Early Maladaptive Schema (EMS) Formation in Transgender Women: A Diathesis-Stress Application

Abstract

This study proposes an application of the diathesis-stress model to examine early maladaptive schema (EMS) formation in transgender women to elucidate psychopathological precursors in queer populations. Although researchers frequently explore EMSs’ ability to predict various psychological disorders, few studies utilize a diathesis-stress lens to examine EMS development. The diathesis-stress model is used to establish a baseline understanding of both preexisting vulnerabilities (diatheses) and environmental variables (stressors) responsible for EMS formation in transgender women. Following a semi-meta-analytic review of EMS literature, several thematic areas are identified then categorized as either diatheses or stressors. The analysis classifies personality traits of neuroticism, low agreeableness, negative affectivity, psychoticism, and detachment as diatheses alongside the stressors of interpersonal problems, abuse, trauma, depressive symptoms, and minority stress. Scholarly findings based on Hankin & Abramson’s (2001) cognitive vulnerability-transactional stress theory are also incorporated to highlight the bidirectional relationships between EMSs, depressive stressors, and depressive symptoms. Lastly, Ilan H. Meyer’s (1995) minority stress theory is applied to contextualize the model within queer- and minority-focused literature. Overall, the aforementioned stressors identified by this study are numerous and varied, whereas only select personality traits are identified as diatheses. This finding suggests the formation of EMSs in transgender women may be tied to a wider variety of environmental variables, though it should not be assumed a larger number of stressors equates to greater predictive validity. Further research should include an evaluation of resilience factors in EMS formation, potentially utilizing diathesis-stress expansive models, to further inform schema therapy interventions.

Introduction

One of the most common tools of modern psychology used to examine the development of psychological disorders is the diathesis-stress model. According to the model, certain psychological disorders arise when an individual’s diatheses, typically biological or psychological predispositions, are combined with stressors, or environmental factors. Proposed by Paul Meehl in 1962 and modernized by Marvin Zuckerman in 1999, the model finds much of its continued support from twin studies such as Yoon-Mi Hur’s (2024) study on gaming addiction in late adolescence and Colodro-Conde et al.’s (2017) evaluation of the diathesis-stress model for depression. While studies such as Kendler et al.’s (2002) question the universal applicability of the diathesis-stress model, the model provides insight into the biospsychosocial interactions preceding the development of various psychopathologies.

Early maladaptive schemas (EMSs) are cognitive features frequently associated with psychopathological development. According to Chen et al. (2023), EMSs are substantial, negative beliefs held by an individual impacting nearly every aspect of life. EMSs were first described by foundational scholars Jeffrey Young, Janet Klosko, and Marjorie Weishaar (2003) who propose children exhibit certain basic needs, including connection, emotional validation and free speech, senses of competency and autonomy, leisure and spontaneity, self-control/realistic limitations. Failure to meet one or more of the identified basic needs often results in EMS formation (Young et al., 2003). A recent study has arranged Young et al.’s (2003) 18 EMSs (Emotional Deprivation, Social Isolation/Alienation, Emotional Inhibition, Defectiveness/Shame, Mistrust/Abuse, Pessimism, Dependence/Incompetence, Failure to Achieve, Subjugation, Abandonment/Instability, Enmeshment, Vulnerability to Harm, Self-Sacrifice, Unrelenting Standards, Self-Punitiveness, Entitlement/Grandiosity, Approval Seeking, and Insufficient Self-Control) into the four domains of Disconnection & Rejection, Impaired Autonomy & Performance, Excessive Responsibility and Standards, and Impaired Limits (Bach et al., 2018, as cited in Lockwood & Perris, 2012). Scholars identify Young et al.’s (2003) 18 EMSs as contributors to the development of various psychological disorders, some of whom utilize the diathesis-stress model to do so (Eberhart et al., 2011; Vasilopoulou et al., 2020; Zheng et al. 2022). However, few studies apply the diathesis-stress model to the examination of EMS formation. With an aim to promote awareness of psychopathological predictors in queer populations, this study proposes an application of the diathesis-stress model to examine the formation of EMSs in transgender women. This research concludes transgender women experience relatively few diatheses in comparison to many stressors, each of which may contribute to EMS development.

