Gender Congruence and Mental Well-being Among Transgender Individuals: The Mediating Role of Self-Concept Clarity

The present study was aimed to investigate the mediating role of self-concept clarity in the relationship between gender congruence and mental well-being among transgender individuals. A purposive sample of 200 participants age ranged 19 to 55 years (M = 29.62, SD = 7.51) were taken from different institutions working for transgender communities from two cities that is Lahore and Bahawalpur. A self-constructed demographic sheet, the Transgender Congruence Scale (Kozee et al., 2012), the Self-Concept Clarity Scale (Campbell et al., 1996), and the Mental Health Continuum Scale (Keyes, 2002) were used for assessment. Results showed a positive relationship between gender congruence, self-concept clarity, and mental well-being among transgender individuals. It was also found that self-concept clarity positively predicted mental well-being. However, gender congruence did not predict mental well-being. The results also showed that self-concept clarity mediated the relationship between gender congruence and mental well-being. The study suggests that promoting self-concept clarity in transgender populations could bridge the gap between gender congruence and mental well-being. Hence, high self-concept clarity can also effectively boost the mental health of transgender individuals. 

The World Health Organization (2015 ) defines "transgender individuals" as a broad category encompassing those whose internal gender identity and expression diverge from the societal expectations associated with their sex assigned at birth. According to an estimation, there are almost 25 million people recognized as transgender, which that is nearly 0.4 - 1.3% of the world’s population (Winter et al., 2016 ). In Pakistan, 64.4% of the transgender individuals that included 6,709 persons, are registered as transgenders individuals among overall country’s population (Khan, 2017 , August 26).

They faced low consideration of rights or honor in Pakistan as the people do not accept them as a person of the society (Akhtar, 2016 ). It is found that the psychological health and mental well-being of the transgender people are largely ignored and rejected in many developing countries, which affects their mental well-being (Yousaf, 2021 ). It is estimated that almost 56% of the transgender people experience depression and 59% experience anxiety, 76% reported physical abuse, 86% were sexually abused, and the majority experienced verbal abuse (Manzoor et al., 2022 ). It has also been observed that in the USA, 68% of transgender people are found to be homeless, faced rejection from their family, and it’s also on record that 54% of abuse so experienced is experienced from their family (Durso & Gates, 2012 ). They, as transgender face inequalities at different levels; as a result, they are at high risk of psychological as well as emotional, sexual, and physical abuse/violence. They also experience higher mental health issues such as stress, anxiety, depression, suicidal thoughts or ideas, low self-esteem, and less satisfaction with life (Davey et al., 2014 ). They also face discrimination, low social support, family rejection, and homelessness, hence have low gender congruence that affects their mental well-being (Trujillo et al., 2017 ). Gender congruence is an important construct predicting the mental well-being of transgenders individuals. It refers to a sense of similarity in individuals’ gender and feeling comfortable with regard comfort with regards to their body. Gender congruence is also related to expressing their gender through clothes, manners, rules, and attributes of any gender and indicating that one belongs to that gender (Kozee et al., 2012 ).

Moreover, self-concept clarity is also a contributing factors towards the mental well-being of the transgender people. Self-concept refers to a broad term that describes an individual's process of thinking about, evaluating, or perceiving themselves. Understanding oneself involves having a personal insight or concept of one’s own identity (Tus, 2020 ). A positive self-concept is viewed as a positive contributor to good mental well-being (Chapman & Tunmer, 2003 ). Campbell et al. (1996) suggestedthat self-concept clarity shares similarities with concepts like identity, self-concept stability, and self-concept consistency. However, what sets self-concept clarity apart is its broader focus on the overall consistency of an individual’s self-knowledge or self-description. Rogers (1959) , in his personality theory, described the word self or self-concept as, the organized way of thoughts, a continuous set of perceptions and beliefs about oneself. He explained that people are conscious about themselves and their self-concept, and what they feel in social circles about their self-image, and behave in that way in which they show their personalities. He explained, people need to identify their potential and grow according to their potential. When people identify that their self-image and ideal self are the same, they know more about themselves, their potential, and their worth ( Ford, 1991 ). According to the PERMA model (Seligman, 2011 ), individuals who achieve self-actualization tend to have higher well-being and greater psychological stability. He identified five key components through which self-actualization significantly enhances well-being and fosters personal growth. These components included positive emotion, engagement, relationships, meaning, and accomplishment. For transgender individuals, accepting their identity and developing a positive self-concept can lead to improved well-being, allowing them to maintain stable and balanced emotions even in stressful situations.

