An Exploration of The Body Image Scale In Young People (PDF)

1 An Exploration of The Body Image Scale In Young People: A Comparison Of Persons With Features Of Gender Dysphoria And Control Samples India Webb A thesis submitted in partial fulfillment of the requirements of the University of East London for the Professional Doctorate in Clinical Psychology May 2015  2 ABSTRACT Body image is seen as a central component to those who identify as transgender, that is, a feeling of incongruence between bodily features and assigned gender. Previous research has suggested high rates of body dissatisfaction within adolescent general population samples. Therefore, it is critical that clinicians are able to identify and disentangle distress related to gender and the body, from that of general body dissatisfaction. Furthermore, adolescent transgender persons are an understudied group in the psychological literature and many studies looking at body image in this population have been conducted using small sample sizes. The Body Image Scale (BIS) is used in gender services (GS) around the world and consists of 30 body features that the person is asked to rate in terms of satisfaction with those parts on a 5-point scale. However, there are no studies currently published where the scale has been normed in control samples within young persons populations. This is an important clinical issue as the BIS is used as part of the assessment process in GS‟s. This quantitative study is an exploration of the similarities and/or differences in body-part satisfaction in a control sample (n = 262) and in those referred to the UK Gender Identity Development Service (n= 403) using the BIS. The BIS compares primary, secondary and neutral bodily characteristics as well as differences between the sexes and ages of participants between and within the two populations. Results showed persons with gender dysphoria were significantly more dissatisfied with their bodies than the control group. In addition, this dissatisfaction increased with age during pubertal development, particularly in the clinical group. In the clinical group, natal (biological) males were more dissatisfied with their primary and neutral sexual characteristics, where as in the control group natal females were more dissatisfied than males across all sexual characteristics. Implications for research, service provision and clinical psychology practice are discussed.  3 TABLE OF CONTENTS ABSTRACT............................................................................................................. 2 LIST OF TABLES ..................................................................................................... 5 LIST OF FIGURES.................................................................................................... 5 ACKNOWEDGEMENTS........................................................................................... 6 1. INTRODUCTION.............................................................................................. 7 1.1. Literature Search ................................................................................................................................ 7 1.2. Terminology .......................................................................................................................................... 9 1.3. Epidemiology of Gender Dysphoria ....................................................................................... 16 1.4. Identity Formation in Adolescence ........................................................................................ 18 1.5. Body Image In The General Population ............................................................................... 20 1.6. Body Image and Gender Dysphoria ....................................................................................... 23 1.7. Media, Advertising and Celebrity Culture .......................................................................... 25 1.8. Gender ‘Differences’ ....................................................................................................................... 27 1.9. Sexuality................................................................................................................................................ 29 1.10. Interpersonal Relationships; Family and Peers .......................................................... 31 1.11. Adolescence Body Image And Development Of Co-morbid Problems ............ 33 1.12. Body Image Measurement ....................................................................................................... 42 1.13. Body Image Scale (BIS) .............................................................................................................. 43 1.14. Summary ............................................................................................................................................ 45 1.15. Justification, Aims & Research Question .......................................................................... 46 2. METHOD...................................................................................................... 48 2.1. Epistemological Position ............................................................................................................. 48 2.2. Recruitment ........................................................................................................................................ 50 2.3. Inclusion / Exclusion Criteria ................................................................................................... 51 2.4. Young People Taking Part in the Study ............................................................................... 51 2.5. Materials ............................................................................................................................................... 