El estigma de las identidades no binarias y el trastorno de estrés postraumático. Una revisión crítica de la literatura

The current emergence of non-binary identities can be understood because of the experience of the identity and struggle movements of the 1990s and 2000s, which sought to "normalize" LGBTQ+ (Lesbian, Gay, Bisexual, Trans, Queer/Questioning and other identities). Non-binarism refers to an umbrella term that includes all the dissidences of gender binarism as a system (Matsuno & Budge, 2017; Platero Méndez, 2018; Richards et al., 2016; Vijlbrief et al., 2020). Binarism is a superstructure of power (Matthews, 2017). It arises in a context of profound social changes, both at the level of identity construction, and at the collective level on an international scale. This climate of change has impacted gender as a system of power and its operation, making it, if possible, more complex, and difficult to locate (Duval, 2021). It clearly describes the pattern of bodies, gender identities[1] and relationships that are established with the world to exist in a "normalized" way. Gender identity is distinct from sexual or romantic orientation, non-binary people have different sexual orientations, such as cisgender people (no trans) (GLAAD, 2020).

According to a survey carried out in 2020 by the Injuve Institute, 25 % of young people under 30 years of age do not fully identify with the masculine or feminine condition.

Non-discrimination refers to a general term that includes all dissent from sexism as a system (Matsuno & Budge 2017; Platero Méndez, 2018; Richards et al., 2016; Vijlbrief et al., 2020). However, in the worldwide, there are records that show the existence of multiple non-binary identities societies, as in the cases of Hijra in India, Bakla in the Philippines, Chuckchi in Siberia and Quariwarmi in Peru (Stryker, 2008). This changing climate has impacted gender as a system of power and its function, making it, if possible, more complex, and difficult to define (Duval, 2021).

Through socialization and identification with an assigned gender, other options will be grouped in places of marginalization and dissidence. Being a non-binary means failing to identify fully and satisfactorily, satisfactorily, and consistently over time, with any available gender category, as well as with the social expectations associated with each category. It is a broad or general term that covers many sensitivities. The data obtained is still scarce, but it points to the need for recognition of a generation of young people who have been educated and are part of an active activity, are dedicated to social networks and feel that social movements and institutions are lacking. These deficiencies raise questions about their identity and sense of belonging to society. Research helps to advocate for the recognition and defense of non-binary people, to facilitate access to information on diversity of gender identities and support from early childhood will be essential to create references and safer environments that facilitate communication, access to rights and the opportunity to achieve an adequate quality of life (López-Gómez & Platero Méndez, 2018).

Research with the trans and non-binary (TNB) community in all fields and disciplines has increased considerably in recent decades (Moradi et al., 2016; Valentine & Shipherd, 2018). However, the existing body of work with this community is still in its infancy, with many gaps in actual data, including best practices for professionals working with the unique emotional trauma experienced by TNB people and their collectives (Burnes et al., 2016; Shipherd et al., 2019). Research focused on emotional trauma in LGBT communities and their experiences of traumatic events is recent and insufficient.

PTSD is a major risk factor for suicidal ideation (Leiva-Bianchiet al., 2017). While the suicide rate is 4.6% in the general population, it rises to between 10 and 20% for lesbian, gay or bisexual people and 41% for transgender or non- binary people (Foundation for Suicide Prevention of the United States, 2017).

In order to carry out this critical review article, the methodology of the qualitative paradigm was used with the descriptive foundation in the line of the scientific literature that is based on the search, analysis of conceptual innovation and evaluation of this theme, which synthesizes and critically exposes data from different sources (Grant and Booth, 2009) related to events and processes based on scientific evidence that are linked to psychosocial care to develop innovative concepts in current environments, which allows the application of results (Edgley et al,. 2016; Grant and Booth, 2009). Concepts from different fields of study are used to facilitate a better understanding and representation of this psychosocial reality. The resulting model has constituted a synthesis of models and responses that could be a new interpretation of the existing data through a critical review.

The search has been used in databases such as MEDLINE (PubMed), Elsevier, Scielo, Cochrane Library and PsycINFO, and Redalyc, in addition to the search engine Google Scholar and Eureka. Therefore, for its discrimination and structure, the technique and the sequence of structured contents were used, to provide the analysis of the key concepts related to the investigation. This investigation exposes in a critical way, the essential aspects of the subject and its repercussion in the actuality, marked by a search and selection of exhaustive empirical studies of the existing scientific literature to, in the first place, identify and expose the general reality of this subject and second, analyzing the guidelines, procedures, main criteria and results (Arnau-Sabatés & Sala Roca, 2020).

