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BRIEF REPORT
Relationships Between Transgender Congruence, Gender Identity
Rumination, and Self-Esteem in Transgender and Gender-Nonconforming
Individuals
Femke van den Brink
Utrecht University
Manja Vollmann
Erasmus University Rotterdam and Utrecht University
Shane van Weelie
Utrecht University
The present study investigated the association between transgender congruence and self-esteem in transgender
and gender-nonconforming (TGNC) individuals and whether rumination about gender identity atemporally
meditates this relationship. In a cross-sectional study, 323 TGNC individuals completed an online survey
measuring the 2 factors of transgender congruence (i.e., appearance congruence and gender identity accep-
tance), rumination about gender identity, and self-esteem. Data were analyzed using a mediation analysis with
gender identity acceptance and appearance congruence as predictors, rumination about gender identity as
mediator, and self-esteem as outcome. The results revealed positive associations between both factors of
transgender congruence and self-esteem. Furthermore, it was found that these relationships were partially
atemporally mediated by rumination about gender identity. More specifically, higher levels of appearance
congruence and gender identity acceptance were associated with higher levels of self-esteem through less
rumination about gender identity. These results suggest that transgender congruence and rumination about
gender identity are factors that can be addressed in clinical settings to increase self-esteem and other
components of mental health in TGNC individuals.
Public Significance Statement
This study suggests that transgender and gender-nonconforming (TGNC) people who feel comfort-
able with their appearance and are acceptive of their gender identity have more self-esteem, which
can partly be explained by the fact that they ruminate less about being TGNC. The findings imply
that supporting TGNC people to feel comfortable with their appearance and to accept their gender
identity by psychological or medical treatments will result in better mental health.
Keywords: transgender and gender-nonconforming, transgender congruence, rumination about gender
identity, self-esteem, mental health
Transgender and gender-nonconforming (TGNC) is an um-
brella term for individuals whose gender identity differs from the
sex assigned to them at birth (Dozier, 2005). An estimated .4% to
1.3% of the world’s population identifies as transgender or gender-
nonconforming, which accounts for around 25 million individuals
(Winter et al., 2016). It is well documented that TGNC individuals
experience less psychological well-being (e.g., more stress, less
self-esteem, lower life satisfaction) and more mental health prob-
lems (e.g., depression, anxiety, suicidal ideation) than cisgender
individuals do, that is, individuals who experience congruence
between sex assigned at birth and gender identity (e.g., Davey,
Bouman, Arcelus, & Meyer, 2014;Dhejne, Van Vlerken, Heylens,
& Arcelus, 2016;Meyer, Brown, Herman, Reisner, & Bockting,
2017;Warren, Smalley, & Barefoot, 2016). According to the
minority stress model and the gender affirmation framework as
well as empirical findings, these adverse outcomes are due to
social stigma, rejection, and discrimination related to gender iden-
tity or expression (Bockting, Miner, Swinburne Romine, Hamil-
This article was published Online First October 17, 2019.
XFemke van den Brink, Department of Clinical Psychology and De-
partment of Developmental Psychology, Utrecht University; XManja
Vollmann, Department of Socio-Medical Sciences, Erasmus School of
Health Policy and Management, Erasmus University Rotterdam, and De-
partment of Clinical Psychology, Utrecht University; Shane van Weelie,
Department of Clinical Psychology, Utrecht University.
Femke van den Brink and Manja Vollmann contributed equally to this article.
Correspondence concerning this article should be addressed to Femke van den
Brink, Department of Developmental Psychology, Utrecht University, P.O. Box
80140, 3508 TC, Utrecht, the Netherlands. E-mail: f.vandenbrink@uu.nl
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Psychology of Sexual Orientation and Gender Diversity
© 2019 American Psychological Association 2020, Vol. 7, No. 2, 230–235
ISSN: 2329-0382 http://dx.doi.org/10.1037/sgd0000357
230
ton, & Coleman, 2013;Hendricks & Testa, 2012;Meyer, 2003;
Sevelius, 2013;Valentine & Shipherd, 2018). Therefore, it is
important to identify resilience and protective factors facilitating
psychological well-being and mental health in TGNC individuals.
