The association of attachment,mentalization and reflective functioning with mental health in gender diverse children and adolescents: A systematic review

Abstract

Gender diverse children (here defined as minors under 18) face greater risk for depression, anxiety and suicidality than their cisgender peers. This situation calls for research on protective factors of mental health in this population, and on appropriate therapeutic and supportive interventions. This systematic review aimed at (1) examining literature on the role of attachment, mentalization and reflective functioning in protecting mental health of gender diverse children and identifying the mental health outcomes that have been assessed; and (2) outlining interventions based on attachment, mentalization and reflective functioning that have been proposed. The work was conducted according to the PRISMA guidelines. Fifty-one studies were identified and 9 met the inclusion criteria. Results indicate that, besides a general protective role for mental health, attachment, mentalization and reflective functioning moderate and mediate, through different pathways, (1) the association between gender diversity and emotional/behavioural problems; and (2) the negative effects of minority stress. Mentalization seems to be an individual resilience factor; the capacity of the caregiver to serve as a secure base and validate the internal experience of incongruence of the child promote a healthy psychological development. Three levels of action for interventions were identified: individual, family and community.

Keywords

Gender diverse transgender children and adolescents mental health mentalization attachment

Introduction

Transgender and gender diverse (TGD) children and adolescents face greater risk of mental health issues compared with cisgender peers. To promote a healthy gender development, it is important to consider both the child’s individual resilience factors and their interaction with the family, school and social context. The Minority Stress Model (Meyer, 1995) clarified how social stigma experienced by sexual minorities is associated with high risk of self-harm and psychological distress as a result of social exclusion, family rejection, and experiences of hate speech and aggression. Hendricks and Testa (2012) presented an adaptation of Meyer’s Minority Stress Model to the TGD community. When looking at childhood and adolescence, alarming levels of psychological suffering and mental health issues are observed in gender-referred population (Holt et al., 2016). The most frequently reported difficulties are depression, anxiety, eating disorders, non-suicidal self-injury (NSSI), suicidal ideation and suicide attempts (de Graaf et al., 2018; Diemer et al., 2015). The association between gender diversity and mental symptoms has been described also in community samples (Strauss et al., 2020). In their review, Rogers and Taliaferro (2020) reported that, across the different studies, rates of self-injurious thoughts and behaviours among sexual and gender minority youth were higher than those observed in heterosexual and/or cisgender youth. de Graaf et al. (2020) underlined the importance of understanding the factors that contribute to individual differences in suicidality.

Attachment, mentalization and reflective functioning are related to psychological development. Luyten et al. (2020) argued that they are interrelated and partly overlapping. Attachment, known as the bond that allows caregiver to answer needs and requests of the child, is the frame inside which mentalization and reflective functioning develop. Insecurity of attachment has many developmental implications, including a connection with child anxiety (Bowlby, 1973; Colonnesi et al., 2011). More specifically, insecure attachments may underlie separation anxiety (Milrod et al., 2014). Mentalization can be defined as the capacity to ‘understand the self and others in terms of intentional mental states, such as feelings, desires, wishes, attitudes, and goals. It […] enables people to navigate the complex social world they live in’ (Luyten et al., 2020, p. 298). Reflective functioning is considered as an ‘operationalization of mentalizing capacity […]; used synonymously with mentalizing in some research and clinical literature’ (Bateman & Fonagy, 2012, p. 516). Difficulties in attachment, mentalization and reflective functioning are associated with increased difficulties in emotional regulation processes (Nolte et al., 2011). The interconnection between these factors is complex and multidirectional. Attachment disruptions are involved in vulnerability to depression and anxiety, which may in turn have an effect on mentalizing. Vice versa, impaired mentalization abilities may increase the risk for depression and anxiety (Luyten et al., 2020). Studies on adolescent populations showed the protective role of mentalizing against depression, NSSI and suicidality (Fischer-Kern & Tmej, 2019). Within a resilience framework, robust mentalizing promotes a flexible and positive appraisal of stressors, which, in turn, can enable specific coping strategies (Schwarzer et al., 2021).