From the literature, it is concluded that gender congruence is positively related to psychological well-being (Holbrook & Cartwright, 2019 ), reduced anxiety, depression, and greater mental well-being (Olson et al., 2011 ). Furthermore, transgender congruence positively correlated with self-esteem indicating that higher appearance congruence and gender identity acceptance related with the higher self-esteem (Van den Brink et al., 2020 ). It is suggested that transgender people who do not accept their identity, face psychological problems that have an impact on mental well-being (Smith et al., 2018 ). Most of the transgender individuals have poor self-concept because society rejects them in everyday life, which may harm their mental well-being (Reyes et al., 2020 ). Based on the scenario, it can be concluded that transgender individuals who embrace their identity and possess high self-concept clarity may experience better mental well-being. Therefore, the study aims to investigate the positive correlation between gender congruence, self-concept clarity, and mental well-being among transgender individuals. Additionally, the study seeks to explore the mediating role of self-concept clarity in the relationship between gender congruence and mental well-being among this population.

Hypotheses

• Gender congruence and self-concept clarity are likely to be positively related to mental well-being among transgender individuals.
• Self-concept is likely to mediate the relationship between gender congruence and mental well-being among transgender individuals.

Figure 1.  Proposed Model for Research

Method

Research Design

A correlation research design was employed in the present study.

Sample

Transgender individuals (N = 200) with an age range of 19-55 years (M = 29.62, SD = 7.51) were taken from two cities of  Punjab i.e., Lahore and Bahawalpur. The average monthly income was reported as 20950/- PKR with SD = 3.34. The data were taken from Fountain House, Khawaja Sara Society, Bheer Pind Community, The Gender Guardian, Hijra Community of Lahore and Bahawalpur. The participants were taken using a nonprobability purposive sampling technique. Transgender people below the age of 55 were included because above the age of 55 become guru who do not work and stay at home.Further, those transgender people with serious physical illness such as AIDS, thalassemia, or cancer etc. were excluded. The detailed demographic characteristics of the participants are given in Table 1.

Table 1: Demographic Characteristics of the Participants (N = 200)

Measures

Demographic Information Sheet

It comprised of questions regarding age, education, religion, no. of siblings, birth order, residence, contact with parents, nature of relationship with father and mother, no. of friends, nature of relationship with friends, occupation, income, information related to psychological and physical illness, and history of victimization (physical abuse, verbal abuse, and sexual abuse).

Transgender Congruence Scale (Kozee et al., 2012)

This scale was used to determine the level of transgender congruence among transgender individuals. The scale consisted of 12 items. The scale has two subscales which include Appearance Congruence and Gender Identity Acceptance. Items are scored on a 5-point Likert scale ranging from strongly disagree (1) to strongly agree (5). Higher scores indicated higher transgender congruence. The Cronbach's alpha value is reported as .92. This scale was translated in the present study using the MAPI guideline (Mapi Research Institute, 2017).

Self-Concept Clarity Scale (Campbell et al., 1996)

This scale was used to determine the level of self-concept among transgender individuals. The scale has 12 Items and the items are scored on a 5-point Likert scale ranging from strongly disagree (1) to strongly agree (5). A high score of self-concept clarity indicated a stable and consistent self in transgender individuals. The Cronbach’s alpha value of the scale is reported as .79. This scale was also translated into the Urdu language by the authors in the present study.

Mental Health Continuum (Keyes, 2002)

The Mental Health Continuum Scale was used to determine the level of mental well-being among transgender individulas. The scale consists of 14 items. The scale has three subscales including Social Well-being, Emotional Well-being, and Psychological Well-being. Items are scored on a 6-point scale ranging from Never (0) to Every Day (6). The higher score indicated higher mental well-being. An Urdu-translated version of the Mental Health Continuum Scale by (Faran & Malik, 2021) was used in the study. Cronbach’s alpha value of this scale is reported as .91.

Procedure 

First, the synopsis was approved by the Departmental Graduate Committee (DGC). Following this approval, permissions were obtained to use and translate the scales into Urdu from the respective authors. For data collection, formal authority letters were sought from the Department of Applied Psychology, University of Management and Technology, Lahore and the required documents were attached with them. Permissions to collect data were taken from transgender Communities of Lahore and Bahawalpur. Informed consent was taken from participants, and they were briefed about the nature and purpose of the study. Participants were instructed about their right to privacy along with the right to leave the study at any time they wished. Each set of questionnaires required time around 15 to 20 minutes of administration. For the present study around 300 participants were contacted, out of which 200 participants volunteered for the participation, so the response rate was 66.67%. 

Results

The results were analyzed using SPSS version 26. Psychometric properties of the measures were determined using descriptive statistics and reliability analyses (see Table 2). Pearson Product-Moment Correlation was carried out to investigate the relationship between gender congruence, self-concept clarity, and mental well-being among transgender individuals (see Table 3). Multiple hierarchical regression analysis was used to see the prediction of mental well-being from gender congruence and self-concept clarity among transgender participants (see in Table 4). Mediation analysis through the PROCESS macro was run to see the mediating role of self-concept clarity influencing the relationship between gender congruence and mental well-being among transgender individuals (see Table 5 ).  The results of descriptive statistics and Cronbach’s alpha are given  in Table 2.