Transgender congruence has been introduced as an important
resource protecting TGNC individuals against adverse psycholog-
ical outcomes (Glynn et al., 2016). Transgender congruence refers
to “the degree to which transgender individuals feel genuine,
authentic, and comfortable within their external appearance/pres-
ence and accept their genuine identity rather than the socially
prescribed identity” (Kozee, Tylka, & Bauerband, 2012, p. 181).
Thus, transgender congruence comprises two factors, that is, ap-
pearance congruence and gender identity acceptance. Empirical
findings revealed that transgender congruence is positively asso-
ciated with a variety of indicators of psychological well-being and
mental health (Chodzen, Hidalgo, Chen, & Garofalo, 2019;Glynn
et al., 2016;Ho & Mussap, 2017;Jackman, Dolezal, Levin, Honig,
& Bockting, 2018;Kozee et al., 2012;McLemore, 2015). How-
ever, factors accounting for these associations, which can reveal
further insights relevant to facilitating mental health among TGNC
individuals, are not yet fully understood.
One factor possibly accounting for the associations between
transgender congruence and psychological outcomes might be
rumination about gender identity, an important process specifically
relevant in the context of emotion regulation in TGNC individuals
(Bauerband & Galupo, 2014;Shulman et al., 2017). Rumination in
general refers to a maladaptive emotion-focused coping strategy
that is characterized by persistent negative thoughts about distress-
ing experiences (Nolen-Hoeksema, Wisco, & Lyubomirsky, 2008).
Previous research has indicated that rumination negatively affects
psychological well-being and mental health in both the general
population and in TGNC individuals (Kirkegaard Thomsen, 2006;
Nolen-Hoeksema et al., 2008;Timmins, Rimes, & Rahman, 2017).
Rumination about gender identity specifically captures the unman-
ageable negative thoughts regarding one’s gender identity and
expression (Bauerband & Galupo, 2014), which are found to be
evident in TGNC individuals (Brewster, Velez, DeBlaere, & Mo-
radi, 2012). Based on the assumptions of the minority stress model
and the gender affirmation framework (Meyer, 2003;Sevelius,
2013), it can be expected that not feeling comfortable with the
external appearance and not accepting the gender identity results in
significant distress, which in turn contributes to increased rumina-
tion about gender identity. Accordingly, Bauerband and Galupo
(2014) showed that transgender congruence is strongly negatively
related to rumination about gender identity. Following the empir-
ical findings regarding the adverse effects of general rumination on
psychological outcomes, it may be assumed that rumination about
gender identity negatively affects psychological well-being and
mental health in TGNC individuals (Bauerband & Galupo, 2014).
Thus, transgender congruence may facilitate psychological well-
being and mental health, because it protects TGNC individuals
from ruminating thoughts about gender identity.
The Present Study
The present study explored the associations between transgen-
der congruence, rumination about gender identity, and psycholog-
ical outcomes in TGNC individuals using a cross-sectional design.
More specifically, it was examined whether rumination about
gender identity atemporally mediates (due to the cross-sectional
design; Winer et al., 2016) the relationships between the two
factors of transgender congruence, that is, appearance congruence
and gender identity acceptance, and self-esteem. Self-esteem, de-
fined as a global evaluation of the self and one’s own feeling of
worthiness (Rosenberg, 1965), was chosen as outcome because of
its central role in the etiology of mental health problems (for
meta-analyses, see Mann, Hosman, Schaalma, & de Vries, 2004,
and Sowislo & Orth, 2013).
Based on previous findings, it was expected that higher levels of
appearance congruence and gender identity acceptance would be
associated with higher levels of self-esteem. Additionally, it was
expected that rumination about gender identity would atemporally
mediate the relationships between the factors of transgender con-
gruence and self-esteem, with higher levels of appearance congru-
ence and gender identity acceptance being associated with lower
levels of rumination about gender identity, which in turn would be
associated with higher levels of self-esteem.
Method
Participants and Procedure
Participants were recruited via various TGNC Facebook groups.