Attachment theory has been sometimes misinterpreted as indicative of causal relationship between poor attachment and trans identity, which would be consequent to attachment disruption (Ehrensaft, 2011). Instead, the advance of research put in light the positive relation between attachment and mental health in TGD children and adolescents. Parents who encourage ‘age-appropriate exploration and value the child as a unique individual’ (Mills-Koonce et al., 2018, p. 1014) promote a secure attachment in the young person. Secure relationships can attenuate the psychopathological effects of victimization experienced by sexual minority youth (Brown et al., 2020). A recent study on a sample of adults (Scandurra et al., 2020) showed the protective role of mentalization as individual resilience factor moderating the negative effects of minority stressors was proved. A case report showed that, after the application of a manualized attachment-based family therapy intervention to TGD youth, suicidal thoughts and behaviour of a young TGD person diminished markedly (Russon et al., 2021).

In the light of the literature outlined above it would be important to have an overview of research on the role of attachment, mentalization and reflective functioning in mental health of TGD children and adolescents.

Review questions

This review addresses two questions:

1. What is the evidence for the role of attachment, mentalization and reflective functioning in supporting mental health in TGD children and adolescents and for the mechanisms underlying such a role? And which specific mental health outcomes have been identified by research?

2. Do the reviewed articles make any proposal about clinical interventions based on attachment, mentalization and reflective functioning aimed at mental health in this population?

Method

Design and ethical statement

This systematic review was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009). The protocol was submitted to PROSPERO (ID CRD42019121519).

Since this systematic review is exclusively based on published literature and did not involve the study of animals or people, it was exempt from institutional review board.

Eligibility criteria

We searched for articles that were published in international, peer-reviewed journals between 1 January 1996 and 30 December 2020; written in English; used a quantitative, qualitative or mixed-methods design; involved children or adolescents. We considered eligible also those retrospective studies on adult samples which explicitly asked participants to recall attachment and relational experiences of childhood and adolescence. Reviews, guidelines, theoretical papers, clinical essays, case reports and commentaries were not included.

Information sources, search strategies and study selection

Box 1 shows the used key-words. The full electronic strategy is available in the Supplemental Material (Supplementary Appendix A). EBSCO and Pubmed searches underwent duplicate removal; in addition, we searched for other relevant papers among the references of the identified articles.

The search process was run by two independent reviewers (AC and CT), who compared and discussed the preliminary results. The same reviewers independently finalized the formal screening by title and abstract in order to subsequently compare and discuss the results, to achieve a common list of selected papers. As a second step, the reviewers screened the selected articles by reading the full-text, according to the abovementioned criteria. Any disagreement was worked out by discussion between the two reviewers (AC and CT), or by involving a third reviewer (DB). In order to have an index of the inter-rater agreement, we calculated the percent agreement (Hartmann, 1977) in both stages¹.

Box 1. Key-words

(child* OR adolescen* OR pediatric)

AND

(attachment OR mentaliz* OR (‘reflective function*’))

AND

((‘gender dysphor*’) OR (‘gender identity disorder’) OR (‘gender varian*’) OR (‘gender diverse’) OR (‘gender nonconforming’) OR (‘gender nonconformity’) OR (transgender OR transsexual)) AND ((‘well-being’) OR (‘Psychosocial adjustment’) OR (‘psychological adjustment’) OR (‘mental health’) OR (‘behavioral problems’) OR (‘behavioural problems’) OR (symptoms) OR (‘emotional problems’) OR (‘psychological suffering’))

Quality assessment

The quality of the reviewed studies was assessed using the appraisal system Mixed Method Appraisal Tool (MMAT) described by Pluye et al. (2011). Detailed information is available on the user guide (Hong et al., 2018). As proposed by Vusio et al. (2020) the quality of the studies was rated as low, medium or high². The selected studies were individually rated by two reviewers (CT and DB), and subsequently discussed with a third (AC), in order to achieve agreement on each rating.