Gender identity in childhood and adolescence

In the first years of life and adolescence, greater self-regulation and adaptation take place, relationships with peers (especially) and sexual and gender norms are established (Mulvey & Killen, 2015). During adolescence, young men and women tend to display more harmful negative attitudes and more intense homophobic behaviors. Adolescents are more vulnerable to this social exclusion, affect their behavioral and emotional development more acutely, while older adolescents or adults possess more sophisticated adaptive resources on human rights, equity, and goals. This stage of development is characterized by being conditioned by strong influences and opinions from their peers, this increases the probability of becoming adult victims of abuse by their co- workers when they express their gender or sexual identity. Such victimization has well-documented psychological consequences (Russell & Fish, 2016).

No one can live well or prosper outside of a social world that provides the conditions for such development which begins in childhood. This is due to the stress that minority gender identity minors face for being a minority (McLemore, 2018). At this stage the risk of toxic habits, behavior changes, ethics, and responsibility increase. Adolescent membership in an LGBT community may increase their risk of expressing suicidal thoughts or having suicidal thoughts by up to 40% compared to their gender binary peers (Stone et al., 2014).

According to Shipherd et al. (2019) many of the harmful mental health symptoms experienced by TNB people derive from the trauma experienced during the development of their gender identity or from being discriminated against since childhood, because they are not considered fit for the job, assigned according to the established role, two criteria were identified in adults and adolescents in the elaboration of a valid diagnosis: Strong and persistent discomfort with physical gender characteristics or with inappropriately assigned social gender roles with a persistent gender identity (van der Kolk, 2015). Adolescence is a critical time for mental health, with many mental disorders beginning at this stage

PTSD and Minority Stress Theory: Related Factors

Recently, behaviors and risk factors associated with trauma have begun to be studied in NB people (Colizzi et al., 2015), but studies of PTSD or emotional trauma are still very scarce. Compared to the general population, people with NB have been shown to be more subject to devaluation, oppression, and discrimination.  As Schnarrs et al. (2019) noted that boys and girls who are part of sexual orientation, gender identity or sexual minorities are at increased risk of abuse and harassment, and face retaliation from their parents for their transgender behaviors.

This is worrying, as TNB people are more likely to bear potentially traumatic events, such as physical assaults (Shipherd et al., 2019) and victimization by overt and covert acts of bias and transphobia, such as gender confusion and workplace discrimination. Each of these experiences has negative impacts on mental health, leading to higher rates of psychopathologies in TNB people compared to cisgender people (Lefevor et al., 2019). So, it is paramount that practitioners examine the experiences and consequences of trauma in TNB communities to employ culturally and socially sensitive and trauma-informed approaches to psychological practice.

Although the high rates of discrimination and PTSD among TNB people, the relationship between these realities remains largely unexplored (Dolezal, 2022). Although, like acute traumatic stress, chronic and persistent threats to identity in the form of discrimination continue to threaten basic human needs for self-concept, confidence, understanding, control, and belonging, with deleterious effects on mental health. Furthermore, trauma and discrimination, whether acute or chronic, produce heightened stress responses, including avoidance of stimuli associated with the traumatic or discriminatory event and hypervigilance (anticipatory stress) about the possibility of future trauma or discrimination), as well as similar physiological responses in reaction to acute laboratory stressors (Cogan et al., 2021). There is evidence that exposure to traumatic stress and stigma-related stress operate through similar minority stress processes (Meyer, 2020),

Minority stress theory (Meyer, 2020) have proportioned an essential framework for understanding mental health differences among gender minorities. It is argued that sexual minorities experience various chronic stresses related to their stigmatized identities, including victimization, prejudice, and discrimination. These different episodes, along with common stressors, extremely affect the mental health and well-being of TBN people. An extension of this work also focuses on how individual internal sociopsychological processes (eg, appraisal, coping, and emotion regulation) mediate the association between stressful experiences and minority sociopsychology (Cogan et al., 2021).

The data alerts to overwhelming evidence of a higher risk of poor mental health at all stages of development than TNB people. Studies using adult samples show high rates of depression and mood disorders, anxiety disorders, post-traumatic stress disorder (PTSD) (Cogan et al., 2021), alcohol use and abuse suicidal ideation and attempts, and mental illness. Studies of adolescents trace the origins of these mental health disparities from adolescent to adult sexual orientation, some studies show that rates of distress, symptoms, and behavior associated with these disorders are disproportionate among young LGBT people before adulthood (Fish & Pasley, 2015).

In their meta-analysis, Marshal et al. (2011) found that bisexual youth reported more suicidal behavior than lesbian and gay youth. Preliminary research also shows that youth who question their sexuality report higher levels of depression than those who report other sexual identities, both heterosexual and LGBT. In addition, they have been shown to be less psychologically adjusted to deal with bullying and victimization than heterosexual or LGBTQ students.