Individuals with a minimum age of 18 years and self-identify
under the trans
ⴱ
umbrella (i.e., not identify as cisgender) were
invited to take part in the online study Comfort With Gender
Identity. After participants opened the link to the online survey,
they were provided with information about the study and com-
pleted an informed consent form, in which voluntary participation,
anonymity, and professional data handling were assured. Subse-
quently, demographic questions and questionnaires measuring self-
esteem, transgender congruence, and rumination about gender identity
were presented. On average it took 10 min to complete the question-
naire. Participants received no compensation for their participation.
The study was approved by the Ethics Committee of the Faculty of
Social and Behavioral Sciences of Utrecht University, the Nether-
lands.
A total of 323 participants between 18 and 70 years of age fully
completed the survey. Participants identified themselves as (trans)
man (n⫽176; 54.5%), (trans) woman (n⫽56; 17.3%), nonbinary
(n⫽42; 13%), agender (n⫽10; 3.1%), genderqueer (n⫽9;
2.8%), demiboy (n⫽8; 2.5%), genderfluid (n⫽5; 1.5%), demi-
girl (n⫽1; .3%), and bigender (n⫽1; .3%). Participants who did
not choose one of these options (n⫽15; 4.6%) identified them-
selves, for example, as transmasculine, maverique, nonbinary trans
man, and queer. The mean age of the total sample and the three
largest subgroups are presented in Table 1. The majority of the
participants were from the Netherlands (41.8%) or New Zealand
(32.2%), followed by United States (7.1%) and Australia (6.2%).
The rest of the participants lived in mainly European countries.
About half of the participants (53.3%) were involved in a romantic
relationship.
Measures
Means and standard deviations for all measures for the total
sample and the three largest subgroups (i.e., (trans) men, (trans)
women, nonbinary) can be found in Table 1.
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231
TRANSGENDER CONGRUENCE, RUMINATION, SELF-ESTEEM
Transgender congruence. The Transgender Congruence Scale
(Kozee et al., 2012) was used to measure the two factors of
transgender congruence, that is, appearance congruence (nine
items; e.g., “My outward appearance reflects my gender identity”)
and gender identity acceptance (three items; e.g., “I have accepted
my gender identity”). The items were answered on a 5-point Likert
scale ranging from 1 (strongly disagree)to5(strongly agree).
Items were recoded if appropriate and averaged so that higher
subscale scores indicated greater appearance congruence and gen-
der identity acceptance. In this study, Cronbach’s alphas were .94
and .79 for appearance congruence and the gender identity accep-
tance, respectively.
Rumination about gender identity. Rumination about gen-
der identity was measured using the rumination subscale of the
Gender Identity Reflection and Rumination Scale (Bauerband &
Galupo, 2014). The five items (e.g., “I waste time thinking
about my gender identity”) were answered on a 4-point Likert
scale ranging from 1 (almost never)to4(almost always). Items
were recoded if appropriate and averaged so that higher scores
indicated more rumination. In the current study, Cronbach’s
alpha was .81.
Self-esteem. Self-esteem was measured with the Rosenberg
Self-Esteem Scale (Rosenberg, 1965) consisting of 10 items cap-
turing individuals’ global perception of their own worth. The items
were answered on a 4-point Likert scale ranging from 1 (strongly
agree)to4(strongly disagree). Items were recoded if appropriate
and averaged so that higher scores indicated greater self-esteem. In
the current study, Cronbach’s alpha was .92.
Statistical Analysis
Statistical analyses were performed with IBM SPSS Statistics
Version 25 and PROCESS for SPSS 3.3. In Step 1, bivariate
associations between the study variables were analyzed using
Pearson correlation coefficients. In Step 2, a mediation analysis
with the two factors of transgender congruence, that is, appearance
congruence and gender identity acceptance, as independent vari-
ables; rumination about gender identity as mediator; and self-
esteem as dependent variable was conducted. Age was included as
control variable because it was significantly related to appearance
congruence, rumination about gender identity, and self-esteem.