In addition to basic need deficiencies identified by Young et al. (2003), several other salient factors are examined as potential contributors to EMS development. One such factor is interpersonal problems with a focus on parental relationships. A meta-analysis by Janovsky et al. (2020) identifies a moderate positive correlation between EMSs and interpersonal problems which are defined as any psychological distress caused by relationships with others (Mojallal et al., 2015). Highlighting a specific interpersonal problem, several scholars associate EMS formation with poor parental relationships (Zafiropoulou et al., 2014; Akbari et al., 2024; Başer Baykal & Erden Çınar, 2023). Though a poor maternal bond is frequently associated with EMS formation (Akbari et al., 2024; Zafiropoulou et al. 2014), studies also connect paternal issues such as overprotection, authoritarian parenting, physical or emotional absence, and fathers coping with personal trauma with EMS development (Zafiropoulou et al., 2014; Başer Baykal & Erden Çınar, 2023). The significance of these findings is strengthened by McCarthy & Lumley’s (2012) study identifying parental emotional maltreatment as the most profound predictor of EMS development, and Başer Baykal & Erden Çınar (2023) propose a causal relationship between dysfunctional parenting and EMS formation. Such a relationship, if it existed, would likely exacerbate the presence of EMSs among transgender women, as queer individuals commonly experience rejection from their parents upon coming out (Schmitz & Tyler, 2021).

Scholars also examine the relationship between bullying, a specific interpersonal problem, and EMS formation, highlighting a potential bidirectional relationship. Key studies by Calvete (2014) and Calvete et al. (2016) identify both bullying victimization and cyberbullying as predictors of EMS intensification. However, the most salient conclusion regarding interpersonal problems and EMS formation is Calvete et al.’s (2018) proposal of EMSs as a mediator between various interpersonal problems and bullying victimization, another increasingly common experience among transgender youth (Sares-Jäske et al., 2023; Gay, Lesbian, and Straight Education Network, 2020; Abreu & Kenny, 2018). The authors suggest EMSs may both result from and perpetuate interpersonal problems, and is supported by Tezel et al.’s (2015) study identifying EMSs as a mediator between childhood abuse and adult interpersonal styles. The relationship between interpersonal problems and EMSs is complex, likely involves dysfunctional parenting, likely manifests in higher intensity for transgender individuals, and may exhibit bidirectionality.

Further examining the cognitive implications of interpersonal problems, scholars debate the association of sexual, physical, and emotional abuse with EMSs. While several researchers associate abuse with EMS formation (May et al., 2022; Pilkington et al., 2021; Fathi et al., 2023; Zheng et al., 2022), not all scholars agree on the associative properties of each type of abuse. While Pilkington et al. (2021) and Fathi et al. (2023) suggest each type of abuse is associated with EMS development, and Sieński & Ziarko (2022) identify a positive correlation specifically between physical abuse and EMS intensity, Zheng et al.’s (2022) study does not find physical abuse to be associated with schema formation—indicating scholarly disagreement on the role of physical abuse in EMS development. While the impact of physical abuse on EMSs is called into question, Fathi et al. (2023) find emotional abuse/neglect exhibits the strongest association with EMS formation in comparison to physical and sexual abuse. Fathi et al.’s (2023) observation exhibits critical implications for the transgender experience; one study of transgender women in Rio de Janeiro, Brazil reported over 60% of participants experienced emotional abuse (Rafael et al., 2024). To contextualize the link between abuse and EMSs, EMSs are frequently described as a mediating variable—meaning abuse is a predictive variable of later psychological or interpersonal challenges only to the extent EMSs contribute to these later ailments (Estévez et al., 2016; Fernando et al. 2024; Zheng et al., 2022; Calvete, 2014; Da Costa et al., 2020; Mojallal et al. 2021; Gong & Chan, 2018). Such findings highlight the critical role of EMSs in the development of psychopathologies and advocate for further research examining the relationship between abuse and EMS formation.

Fortunately, a handful of scholars conduct explorative analysis to extensively characterize relationships between EMSs, abuse, and depressive symptoms. Through a two-wave longitudinal study of adolescents, Wang et al. (2023) find childhood abuse and neglect does not directly cause EMSs. Instead, the authors argue childhood abuse and neglect cause depression which then causes EMS formation. Interestingly, Wang et al.’s (2023) findings are similar to Calvete et al.’s (2013)—in an application of Hankin & Abramson’s (2001) cognitive vulnerability-transactional stress theory, Calvete et al. (2013) confirm bidirectional relationships between cognitions, stressors, and depressive symptoms in adolescents. Calvete et al. (2013) found this relationship occurs as follows: depressive symptoms and select EMSs predict an increase in stress—the stress and accumulated depressive symptoms then predict a worsening of the investigated EMSs. Furthermore, May et al. (2022) observe, in their study identifying a correlation between childhood abuse and EMSs, EMS formation may impact an adolescent’s ability to balance their needs of belonging and autonomy. However, Young et al. (2003) identified failure to meet a child’s basic needs as a primary factor resulting in EMS formation, further supporting the bidirectional model of EMS development. Such bidirectional potential between EMSs, stressors, and depressive symptoms may be exacerbated for the transgender community which experiences heightened levels of depression (Jäggi et al., 2018). Through complex research involving multivariable inquiry, Wang et al. (2023), Calvete et al. (2013), and May et al. (2022) highlight the possibility of the relationship between EMSs and their potential diatheses/stressors being more complex than simple correlation or causality.