Data extraction and sought variables

Due to the heterogeneity of studies and methods used in the reviewed articles, the most suitable approach to outline a synthesis of findings was a narrative summary (Thomas et al., 2012). In order to have a systematization of data, we set up a table for quantitative and another for qualitative studies (see Tables 3 and 2). From each article two reviewers (AC and CT) extracted the following data: authors, year of publication, participants’ ethnicity, type of design, study population (general population, gender-referred children and adolescents, other clinical samples), sample size, age, outcome measure, key findings and whether the study mentioned any clinical implication for interventions to promote mental health.

Synthesis of results

Starting from the data reported in our tables, we organized a short quantitative synthesis of the study characteristics: the thematic focus and the different groups of participants, including ethnicity and age range. Afterwards, we narratively summarized the findings trying to compare differences and similarities across studies.

Results

Study selection

As shown in the flow diagram (Figure 1), once all duplicates were removed, 51 articles were screened for titles and abstracts independently by two researchers (AC and CT). The reviewers agreed about excluding 35 articles and including 11 (total number of articles about which there was agreement: 46). There was disagreement about five articles. The percent agreement was 90.20%, which can be considered satisfactory (Hartmann, 1977). After discussion, three of the five papers were excluded and two were included in the following screening, by full-text: so, in total, 38 were excluded, and 13 were admitted to screening for eligibility by full-text. Also the screening by full-text was done independently by two researchers (AC and CT), who agreed on decision about 11 articles (9 to be included and 2 excluded), and disagreed about 2. The percent agreement was 84.6%, once again satisfactory. The disagreement between the researchers was handled by involving a third party (DB); after this process, four articles in total were excluded, and 9 (eight quantitative and one qualitative) were included in the narrative synthesis.

Study quality assessment

The quality of six studies was rated as high. Two non-randomized studies were found to have medium quality for outcome data and confounders. The qualitative study was rated of medium quality. Detailed MMAT ratings are available in the Supplemental Material (Supplementary Appendix B, ‘MMAT ASSESSMENT’).

Study Characteristics

Table 1 shows that, of the 9 articles, 8 were focused on attachment, and one on mentalization and attachment. Of the eight on attachment, four were particularly focused on separation anxiety.Table 3

Table 1.

Reviewed articles: thematic focus and mixed method appraisal tool quality assessment.

Authors, year	Thematic focus^a	Quality assessment
MacMullin et al. (2021)	Attachment (PWSB)	High
Santarossa et al. (2019)	Attachment (PWSB, SA)	High
Giovanardi et al. (2018)	Attachment	Medium
VanderLaan et al. (2018)	Attachment (SA	High
Gomez et al. (2017)	Attachment (SA)	Medium
Greene and Britton (2015)	Attachment (childhood warmth and safeness)	High
van Beusekom, et al. (2015)	Attachment (parental acceptance)	High
Lemma (2012)	Mentalization, attachment (parental mirroring)	Medium
Zucker et al. (1996)	Attachment (SA)	High

PWSB: Parental willingness to serve as a secure base; SA: Separation Anxiety.

^aBetween brackets we specified the related construct which was examined for each thematic focus.

Table 2.

Synthesis of quantitative studies.