Note that, due to the cross-sectional data, the mediation analysis
reflects an atemporal mediation yielding evidence of correla-
tional associations rather than evidence of causality (Winer et
al., 2016).
The mediation analysis contained the following subanalyses
(Hayes, 2018): First, to estimate the effects of appearance congru-
ence and gender identity acceptance on rumination about gender
identity, we calculated a multiple regression analysis by entering
both factors of transgender congruence simultaneously. Second, a
hierarchical regression analysis in which the two factors of trans-
gender congruence were entered in Step 1 and rumination about
gender identity was entered in Step 2 was calculated to estimate
the total (Step 1) and direct (Step 2) effects of appearance con-
gruence and gender identity acceptance as well as the effect of
rumination about gender identity (Step 2) on self-esteem. Third,
indirect effects of appearance congruence and gender identity
acceptance on self-esteem through rumination about gender iden-
Table 1
Descriptive Statistics and Bivariate Correlations of the Study Variables for the Total Sample and the Three Largest Subgroups
Variable Sample M(SD) 1234
1. Appearance congruence
a
Total sample
c
3.03 (1.14) —
(Trans) men
d
3.22 (1.12)
1
(Trans) women
e
3.21 (1.24)
1
Nonbinary
f
2.31 (.90)
2
2. Gender identity acceptance
a
Total sample
c
3.98 (.99) .28
ⴱⴱⴱ
—
(Trans) men
d
3.83 (1.02)
1
.31
ⴱⴱⴱ
(Trans) women
e
4.29 (.96)
2
.44
ⴱⴱ
Nonbinary
f
4.07 (.94)
1, 2
.05
3. Rumination about gender identity
b
Total sample
c
2.00 (.73) ⫺.52
ⴱⴱⴱ
⫺.41
ⴱⴱⴱ
—
(Trans) men
d
2.01 (.74)
1
⫺.52
ⴱⴱⴱ
⫺.45
ⴱⴱⴱ
(Trans) women
e
1.83 (.73)
1
⫺.53
ⴱⴱⴱ
⫺.22
Nonbinary
f
2.04 (.68)
1
⫺.54
ⴱⴱⴱ
⫺.19
4. Self-esteem
b
Total sample
c
2.74 (.69) .44
ⴱⴱⴱ
.32
ⴱⴱⴱ
⫺.48
ⴱⴱⴱ
—
(Trans) men
d
2.73 (.67)
1, 2
.39
ⴱⴱⴱ
.34
ⴱⴱⴱ
⫺.49
ⴱⴱⴱ
(Trans) women
e
2.98 (.76)
1
.58
ⴱⴱⴱ
.32
ⴱ
⫺.38
ⴱⴱ
Nonbinary
f
2.57 (.68)
2
.39
ⴱ
.13 ⫺.36
ⴱ
5. Age Total sample
c
28.54 (11.23) .26
ⴱⴱⴱ
.09 ⫺.24
ⴱⴱⴱ
.32
ⴱⴱⴱ
(Trans) men
d
26.69 (9.57)
1
.32
ⴱⴱⴱ
.14 ⫺.29
ⴱⴱⴱ
.33
ⴱⴱⴱ
(Trans) women
e
37.80 (15.20)
2
.15 ⫺.03 ⫺.07 .31
ⴱ
Nonbinary
f
26.71 (9.28)
1
.35
ⴱ
⫺.33
ⴱ
⫺.21 .14
Note. A multivariate analysis of variance with post-hoc Bonferroni comparisons with subgroup ([trans] man vs. [trans] woman vs. nonbinary) as
independent variable and all study variables as dependent variables resulted in a significant overall effect for subgroup, F(10, 534) ⫽9.13, p⬍.001, Wilks
⌳⫽.73, p
2⫽.15. Means that do not share subscripts are significantly different at the p⬍.05 level. Moderation analyses revealed that the bivariate
correlations did not significantly differ between the three subgroups, except for the correlation between appearance congruence and gender identity
acceptance, which differed between the (trans) women and nonbinary group (p⫽.02).
a
Scale range ⫽1–5.
b
Scale range ⫽1– 4.
c
N⫽323.
d
n⫽176.
e
n⫽56.
f
n⫽42.