Appearance-related stigma is one of the possible mechanisms by which TNB people are discriminated against. Appearance stigma refers to the extent to which one's physical appearance induces negative reactions in others (Worthen, 2021). TNB individuals who do not conform to society's designated gender expression at birth are often abused by others who view their expression as non-normative

The suicide risk: The invisibility of minorities

PTSD may be associated with depression, substance abuse, or other anxiety disorders. This disorder has well-defined diagnostic criteria. Regarding the relationship between suicidal ideation and PTSD, the presence of this disorder can lead to suicidal ideation and other behaviors. In the general population, people with PTSD are 14.9 times more likely to attempt suicide than the general population (Tiet & Moos, 2021).

They are considered an invisible and minority group, evidence of increased risk was found in bisexual adults and TNB, experts believe that another reason why this population suffers more diseases and related health disorders is the stress of being a minority. In other words, they are a minority within a minority. It is no secret that bisexuals have experienced constant invisibility, which has contributed to many of their health problems (Dyar et al., 2018). In a recent meta-analysis, Marshal et al. (2011) reported that sexual minority youth were almost three times more likely to commit suicide.

Gender identity and recognition labels

For some people, gender identity labels provide a sense of community. Labels give people the opportunity to express themselves and represent similar identities. However, labels have the power to regulate our actions and can lead to discrimination. Ferguson (2015) point out that label confusion is common because their research has shown that people often give a different definition of sexual or gender labeling.

There is still no recognition of TNB as well as bisexuality in which more studies have been carried out, which provide strong evidence that bisexuals (minorities) have greater mental health problems than "gays" and lesbians (Barker et al., 2012). It could be a dual or synergistic effect of the social rejection of heterosexual and homosexual communities (Olvera-Muñoz and Granados, 2017). They feel reflected with negative attributes towards their own bisexual orientation (Olvera-Muñoz, 2020), even in certain people there is social non-acceptance towards their own identification. To illustrate the above, Holloway et al. (2021) argue that bisexuals have a high rate of poor physical and mental health.

Batista and Pereira (2020) show that bisexual men mention greater mental suffering compared to homosexuals, and more recent research finds that bisexual men report greater emotional devaluation (Olvera-Muñoz et al, 2017), as well as feelings of concealment, lack of social recognition, discomfort, or shame), which are generated by social rejection in their various socialization environments.

Authors such as Olvera Muñoz et al. (2017), affirm that one of the main social problems of bisexuals is the lack of recognition as a consolidated group, we can also apply this principle in the NB. The foregoing, due to the social imagination that links sexual performance in the two extremes of heterosexuality and homosexuality. Therefore, following this statement, NB people are defined as non-existent.

Critique of research on risk factors for traumatic disorders and the need for recognition of identity rights

In general, there is very little research that focuses on non-binary people, even though non-binary people make up a significant part of the community and are associated with higher mental health risks. Non-binary people face a variety of challenges in a society. Through this article, researchers and society are encouraged to challenge the majority binary assumption about gender and create an egalitarian environment that includes and affirms those minority groups that are not gender binary.

The recognition of the rights and identity of NB people is a fundamental step in the psychosocial improvement of these people, so the promotion of laws through normalization and knowledge that operates contrary to prejudices, will allow equalizing the personal, family, educational, community, social and legal situation of all people.

These divergent thoughts share some themes, and the vast majority are very positive towards the acceptance and perception of gender as an identity. The most important overall result of this study is the difference between binary gender, non-binary gender, and different types of sexual orientation identities. They are unique and distinct gender identity and orientation traits, but equally valid, belonging to a minority group and consequently it is necessary to consider the stress theory that minorities are more predisposed to PTSD.

The present critical review makes it possible to identify the experiences of social rejection of NB and to know the impact on psychological suffering, the possible repercussions and risks for mental health, the need to avoid, identify or treat symptoms associated with PTSD, to promote a set of practices that generate various coping strategies of this human group, however, the need arises to carry out more studies and research to the needs of NB populations. Based on the results found, it is considered necessary to promote the recognition of NB as a socially formed human group and foster socialization spaces free of social rejection, make diversity visible and normalize to accommodate identity referents with which NB people can be. recognized without repercussions, from the richness that inclusion and diversity bring.

More attention is needed in the study of adaptive responses, PTSD, and the risk of suicidal behaviors of the group at risk, which allow us to provide useful knowledge for prevention, the development of interventions and fundamental, effective, and relevant rights. It is necessary to facilitate access to information and programs that make it possible to promote the intervention and research of family, psychosocial educational programs on diversity of gender identities and support from early childhood will be essential to create referents and safer environments that facilitate communication, access to rights and the opportunity to achieve an adequate quality of life from inclusion, diversity.

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The author declares that he does not incur in conflicts of interest.

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