Table 2: Psychometric Properties for the Scales and Subscales (N = 200)

The result of Table 2 showed descriptive statistics (Mean, standard deviation, range, Cronbach’s Alpha) and internal consistency of the scales used in the study.  The reliability of all the scales is good enough to carry out further analyses.

Table 3: Correlation Between Study Variables (N = 200)

Note. MI = Monthly income; PA = Physical abuse; VA = Verbal abuse; SA = Sexual abuse; GC = Gender Congruence; AC = Appearance Congruence; GIA = Gender Identity Acceptance; SCC = Self-concept clarity; MW = Mental well-being; SW = Social well-being; EW = Emotional well-being; PW = Psychological well-being.
*p < .05. **p < .01.

Table 3 shows that gender congruence, and its domain i.e., appearance congruence and gender identity acceptance are positively related to self-concept clarity. Further, self-concept clarity is found to be positively related to overall mental well-being and its subscales, social and emotional well-being, but not psychological well-being. The results also show that gender identity acceptance is found to be significantly positively related to overall mental well-being and its subscale psychological well-being, but not social and emotional well-being. The results also show that the history of physical and sexual abuse (also with all its domains) is significantly negatively related to overall mental well-being, while the history of verbal abuse is negatively related to self-concept clarity among participants. Age has a nonsignificant relationship with all study variables.

Table 4: Multiple Hierarchical Regression Results for Mental Well-being (N = 200)

Note. β = Standardized Beta; B = Unstandardized Beta; SEB = Standard Error of Beta; CI = Confidence Interval; LL = Lower Limit; UL = Upper Limit.
*p < .05. **p < .01. ***p < .001.

Table 4 shows that overall variance explained by the model is 13% with F = 8.06, p < .001. The results indicate that self-concept clarity positively predicts mental well-being (β = .19, p < .01). However, gender congruence does not predict it. The results also show that both physical abuse (β = .17, p < .01) and sexual abuse (β = .27, p < .01) negatively predict the mental well-being of transgender individuals.

Table 5 summarizes the findings of the mediation analysis conducted through the PROCESS macro for SPSS (Hayes, 2018) for testing the proposed model of mental well-being. Model 4 was specified in the PROCESS macro in SPSS.

Table 5: Systematic Presentation of Direct and Indirect Path of Gender Congruence Through Self-Concept on Mental Well-being Among Transgender (N = 200)

Note. β = Standardized Beta; CI = Confidence Interval; LL = Lower Limit; UL = Upper Limit.
*p<.05. **p < .01. ***p<.001.

The results in Table 5 reveal that the overall variance explained by the model is 20% with F (1,198) = 49.20, p < .001. Gender congruence significantly positively predicts self-concept. The results also show that gender congruence does not predict mental well-being, whereas self-concept clarity significantly positively predicted mental well-being. This is suggested that self-concept clarity positively mediates the gender congruence and mental well-being, as shown by the indirect effect. It shows that there is likely to be a true indirect effect. So, in the relationship between gender congruence and mental well-being, the mediating role of self-concept clarity is confirmed. 

The mediating effect of self-concept was further established as the direct and indirect effect on mental well-being through the conceptual diagram in Figure 2 along with the significant path coefficients.   Figure 2 summarizes the direct (c = .07) and indirect effect
(c’ = .11) of gender congruence and self-concept on mental well-being. This shows that significant positive relationship between gender congruence and self-concept on mental well-being among transgenders individuals, whereas gender congruence is found to be a positive predictor of mental well-being.

Figure 2: Schematic Presentation of Direct and Indirect Path of Self-Concept Clarity Between Gender Congruence and Mental Well-Being Among Transgender Individuals

Discussion

The present study highlighted the positive relationship between gender congruence, self-concept clarity, and mental well-being among transgender individuals. These findings of the present study are consistent with the study conducted by Holbrook and Cartwright (2019) determining the relationship between gender congruence and gender related well-being among transgender individuals. Their sample was 26 transgender participants with age ranging 21 to 80 years old. Their finding showed a significant positive relationship between gender congruence and gender related well-being among transgender individuals. Further, they experience higher gender congruence which indicates higher levels of mental well-being and lower level of depression and anxiety among them. In another study conducted by Reyes et al. (2020), who investigated the relationship between transgender congruence and psychological well-being. The sample was 108 transgender participants with age range were 18-40 years old. Their results suggested that gender identity acceptance was positively related to psychological well-being, but appearance congruence was negatively related to psychological well-being, among transgender people. So, this also confirms the results of the present study that gender identity acceptance positively related with psychological well-being, indicating that transgender individuals who had high gender identity acceptance indicated a higher level of psychological well-being. Furthermore, Van den Brink et al. (2020) examined the relationship between transgender congruence and self- esteem among transgender individuals. The results suggested that higher appearance congruence and gender identity acceptance were positively associated with higher self-esteem, which also confirms the findings of the present study. Further, Wang and Castañeda-Sound (2008) explored the relationship between self-esteem, self-efficacy and perceived support from family and friends and psychological well-being. The sample was 429 participants with an age of 18 to 24 years. The results suggested that the transgender participants who had higher self-esteem and self-efficacy indicated higher psychological well-being, also the transgender participants who perceived higher family and friends support indicated higher psychological well-being. So, the discussed studies confirm the findings of the present study.