ⴱ
p⬍.05.
ⴱⴱ
p⬍.01.
ⴱⴱⴱ
p⬍.001.
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232 VAN DEN BRINK, VOLLMANN, AND VAN WEELIE
tity were determined by means of bootstrap analyses with 5,000
bootstrap samples generating 95% percentile bootstrap confidence
intervals (CIs). All coefficients are reported in standardized form.
Results
Bivariate Associations Between Transgender
Congruence, Rumination About Gender Identity, and
Self-Esteem
The results of the correlation analyses of the study variables are
presented in Table 1. As expected, appearance congruence and
gender identity acceptance were significantly negatively related to
rumination about gender identity and significantly positively re-
lated to self-esteem. Also, a significant negative association be-
tween rumination about gender identity and self-esteem was found.
Total, Direct, and Indirect Effects of Transgender
Congruence on Self-Esteem Through Rumination
About Gender Identity
The results of the regression analyses are presented in Figure 1.
The multiple regression analysis revealed significant negative ef-
fects of both factors of transgender congruence on rumination
about gender identity (controlled for age), indicating that higher
levels of appearance congruence and gender identity acceptance
are associated with less rumination about gender identity. A total
of 35% of the variance in rumination about gender identity could
be explained, F(3, 321) ⫽58.35, p⬍.001.
The hierarchical regression analysis revealed significant posi-
tive total effects in Step 1 and significant positive direct effects of
both factors of transgender congruence on self-esteem (controlled
for age) in Step 2. This indicates that higher levels of appearance
congruence and gender identity acceptance are associated with
higher levels of self-esteem. Furthermore, Step 2 of the hierarchi-
cal regression analysis yielded a significant negative effect of
rumination about gender identity on self-esteem (controlled for
age), indicating that less rumination about gender identity is asso-
ciated with higher levels of self-esteem. In Step 1, a total of 28%
of the variance in self-esteem could be explained by the two
factors of transgender congruence and age, F(3, 321) ⫽41.52, p⬍
.001. Adding rumination about gender identity in Step 2 resulted in
a 4.6% increase of the explained variance in self-esteem, ⌬F(1,
317) ⫽21.85, p⬍.001. Together, the two factors of transgender
congruence, rumination about gender identity, and age explained a
total of 32% of the variance in self-esteem, F(4, 321) ⫽38.65, p⬍
.001.
The bootstrap analyses revealed significant positive indirect
effects of appearance congruence (⫽.11; 95% CI [.062, .169]),
as well as of gender identity acceptance (⫽.08; 95% CI [.037,
.124]) on self-esteem through rumination about gender identity
(controlled for age). This indicates that higher levels of appearance
congruence and gender identity acceptance are associated with
higher levels of self-esteem through less rumination about gender
identity.
Discussion
The current study investigated the relationships between trans-
gender congruence (i.e., appearance congruence and gender iden-
tity acceptance), rumination about gender identity, and self-esteem
in TGNC individuals using a cross-sectional design. As expected,
the results showed that higher levels of both appearance congru-
ence and gender identity acceptance as well as lower levels of
rumination about gender identity were associated with higher levels of
self-esteem. These results are in line with previous findings (e.g.,
Bauerband & Galupo, 2014;Glynn et al., 2016;Kozee et al., 2012)
and suggest that transgender congruence may be a protective factor in
the context of psychological well-being and mental health in TGNC
individuals.
Furthermore, as expected, the results of the mediation analysis
revealed that the relationships of both factors of transgender con-
gruence with self-esteem were atemporally mediated by rumina-
tion about gender identity. These findings suggest that experienc-
ing comfort with external appearance and accepting one’s gender
identity may protect TGNC individuals from ruminating about
their gender identity, which in turn may contribute to a more
positive global evaluation of the self and more feelings of self-
worth. The present findings indicate that rumination about gender
identity only partially accounts for the associations between the
two factors of transgender congruence and self-esteem, suggesting
that transgender congruence may also have a more direct associ-
Figure 1. Results of the multiple and hierarchical regression analyses that were calculated as part of the
mediation analysis linking the two factors of transgender congruence with self-esteem via rumination about
gender identity. Total effects derived from Step 1 of the hierarchical regression analysis are displayed in
parentheses. All coefficients are reported in standardized form. Control paths for age on rumination about gender
identity (⫽⫺.11, p⫽.02) and on self-esteem (⫽.19, p⬍.001) were omitted for figure clarity.