Authors, year	Country, ethnicity	Design	Study population	n	Age	Outcome measures	Key findings	Intervention
MacMullin et al. (2021)	Canada	Cross-sectional	Parents and guardians of children, community sample	1719	Children 6–12	CBCL total problems scale	The association between GNC and CBCL total problems scores was moderated by parental willingness to serve as a secure base for the child (B = −9.59, p < .001), along with poor peer relations and parental gender-stereotyped attitudes (linear regression). A moderation effect was found when running quadratic regression analyses on the AFAB subgroup (B = −11.25, p < .001)	YES
Santarossa, et al. (2019)	Canada, including different ethnicities	Cross- sectional	Parents and guardians of children, community sample	1825 (933 girls; 892 boys)	Children 6-12	SAI	Significant association between GNC and SA among birth-assigned boys (r = .16, p < .001) but not girls (r = .004, p > .05). SA is associated with GNC among boys above and beyond internalizing problems more generally. Parental willingness to serve as an attachment figure was found to protect gender-variant children in regards to SA (AMAB: B = −3.95, p < .001; AFAB: B = −1.48, p = .03), along with warm parenting styles, closeness in the parent–child relationship, and liberal parental attitudes towards gender stereotypes in children	YES
Giovanardi, et al. (2018)	Transmen: Italian. Transwomen: 86% Italian; 14% South American. Controls: Italian	Retrospective	Gender-referred	95 adults (74 trans women; 21 trans men)	Adults	AAI, CTQ	Significant different distribution of attachment classifications: Relative to controls, in GD sample more insecure (p < .001) and disorganized classification (p < .001). Compared to controls, GD participants reported significantly [χ²(1, N = 218) = 61.881, p < .000] more traumatic experiences, as measured with a questionnaire (CTQ) considering a wide range of traumatic experiences (from active trauma to neglect). Fathers of GD participants were less accepting, available and supportive compared to fathers of controls (t = 4.979, p < .001, d = .70)	YES
VanderLaan, et al. (2018)	Canada	Cross-sectional	Gender-referred	360	6–9	SAI	Birth-assigned boys, but not girls, more likely (OR:2.12) to be diagnosed with SAD (conservative DSM-IV criterion) compared with the estimated US population prevalence. When testing the predictive role of socio-demographic characteristics, gender nonconformity, CBCL internalizing, externalizing and poor peer relations scores, gender nonconformity did not significantly predict SA; only the CBCL internalizing score significantly predicted separation anxiety (p < .0001), in addition to age (p = .035) and parental marital status (p = .002). SA could be understood as a problem within the spectrum of internalizing problems for which AMAB gender-referred children show elevation	NO
Gomez, et al. (2017)	Southern Mexico	Retrospective	Istmo-Zapotec men, women, muxe gunaa, muxe nguiiu	454	M 31.03 SD 9.90	SAS	A sex difference was found in recalled indicators of childhood SA, with women exhibiting elevated scores compared to men (p<.001, Cohen’s d=.54). Muxes exhibited elevated scores compared to men. Muxes and women did not differ in this regard (all p >.17)	NO
Greene and Britton (2015)	68% white, 32% different ethnicities	Retrospective	LGBTQ persons, community sample	523	18–80	SHS	Results indicated a small difference for transgender as compared with lesbian status, but the p value was .055. Feelings associated with childhood warmth and safeness, b = .03, p < .01, self-compassion, b = .21, p < .001, and personal mastery, b = .63, p < .001, significantly predicted participants’ adult subjective happiness over and above contributions made by identity subgroup, age, and income. Self-compassion and personal mastery serially mediated the relationship between childhood warmth and safety and adult subjective happiness	YES
van Beusekom et al. (2015)	Dutch	Cross-sectional	Community	1121 (539 boys and 582 girls)	15–18	Shortened version of the brief symptom inventory and of social interaction anxiety scale	For birth-assigned boys, father acceptance moderated the associations of GNC with psychological distress (B = −.14, p = .008) and social anxiety (B = −.19, p < .001). Mother acceptance moderated the association between SSA and social anxiety for birth-assigned girls (B = −.13, p = .003)	NO
Zucker et al. (1996)	USA	Cross-sectional	Gender-referred	115	4–11	Interview schedule for SAD; CBCL; TRF	A liberal definition of SAD showed that it occurred significantly more often in the subgroup of boys who met the complete criteria for gender identity disorder than in the subgroup who did not meet the complete criteria (p = .01), whilst the association was not significant when using a conservative definition. Maternally reported SA traits correlated more strongly with maternal CBCL internalizing T scores than with externalizing T scores (consistent with an understanding of SA as an internalizing trait)	NO

CBCL: Child Behaviour checklist; SAI: Separation Anxiety Interview; AAI: Adult Attachment Interview; SAS: Separation Anxiety Scale; SHS: Subjective Happiness Scale; SAD: Separation anxiety disorder; TRF: Teacher Report Form; GID: Gender Identitty Disorder, diagnostic category according to DSM-IV (the edition used when the article was published).