52 2.6. Ethical Approval ............................................................................................................................... 53 2.7. Consent .................................................................................................................................................. 54 2.8. Procedure ............................................................................................................................................. 54 2.9. Participants ....................................................................................................................................... 57 3. RESULTS ..................................................................................................... 59 3.1. Exploring the Data ........................................................................................................................... 59 3.2. Differences between the clinical and control groups .................................................. 62 3.3. Differences between males and females within and between the clinical and control groups .............................................................................................................................................. 65 3.4. Differences between the age groups of the clinical and control groups ........... 72 3.5. Change .................................................................................................................................................... 80 4. DISCUSSION................................................................................................ 87 4.1. Introduction ........................................................................................................................................ 87 4.2. Review of Findings .......................................................................................................................... 87 4.3. Critical Review ................................................................................................................................ 102 4.4. Implications ...................................................................................................................................... 109 4.5. Reflections of the researcher .................................................................................................. 115 5. REFERENCES ...............................................................................................118 6. APPENDICIES..............................................................................................164 APPENDIX A: Body Image Scales....................................................................................................... 164  4 APPENDIX B: Application For Research Ethics Approval ................................................... 166 APPENDIX C: Research Registration............................................................................................... 178 APPENDIX D: Confirmation of Ethical Approval Granted by UEL ................................... 179 APPENDIX E: Email correspondence showing confirmation from NHS ethics and academic tutor at UEL of exemption from requiring NHS ethics .................................... 181 APPENDIX F: Email correspondence indicating permission for recruitment from SENCO at the school ................................................................................................................................. 186 APPENDIX G: Participant Invitation Letter ................................................................................. 187 APPENDIX H: Instruction Sheet for Teachers ............................................................................ 189 APPENDIX I: List of Appropriate Support Organisations to Direct Parents To (Given to SENCO) ....................................................................................................................................... 192  5 LIST OF TABLES Table 1. Databases, dates and total articles found for literature searchers. ...... 8 Table 2. Sexual characteristics for transgender persons shown by the BIS. . 44 Table 3. Characteristics of final sample used for analysis, including: group, sex at birth and age group ............................................................................................. 58 Table 4. Descriptive statistics of the control group scores (n = 262) addressing the overall mean, subscales and item scores. ..................................................... 60 Table 5. Descriptive statistics of the clinical group scores (n = 403) addressing the overall means, subscales and item scores. ................................................... 61 Table 6. Total score, subscales, items scores for control group males and females. .................................................................................................................................. 66 Table 7. Total score, subscales, items scores for clinical group males and females .................................................................................................................................... 67 Table 8. Comparison of natal sexes within the groups. ............................................ 70 Table 9. Total score, subscales and item scores for age groups within the control group. ....................................................................................................................... 73 Table 10. Total score, subscales and item scores for age groups within the clinical group ........................................................................................................................ 74 Table 11. The ten highest mean scores for individual body parts for group, natal gender and age group. ........................................................................................ 