The results of the present study also highlighted that self-concept clarity significantly positively predicted the mental well-being, which is consistent with the findings of a study conducted by Reyes et al. (2015) who examined the relationships between self-stigma, self-concept clarity, and mental health status in a study involving 566 self-identified Filipino LGBTs. Their findings indicated that elevated self-stigma was associated with poorer mental health outcomes, whereas higher self-concept clarity was linked to better mental health. Few other studies have also supported the findings of the present study; indicating that self-concept clarity is positively predicted the life satisfaction and better mental health (Locke, 2006; Na et al., 2018).

The result of the present study revealed that self-concept clarity positively mediated the gender congruence and mental well-being among transgender individuals. Similar study indicated by Scheer et al. (2021) indentified the self-concept and mental health outcomes among transgender youth. The sample of the study was 20,306 transgender youth. Their result showed that self-concept negatively mediated the mental health outcomes among transgender individuals. Transgender individuals who have better understand their self, may results in negative prediction of the mental health and positive prediction of the mental well-being among transgender individuals. Another study conducted by Zhu et al. (2016) also suggested that self-concept can also protect the social dysfunction but can also protect the mental health problems. They suggested that individuals with good self-concept are more likely to have an objective evaluation of themselves, and acceptance of self, maintaining their own mental health. Furthermore, Shemesh and Heiman (2021) explored the mediating role of self-concept and the resilience relationship between victimization and subjective well-being. The sample was 507 participants with an age range were 11-16 years old.  Their results showed a negative relationship between victimization and self-concept and resilience. Their results also suggested that both self-concept and resilience significantly mediated for subjective well-being. According to Epstein (1973), self-concept is developed for the purpose of solving problems, hence, to improve the social, emotional, and psychological well-being. The basic functions of self-concept are to maintain internal pleasure and pain or to maintain self-esteem, and to improve mental well-being. A good self-concept can maintain these functions effectively, while a poor self-concept cannot, so it can negatively influence the mental well-being of an individual.

In the present study, almost 86% of transgender individuals lived with Guru, 93% do not have a good relationship with parents because families do not accept them as a transgender and throw them out of communities since childhood which may have a bad impact on their mental health (Pirzada et al., 2022; Simons et al., 2013). Almost 66% of the transgender participants occupation was singing and dancing, and most of the transgender participants were facing sexual, verbal, and physical abuse that can trigger social, emotional, and psychological problems in them (Kussin-Shoptaw et al., 2017; Nuttbrock et al., 2012).

Conclusion

It is concluded that high gender congruence is positively associated with higher self-concept clarity in transgender individuals. Further, increased gender identity acceptance and self-concept clarity both are positively associated with higher mental well-being in transgender individuals. It is also concluded that self-concept clarity mediates the relationship between gender congruence and mental well-being among transgender individuals.

Limitations and Suggestions

The present study was done on general transgender individuals in general, but the category-based differences were not considered. For future research category-based differences should also be analyzed with the study variables. The present study was conducted on those transgender individuals who were visiting various centers for aid and earning in the streets. So, a similar study should be done with the transgender individuals working in various fields and offices. Most of the transgender people were illiterate or did not know how to read Urdu. So, the researcher filled in the questionnaire herself by asking them each statement. So, there may be possibilities of social disabilities in response. For future research, a qualitative research design can be employed to understand the psychological issues related to gender congruence and self-concept among transgender people.

Implication

The findings of the study are an addition to the indigenous literature investigating the mediating role of self-concept in determining the relationship between gender congruence and mental well-being among transgender individuals. The study is useful in highlighting the predictors of mental well-being of transgender people, based on findings, strategies can be devised to improve the mental well-being in transgender individuals. This study is useful for professionals who are dealing with transgenders having low identity acceptance and poor self-concept, negatively influencing their mental well-being. So, this study can be helpful in facilitating the transgender individuals in different professional settings, considering their psychological states.

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Received 15 June 2023
Revision received 29 August 2024