Table 3.

Synthesis of qualitative studies (n = 1).

Authors, year, ref. No	Country, ethnicity	Design	Study population (gender-referred, etc.)	n	Age	Addressed issues	Main results/key findings
Lemma (2012)	UK	Qualitative	Transgender adults screened for taking part in a TV series about transsexuality	8	22–50	During the semi-structured interviews, participants were invited to talk about ‘(a) their understanding of their transsexuality and its origins, as perceived by them, (b) their anxieties and hopes in relation to past and anticipated body modifications (including hormone treatments) and (c) their motivation for taking part in the TV series’ (p. 266)	Two themes emerged. 1: An incongruity between the given body and the body participants ‘identified as their ‘true’ physical home’ (p. 267). Participants reported this experience of incongruity as difficult to communicate to key attachment figures during childhood and adolescence. 2: The experience of being seen, of the self as a visual object; ‘an unmentalized incongruity experienced at the level of the body-self may contribute […] to the search for the “right” body that will relieve the incongruity through the certainty […] that the image in the mirror (literally and metaphorically) will match the subjective experience of the body’ (p. 278)

The selected studies involved participants from different countries (Table 1).

Eight studies were carried out with a quantitative methodology and a non-randomized design. Five of these quantitative studies used a cross-sectional design, whilst three were retrospective. One study used a qualitative approach, and is based on data (both actual and retrospective) from semi-structured interviews to adult transgender participants.

Narrative synthesis of results

All the reviewed articles took into consideration variables related attachment: feelings associated with childhood warmth and safeness, parental acceptance and willingness to serve as a secure base. Four of these articles focused on the construct of separation anxiety (SA). A retrospective study used the Adult Attachment Interview (Giovanardi et al., 2018). The qualitative study by Lemma (2012) touched upon attachment, mentalization and reflective functioning.

Attachment

Overall, the studies confirmed the protective role of attachment. Parental willingness to serve as a secure base moderated³ the association between childhood gender nonconformity and emotional/behavioural problems in MacMullin et al. (2021); and, in the article from Santarossa et al. (2019) it was a protective factor against SA (along with warm parenting styles and parental gender-stereotyped attitudes). In particular, in Santarossa the outcome variable was separation anxiety and in MacMullin it was the CBCL Total Problems scale. The data for these two researches were collected in samples of children aged 6–12, by using parent report measures, which, as underlined by the Authors themselves, could represent a source of bias. However, findings pointing to a similar direction come with the article from Van Beusekom et al., who analysed data collected from a group of adolescents aged 15–18 through self-report questionnaires, and found that father acceptance moderated the relation between GNC⁴ and psychological distress.

Another finding which points to the same direction in all the three studies is connected with different results as a function of birth-assigned sex. MacMullin et al. (2021) found that

Increases in GNC were associated with increased behavioral and emotional challenges in children AMAB⁵ (i.e., a linear association), whereas for children AFAB⁶ increases toward either GNC or gender conformity were associated with increased behavioral and emotional challenges (i.e., a quadratic association). (p. 834)

In other words, results showed that in birth-assigned boys higher levels of gender nonconformity were associated with increased behavioural and emotional issues; whilst, in birth-assigned girls, not only higher levels of gender nonconformity, but also higher level of gender conformity were associated with increased behavioural and emotional issues.

In Santarossa and colleagues (2019) the association between GNC and separation anxiety was significant for birth-assigned boys, but not for girls; however, the interaction between GNC and parental willingness to serve as a secure base was significant both in birth-assigned boys and in birth-assigned girls. Similarly, in van Beusekom et al. (2015), birth-assigned boys who reported higher levels of father acceptance showed lower levels of psychological distress and social anxiety associated with GNC; whilst for birth-assigned girls, the association between parents’ acceptance and psychological distress (and social anxiety) was significant, but the interaction of GNC with parents’ acceptance was not significant.