79 Table 12. Percentages wanting to change body parts; for group and natal sex. Chi-square (Χ2) for natal genders and groups. .................................................... 82 Table 13. Percentage and chi-square of those wanting to change individual body parts across age groups. .................................................................................... 84 LIST OF FIGURES Figure 1. Age group means for the top five highest scores on individual body parts for the control group. ............................................................................................ 75 Figure 2. Age group means for the top five highest scores on individual body parts for the clinical group. ............................................................................................ 75 Figure 3. The five highest significant scores for participants in both groups wanting to change body parts across age groups. ............................................ 85 Figure 4. The five highest significant scores for participants in the clinical group wanting to change body parts across age groups. ............................... 85 Figure 5. The five highest significant scores for participants in the control group wanting to change body parts across age groups. ............................... 86  6 ACKNOWEDGEMENTS I would like to express my sincerest appreciation to the young people who took part in this study. My heartfelt thanks also go to Sarah Davidson and Elin Skagerberg for their support, guidance and supervision throughout the research process. This study has grown and developed from Sarah‟s initial idea and I hope I have done this justice. I would like to voice my deepest gratitude to my friends, family and colleagues for their support and encouragement throughout the writing of this thesis. In particular, Lucy and Laura, my fellow trainees and now close friends, who I met at the beginning of this journey and they have been my inspirations throughout. I would like to thank my parents, who have listened patiently to my stresses and frustrations and never wavered in their relentless devotion to me, calmly bringing me back to reason when needed. Lastly, I would like to give very special thanks to my fiancée Nick, who has been my rock throughout this whole process, providing me with a home full of calm and laughter, for which I am forever grateful.  7 1. INTRODUCTION This study focuses on young people‟s (dis)satisfaction with their bodies using the Body Image Scale (BIS) (Appendix A) and compares people with gender dysphoria (GD) with the general population. In this chapter I outline my literature search, review the relevant terminology and lay out a multifactorial view of GD and its relevance to body image in young persons. I also outline the measurement of body image. 1.1. Literature Search The review of academic literature deals with gender identity, GD and body image in young people. It presents an overview of concepts and theories relevant to the research and the clinical relevance of comparing body image between those persons with GD and those assumed without. The lack of research using the BIS in samples in the general population, and the variability of body image measurements used in research, was a significant factor in reviewing the literature when comparing studies outcomes. Searches were performed using three online databases (PsycINFO, PubMed and Web of Knowledge), which focus on journals relevant to psychology and allied health professionals. Table 1 shows the output and dates when these searchers were conducted.  8 Table 1. Databases, dates and total articles found for literature searchers. Online Database Date Total Articles PsycINFO September 2014 781 PubMed October 2014 712 Web of Knowledge October 2014 722 Results were initially limited to articles where young people had been used in the studies. The following search terms were used: - Gender identity AND gender dysphoria - Gender identity AND body image - Gender identity AND families - Gender dysphoria1 AND body image - Gender dysphoria AND body dissatisfaction - Body image scales/questionnaires - Body image scales AND gender dysphoria Additionally, the World Professional Association for Transgender Health, seventh edition, Standard of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (WPATH, 2012) was used to identify further references. Publications found using the above methods were used to identify other relevant references (e.g. within adult populations). Key articles or publications – mentioned by several different authors – or those addressing topics closely relevant to this research were examined. 1 Due to the recent changes in terminology used in diagnostic manuals, terms also used in the literature search for GD were: gender identity disorder, gender development, gender variance, transgender, transsexual and gender non-conformity.  9 The literature review showed the complexity of gender identity and body image development. I became interested in the development of gender identity and body image in adolescence and the context to these constructs in the family, peer relationships and the influence of societal and cultural understandings. In addition, the literature search showed the contribution and correlation of emotional and behavioural difficulties to these constructs, such as low self-esteem, low mood, self-harm and eating disorders. 1.2. Terminology Terminology used in relation to gender identity is not neutral and many terms continue to be questioned. The terms used to describe gender identity are often used incorrectly (e.g. Johnson & Repta, 2012). Therefore, I will start by defining and reviewing the terminology used. Each subsequent section will consider the relevance of the literature to the clinical and general population. 