ⴱⴱ
p⬍.01.
ⴱⴱⴱ
p⬍.001.
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233
TRANSGENDER CONGRUENCE, RUMINATION, SELF-ESTEEM
ation with self-esteem or that additional variables not assessed in
the current study, such as transgender community belongingness
(Barr, Budge, & Adelson, 2016), also underlie this association.
The results of the present study suggest that transgender con-
gruence is an important factor facilitating psychological well-
being and mental health of TGNC individuals. Given the high
prevalence of mental health problems among TGNC individuals
(e.g., Meyer et al., 2017), these findings may have important
clinical implications. As highlighted by Kozee and colleagues
(2012), therapists and counselors can help TGNC clients by de-
veloping individualized strategies that can help them to cope in
times when they feel less congruent with their appearance and
gender identity, irrespective of whether they decide to engage in
the transitioning process. Attending to and addressing transgender
congruence in (psychological) health care could help to increase
self-esteem and psychosocial well-being by reducing rumination
about gender identity.
Furthermore, it is important that TGNC clients who consider
engaging in transitioning be supported in this process. Previous
studies have shown that the level of transgender congruence of
treatment-seeking transgender people considerably improved fol-
lowing gender-affirming medical treatments, such as hormone
replacement therapy and genital affirming surgery (e.g., Fisher et
al., 2014;Owen-Smith et al., 2018). However, not all TGNC
treatment-seeking individuals have equal opportunity to access
gender affirmation care. Possibilities greatly vary between coun-
tries depending on laws and health care programs, and barriers
TGNC individuals encounter include long waiting lists, health care
discrimination, and financial barriers (e.g., Gonzales & Henning-
Smith, 2017). Despite increased awareness of barriers to gender-
affirming care, there are a number of improvements that can be
made at a broader policy level to ease and facilitate access to care
that can improve the well-being and health of TGNC individuals
(Puckett, Cleary, Rossman, Mustanski, & Newcomb, 2018).
Our results must be considered in light of study limitations.
First, given the cross-sectional nature of this study, findings cannot
be used to infer causality (Winer et al., 2016). Although the tested
mediation model is based on theoretical assumptions, it is also
reasonable to assume that the direction of the relationships may be
reversed or reciprocal; for example, low self-esteem could (also)
increase rumination, and rumination could (also) negatively affect
transgender congruence. Alternative models were not tested in the
current study. In the future, longitudinal studies are needed to
study causal effects. Second, the recruitment of participants was
restricted to those using Facebook TGNC groups, and the present
sample consisted of primarily Dutch participants who self-
identified as (trans) man. Therefore, the results of this study may
not be representative of the general population of TGNC individ-
uals. Finally, only one aspect of psychological well-being and
mental health (i.e., self-esteem) was assessed in the present study.
Future researchers may use more comprehensive measures to
differentiate between the role of transgender congruence and ru-
mination about gender identity in various aspects of the mental
health of TGNC individuals.
Despite the limitations, this study adds to the literature by
providing further evidence of transgender congruence being an
important factor in the context of mental health in TGNC individ-
uals and by providing first evidence of rumination about gender
identity being a factor accounting for the relationship between
transgender congruence and self-esteem in TGNC individuals. The
present findings suggest that supporting TGNC individuals to
improve their appearance congruence and their gender identity
acceptance by psychological and/or medical treatments would
result in increased mental health. Given the increasing health care
needs for TGNC individuals, it is important to further study the
underlying factors that can be addressed in clinical settings to
increase self-esteem and other components of mental health in
TGNC individuals.
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Received June 6, 2019
Revision received September 9, 2019
Accepted September 22, 2019 䡲
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