While examining another variable’s potential relationship to EMSs, researchers also identify a link between traumatic experiences and EMS development, though this relationship is mostly explored indirectly. Though the trauma’s predictive validity toward EMSs may overlap with that of abuse, it should be noted this study utilizes abuse and trauma as distinct terms. While few scholars examine the specific relationship between trauma and EMSs in detail, several scholars identify links between trauma and psychological difficulties such as intensification of eating disorder symptoms (Fasolato et al., 2024; Meneguzzo et al., 2021), maladaptive interpersonal styles (Tezel et al., 2015), alexithymia (Feyzioğlu et al., 2023), general psychiatric symptoms (Da Costa et al., 2020), and complex post-traumatic stress disorder (Vasilopoulou et al., 2020) with EMSs as a mediating variable. Other than the identification of an association between trauma and EMSs, little can be concluded about the potential nuances of this relationship. However, future scholars should examine trauma and EMS formation through the lens of Hankin & Abramson’s (2001, as cited in Calvete et al., 2013) cognitive vulnerability-transactional stress theory which may provide insights on the established relationship between trauma and EMS formation.

In addition to traumatic experiences, a less-explored yet equally salient scholarly thread is the characterization of a link between personality traits and EMS development. Expanding upon the widely cited 5 Factor Model of Personality, Thimm (2010) identifies a positive correlation between neuroticism and EMS formation, and Ehsan & Bahramizadeh (2011) observe a negative correlation between agreeableness and presence of select EMSs. Brudek et al. (2023) take this inquiry a step further with their identification of EMSs as a mediator between the personality traits of neuroticism, negative affectivity, psychoticism, detachment, and an individual’s tendency to forgive. The mediating role of EMSs, as observed in Brudek et al.’s (2023) study, highlights the capability of select personality traits to impact EMS formation. However, one of the most intriguing investigations of personality in relation to EMSs is Calvete’s (2014) study which identifies both neuroticism and emotional abuse as predictors of EMS formation. Calvete’s (2014) study exhibits direct implications on this study’s model by identifying both a diathesis (personality, specifically neuroticism) and a stressor (emotional abuse) found to play significant roles in EMS development. Furthermore, preliminary study has identified disproportionately high scores on the clinical personality assessment tool Minnesota Multiphasic Personality Inventory (MMPI) among transgender people assigned male at birth (AMAB), indicating high levels of psychological vulnerability and increasing the likelihood of EMS development (Liu et al., 2024). The existing scholarly conversation surrounding personality and EMS development highlights a salient correlation and may exhibit unique effects on EMS formation in transgender women.

Due to the study’s focus on EMS development in transgender women, a need arises to discuss EMS formation within the context of queer studies. A foundational theory pertaining to mental distress in queer populations is the minority stress theory. First proposed by Ilan H. Meyer (1995), the minority stress theory states people of sociocultural minorities experience chronic stressors related to psychological distress (Meyer, 1995; Timmins et al., 2017). In context of transgender status, Hunter et al.’s (2021) findings suggest such psychological distress may manifest as heightened levels of depression, anxiety, and decreased mental wellbeing in comparison to cisgender individuals. This study proposes, within a diathesis-stress model examining the formation of EMSs in transgender women, minority stress is a significant component of the model which contains unique stressors. Such a conclusion is supported by Cardoso et al. (2024) who identify minority stress as a significant contributor to EMS development.