1.2.1. Biological Sex Biological sex describes one‟s anatomical and reproductive structures (Dragowski, Río & Sandigursky, 2011) and is often assumed to be binary – male/female (Diamond, 2006) where socially agreed upon criteria for classifying people as „females‟ or „males‟ is assigned at birth. However, this view has been disputed by the observation that “…absolute dimorphism disintegrates even at the most basic level of biology” (Fausto-Sterling, 2000, p. 213). Having XX chromosomes does not always mean having a female body and having XY chromosomes does not always mean having a male body. Sometimes an individual with XY chromosomes is insensitive to the influence of testosterone, resulting in a female body. There are also other  10 combinations of sex chromosomes, such as XO, XXX, XXY, and exposure of external hormones as a foetus may also influence sexual characteristics. There is a range of variation in anatomical and reproductive characteristics – chromosomes, overies/testes, genitals, bodily appearance – that do not fit typical definitions of male or female. This variability means that sex is much more complicated than the commonly assumed binary and suggests a continuum of sexual characteristics (Cohen-Kettenis & Pfafflin, 2003). Persons whose sex chromosomes and genital structures are thought to be incongruent with the body are not considered within the „lay‟ perspectives of the dichotomous system (Pasterski, 2008), and so the diversity of sexual anatomies within and between the sexes is masked. 1.2.2. Gender Gender and gender role refer to social norms and standards that in the light of normative conceptions prescribe different activities, duties, opportunities and behaviours for one‟s sex category (Mahalik, Good & Englar-Carlson, 2003). Gender roles of femininity and masculinity have been viewed as the public manifestation of gender identity (Money, 1994) and follow a binary construction that structures experience in many sociocultural contexts (Wren, 2014). These binary identities are a powerful means of social organisation and co-define each other by denying unwanted characteristics of the other (Wren, 2014). Gender roles are behaviours that are „scripted‟ by culture (Gagnon & Simon, 1973), social constructions influenced by social processes (Harre, 1991). Studies have shown that gendered assumptions and meanings are projected onto children – even before birth (Hare-Mustin & Marecek, 1990). Individuals inevitably internalise stereotypic gender roles and develop their sense of gender whilst being bombarded by messages about a  11 „right‟ gender role for their perceived gender. Gender roles influence and restrain people‟s experiences; men and women are treated differently because of their assigned role and the extent to which they conform. Customary, binary conceptions of gender roles are problematic, as they do not represent the multiplicity that exists within and across societies (Kelly, 1993). Dualistic gender roles are embedded in populations and penalties occur for people who challenge the gender order, which can result in discrimination, violence and even death (Whittle, 2000). Furthermore, gender is not a static role but is „performative‟, a process by which there is a negotiation of the self, others and culture, which is enforced by social norms (West & Zimmerman, 1987; Wren, 2014). 1.2.3. Gender Identity Development The term gender identity was introduced in the 1960‟s and concerns a person‟s subjective sense of congruence with a particular gender (Di Ceglie, 2010). Contemporary gender identity theories focus on both innate and acquired aspects to the development of gender identity (Diamond, 2006) with development involving an intricate interaction between biological, environmental and psychological factors. Diamonds‟ (2006) biased interaction theory affirms that an infant‟s hormonal, anatomic brain and genetic influences interact with experiences of upbringing and societal values to bring about the expression of sexual and gender patterns. People‟s social environment and others‟ judgements mediate how people view themselves in relation to their gender. Gender identities develop within gendered social contexts, where there is a „correct‟ way of doing gender that „corresponds‟ to one‟s presenting sex (Butler, 2004).  12 In most cases gender identity develops in accordance with physical gender characteristics. A baby with XY sex chromosomes and male genitalia will be assigned to the male gender and have a male gender identity. However, discordance between these gender aspects does occur. These conditions were called „intersex‟ conditions and later, in the 1950‟s, the term „disorders of sex development‟ (American Psychiatric Association (APA), 1952) was used in the clinical literature. Whilst gender identity may be in line with chromosomes and gonads, it may not be with the external genitalia. „Gender dysphonia‟ refers to the distress resulting from incongruence between experienced gender and assigned gender. For GD individuals, their experienced gender identity does not match their sex chromosomes, gonads or genitalia, although the physical sex characteristics all correspond with each other (Steensma, Kreukels, de Vries & Cohen-Kettenis, 2013). It is this experience of GD that the present research focuses on. Little is known about the cognitive gender development of persons who experience gender variance at a young age. However many studies have pointed to the importance of adolescence in early onset gender variant children, either because it consolidates an already existing development, or because “…it initiates a development that eventually leads to full blown GD” (Steensma et al., 2013, p.291). Gender identification is a broad concept. The terms „gender variant‟ or „gender non-conforming‟ are often used for people who violate the societal ideals of what it means to be a man or woman (WPATH, 2012). These umbrella terms denote someone whose self-identity does not imitate conventional ideas of male or female gender (Stryker, 2008). These expressions cover a wide spectrum of gender identity descriptors, such as: „gender neutral‟, „gender  13 fluid‟, instead of male and female (Bocking, 2008). As evidence of these terms entering the social sphere, the social media platform Facebook now has over 50 options of different gender descriptors on their site for people to choose from („Facebook Opens Up LGBTQ-Friendly Gender Identity and Pronoun Options,‟ 2014). Although I acknowledge that a variety of descriptors are used to describe a person whose gender expression falls outside the typical gender norms, for the purpose of consistency in this research, I will use the term „transgender‟ or „trans‟ to talk about such persons. 1.2.4. Diagnoses The term „transvestite‟ was introduced in 1910 (Cohen-Kettenis & Pfafflin, 2010) and later, in 1949, „transsexual‟ was coined. In 1980, the APA listed transsexualism as a „mental disorder‟ in the Diagnostic and Statistical Manual of Mental Disorders (DSM), third edition (DSM-III; APA, 1980). By 1994 the DSM-IV (APA, 1994) had altered this diagnosis to „gender identity disorder‟ (GID) that involved discrete criteria for children, adolescents and adults. GID was described as necessitating “…a strong and persistent cross-gender identification and a persistent discomfort with one‟s sex or a sense of inappropriateness in the gender role of that sex” (APA, 2000). Many viewed the GID diagnosis as controversial; specifically its conjectures of binary gender roles and behaviours (Newman, 2002), its contribution to gender stereotypes and in pathologising gender variance (Lev, 2005). These dualistic notions of gender excluded the experience of people who identify in alternative ways and therefore the reliability and validity of the DSM-IV criteria were called into question (Cohen-Kettenis et al., 2010). Several authors maintained GID was a Western construct that pathologised normal variation  14 within human identities, and consequently disputed its inclusion in the DSM (e.g. Langer & Martin, 2004). The authors of the 2013 revision of the DSM (DSM-V) state that a main aim was to reduce stigma. As a result the name GID was replaced with the new diagnostic category GD, defined as "A marked incongruence between one‟s experienced and expressed gender and assigned gender … a strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one‟s assigned gender)," (APA, 2013, p. 452). Commentators have acknowledged that the revision has been an attempt to shift the focus away from binary gender categories, and place the task of the diagnosis on distress rather than gender nonconformity (Bouman & Richards, 2013). However, others have described the move as “two steps forward, one step back” (Lev, 2013, p. 288). Lawrence (2014) explains how conceptualising GD as distress about „assigned gender‟ rather than biological sex, means the principal understanding of wrong embodiment - being “trapped in the wrong body” (Prosser, 1998, p.69) – becomes redundant in the DSM-V understanding. Lawrence also takes issue with the reasoning that an additional advantage of theorising GD as an incongruence between gender identity and assigned gender is that it makes it conceivable for people who have transitioned successfully to “lose” the diagnosis (Zucker et al., 2013). Lawrence argues that gender transition does not “cure” the profound sense of wrong embodiment that transgender and people with GD typically experience. Some authors have contended that the DSM-V has not gone far enough in de-pathologising gender non-conformity and call for its removal from the DSM. People with GD have conflicted gender identity, but not all individuals with conflicted gender identity inevitably meet the diagnostic criteria for GD,  15 experience distress or want to live as „the other gender‟ (Algars, Santtila & Sandabba, 2010; Diamond & Butterworth, 2008; Lee, 2001). Others have argued that the DSM changes do not resolve the central problem of transgender persons being stigamtised regardless of diagnosis (O‟Hartigan, 1997). Rees (1996) describes how transgender persons experience deep unhappiness and feel they are unable to embody, or belong to, society norms. In addition, the removal of the diagnosis from the DSM would damage a transgender person‟s access to treatment and to a legitimate defense of their legal entitlements (O‟Hartigan, 1997). 1.2.5. Cultural constructions of sex and gender Societies and cultures vary considerably in the nature and intensity of differentiation between the sexes within gender, gender roles, gender-role ideologies and gender stereotypes. Masculine and feminine traits are patterned by culture and are minimised in some cultures and maximised in others (Peoples and Bailey, 2011). For example, Margaret Mead‟s work in Papua New Guinea found that within Arapesh tribes both sexes are expected to act in ways the western world consider “feminine” and within Mundugamor tribes both sexes were what Western culture would call “masculine” (Mead, 1956). Genders that are neither man nor women have been described by many societies, such as “Hiyra” in India is an alternative gender role conceptualised as neither man nor woman (Money & Ehrhardt, 1972). Similarly, some Polynesian societies „Fa‟afafine‟ are considered to be a third gender alongside male and female. Fa‟afafine are accepted as a natural gender and are neither looked down upon nor discriminated against. They are biologically male, but dress and behave in a manner that Polynesians typically consider female (Money et al., 1972). Masculine and feminine have different