Retrospective data from adult samples confirmed the protective role of attachment-related parental factors. Greene and Britton (2015) found that feelings associated with childhood warmth and safeness significantly predicted adult subjective happiness. Although it is not possible to infer causality since this was not a longitudinal study, these findings may suggest that transgender adults who, in early years, experienced higher levels of childhood warmth and safeness are more likely to report higher levels of adult subjective happiness compared to those who report low childhood warmth and safeness.

Separation anxiety

Three cross-sectional studies and one retrospective explicitly addressed the issue of SA: we have already cited the work from Santarossa et al. (2019). VanderLaan et al. (2018) in a clinical sample of birth-assigned boys found SA significantly more prevalent in the gender-referred group, compared to the estimated US population prevalence; however, when testing the predictive role gender nonconformity along with of socio-demographic characteristics, CBCL Internalizing, Externalizing and poor peer relations scores, gender nonconformity did not significantly predict SA; only CBCL internalizing score, age and parental marital status significantly predicted SA. Thus, the authors concluded that SA could be understood as a problem within the spectrum of internalizing problems for which male children clinic-referred for GD show elevation. Gomez et al. (2017), in their retrospective research in a group of adult members of the Mexican Istmo-Zapotec cultural group, found that Muxes, birth-assigned men self-identified with a third gender, reported high levels of childhood separation anxiety as compared to cisgender men, and similar to women. In 1996, Zucker and colleagues examined the prevalence of SA in a gender-referred group of birth-assigned boys, and, in the conclusions point out that SA may be understood as an internalizing trait, which is consistent with the fact that internalizing symptoms are elevated in gender nonconforming birth-assigned boys.

Mentalizing and reflective functioning

Lemma (2012) put in light how the experience of incongruity can be difficult to be communicated to attachment figures during childhood and adolescence, and the importance of mentalizing the ‘incongruity experienced at the level of the body-self’ (p. 278), which can remain unmentalized. No other article explicitly addressed the construct of mentalizing or reflective functioning.

Proposal of interventions

Four of the quantitative studies offered indications for clinical interventions; moreover, the qualitative study by Lemma may offer additional suggestions.

MacMullin et al. (2021) suggested interventions aimed at (1) educating caregivers to serve as a secure base and to be supportive of their TGD children, (2) preventing victimization directed towards TGD children, (3) promoting positive peer relations, in line with Greene and Britton (2015). Santarossa et al. (2019) recommend encouraging parents to focus on providing a secure base for the child as a strategy for reducing SA among gender-variant children. Greene and Britton (2015), along with Giovanardi et al. (2018) addressed the issue of working therapeutically on possible traumatic memories deriving from victimization and rejection experienced over development. Giovanardi and colleagues pointed out also the importance of disseminating a correct knowledge on gender diversity, with families, schools, and communities to promote social acceptance, to reduce stigma and the related developmental risk factors.

The opportunity of working to improve mentalization may be envisaged in Lemma (2012), who focused on the incongruity at the level of the body-self that the transgender person may experience since childhood, and that may remain unmentalized.

Discussion

This systematic review identified nine articles focused on the association of attachment, reflective functioning and mentalization with mental health and psychological wellbeing in TGD children and adolescents. It was possible to identify specific outcomes in relation to mental health: general adjustment as measured by the CBCL Total challenges scale; separation anxiety; psychological distress; social anxiety; and adult subjective happiness.

Attachment moderated the association between childhood gender diversity and emotional/behavioural problems. Also, a positive perception of attachment in childhood significantly predicted adult subjective happiness. Lemma (2012) highlighted the important role of the mirroring experience in early infancy as a factor associated with the possibility of feeling parental support and acceptance, and with the capacity of the attachment figure to validate the internal experience of incongruence.

The possible effect of birth-assigned sex found by MacMullin et al. (2021), Santarossa et al. (2019), and van Beusekom et al. (2015) may indicate that the interaction between GNC, parental factors related to attachment and mental wellbeing operates differently according to birth-assigned sex, with birth-assigned boys appearing to be more vulnerable to distress in relation with GNC.

