic characteristics or other psychological constructs like social support or coping strategies. These factors need to be identified in future research so that they can be a part of prevention and treatment programs for the wellbeing of transgender people. These results are in line with the conceptual point that PWB is multi-dimensional therefore other attributes are also involved in determining PWB (Ryff and Keyes, 1995; Carr, 2013).

CONCLUSION

MT mediates the relationship between FNAE and PWB among young transgender people. In other words, MT plays a significant role in reducing the negative effects of FNAE and improving the PWB of transgender youth. Therefore, practitioners should include strategies to enhance MT while designing the PWB promoting plans for transgender adolescents.

FURTHER STUDY

Future studies may examine more variables that play mediating or moderating roles in promoting the wellbeing of transgender people across their entire life span. Thus, further studies are needed to contribute to improving wellbeing rather than merely exploring the mental health issues of transgender youth.

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