Regarding the studies on SA, it is possible to appreciate how research changed over time, moving from a focus merely on psychopathology to a perspective of promotion of a healthy development: the focus in 1996 was specifically on SA as a symptom of interest in TGD children, whereas moving on to 2020, it switched to the aim of understanding protective factors of psychosocial wellbeing. SA may be understood as a symptom that may present in TGD children as a type of internalizing symptomatology to which this group is more vulnerable.

Five of the reviewed studies interpreted findings within the frame of the Minority Stress Model. A positive, supportive attitude of the caregiver, and the capacity of serving as a secure base for the TGD child or adolescent may be protective factors against distress deriving by the experience of incongruity and by social stigma. Another important finding is that parental attitudes supportive of the TGD child’s gender expression and development may promote itself a secure attachment, whilst negative attitudes lead to insecure attachment.

With regards to proposals for interventions, it is possible to identify three levels of action.

1. At an individual level, mentalization-informed treatments may aim at promoting the capacity of mentalizing the self-body incongruence, and at mitigating the effects of social stigma and possible experiences of victimization; such interventions are indicated both in individual and in group settings.

2. At an family level, it is important to design interventions for caregivers aimed at promoting secure attachment, along with a supportive, affirmative stance Caldarera et al., (2021). Also, mentalization-based treatment principles can be applied to parents of TGD children and adolescents.

3. At an community level, many studies point to carry out interventions aimed at disseminating a correct information about gender diversity, preventing victimization and discrimination, in the school and the social context.

Conclusions

The findings from this review offer some insights on the role of attachment, mentalization and reflective functioning in promoting mental health and wellbeing of gender diverse children and adolescents. However, there are some limitations: despite the importance of the topic, few articles have been published. This could be due to the challenge in designing appropriate studies to investigate the complex interactions between these variables. In addition, the studies included in this review differ as to type of samples and assessment methods. Such heterogeneity can make it difficult to compare the results from the different articles, and limits generalizability of the findings. Finally, none of the studies used a longitudinal design.

These initial results indicate the necessity of improving research in this field, which promises to offer specific indications to protect mental health of TGD children and adolescents against the many distressing factors they face.

Future longitudinal studies could help to gain a deeper understanding of the developmental pathways related to attachment, mentalization and reflective functioning and mental health in TGD children. Another key step will be to carry out process-outcome studies of the application of attachment- and mentalization-based treatments in families of TGD children and adolescents.

Supplemental Material

sj-pdf-1-ccp-10.1177_13591045221075527 – Supplemental material for The association of attachment, mentalization and reflective functioning with mental health in gender diverse children and adolescents: A systematic review

Supplementary material, sj-pdf-1-ccp-10.1177_13591045221075527 for The association of attachment, mentalization and reflective functioning with mental health in gender diverse children and adolescents: A systematic review by Angela M Caldarera, Benedetto Vitiello, Camilla Turcich, Daniela Bechis and Chiara Baietto in Clinical Child Psychology and Psychiatry

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This study was funded by Fondazione Carlo Molo Onlus, within a post-doctoral research grant.

ORCID iD

Angela M Caldarera

Supplemental Material

Supplement material for this article is available in online.

Notes

Author biographies

Angela M Caldarera, PhD, is a research fellow at the Università degli Studi di Torino. She does research and works as a clinical psychologist within the gender identity development outpatient clinic at the Regina Margherita Pediatric Hospital, Torino, Italy.

Benedetto Vitiello is a psychiatrist, Professor of Child and Adolescent Neuropsychiatry at the Università degli Studi di Torino, Turin, Italy.

Camilla Turcich holds an MSc in in Developmental and Educational Psychology from the Università degli Studi di Torino.

Daniela Bechis is a child neuropsychiatrist and works within the gender identity development outpatient clinic at the Regina Margherita Pediatric Hospital, Torino, Italy.

Chiara Baietto is a child neuropsychiatrist and director of the gender identity development outpatient clinic at the Regina Margherita Pediatric Hospital, Torino, Italy.

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