Minority stress theory identifies two main types of stressors, distal and proximal, and both must be investigated for an accurate diathesis-stress model. Distal stressors are defined as external experiences of discrimination, including familial and cultural rejection, bullying, harassment, discriminatory legislation, acts of physical aggression, medical mistreatment, verbal aggressions, and more, whereas proximal stressors constitute internal experiences such as internalized prejudice, expectations of rejection, stigma awareness, and feelings of needing to conceal one’s minority identity (Meyer, 2003; Breslow et al., 2015, Rood et al., 2016). Scholars identify proximal stressors specific to the transgender community, including gender dysphoria, concerns over passing, and body rumination, and internalized transphobia (Cardoso et al., 2024; Meyer, 2015). Furthermore, foundational scholar Meyer (2003) identifies proximal stressors as the result of distal stressors, and Jäggi et al. (2018) expands on this causal relationship by identifying proximal stressors as a mediator between distal stressors and depressive symptoms. Jäggi et al.’s finding, when applied to the cognitive vulnerability-transactional stress theory, highlights the potential for minority stress to result in EMSs, either directly (through proximal stressors) or indirectly (through depressive symptoms and distal stressors).

Methodology

To obtain a comprehensive review of relevant literature, this study obtained data through two key processes: computer database searches and manual searches. The computer database searches included Google Scholar (2010 to the present) and Lone Star Academic Search Complete, a function used to search dozens of databases (1962 to the present). Through Lone Star Academic Search complete, relevant studies from several databases, including Directory of Open Access Journals (DOAJ), JSTOR, and Education Resource Information Center (ERIC) were accessed. Through searches of Lone Star Academic Search Complete and Google Scholar, several relevant journals were accessed, including Journal of Social and Clinical Psychology, Current Psychology, International Journal of Environmental Research & Public Health, International Journal of Transgender Health, Clinical Psychology & Psychotherapy, Journal of Psychological Abnormalities in Children, Journal of Aggression, Maltreatment & Trauma, Journal of Preventive Counselling, Journal of Clinical Medicine, European journal of psychotraumatology, Cognitive Behaviour Therapy, Psychiatry research, Nöro Psikiyatri Arşivi, Brazilian Journal of Psychiatry, Journal of loss and trauma, Journal of child sexual abuse, Clinical Psychologist, Motivation and Emotion, Journal of American College Health, Advances in Cognitive Psychology, Journal of Health and Social Behavior, Psychology of Sexual Orientation and Gender Diversity, Transgender health, Clinical child psychology and psychiatry, and American Journal of Orthopsychiatry, among others. Relevant articles unable to be accessed were submitted though interlibrary loan (ILL) to the library at Lone Star College – Montgomery which obtained relevant studies from participating libraries around the State of Texas.

1962 was selected as the starting date due to the need to include Paul Meehl’s foundational contribution to the diathesis stress model, “Schizotaxia, schizotypy, schizophrenia,” while focusing primarily on recent literature. The study aims to compile recent literature in an application of the diathesis-stress model to the examination of EMS formation in transgender women. The keywords for the search consisted of: diathesis-stress, transgender women, minority stress, early maladaptive schemas, development, formation, mediate, personality, parent relationships, bullying, abuse, and adverse childhood experiences. In addition to Meyer’s (1995) foundational article and Young et al.’s (2003) manual, other salient studies have been identified, and manual searches of their reference lists were manually searched for relevant works.

To have been selected, each article must have met at least one of the following criteria: work contains information relating to EMS development, minority stress, transgender experiences, and/or the diathesis-stress model. Studies solely containing information on EMSs as a contributing factor to psychopathology that could not be connected to the cognitive vulnerability-transactional stress theory were excluded, alongside articles containing evaluations of minority stress theory and studies examining the transgender experience largely through a sociological perspective.

Results

This study examines factors contributing to EMS development in transgender women through an application of diathesis-stress model with an aim to promote awareness of psychopathological forecasters within queer populations. As one of the most widely cited interdiagnostic development models, the diathesis stress model proposes a person’s diatheses (predispositions) and stressors (adverse experiences) contribute to the formation of abnormal psychological states (Zuckerman, 1999). Regarding the formation of EMSs in transgender women, this study identifies select personality traits (neuroticism, low agreeableness, negative affectivity, psychoticism, and detachment) as diatheses and interpersonal problems, experiences of abuse, traumatic experiences, depressive symptoms, and minority stress as stressors. The identified diatheses and stressors are proposed to contribute to the formation of EMSs in transgender women.

Discussion

The most profound diathesis identified by this study is personality traits. As personality is thought to exhibit both inborn and learned characteristics (Spielman et al., 2020), personality is considered both a biological and psychological diathesis. Scholars identify several personality traits associated with EMS formation, including neuroticism, low agreeableness, negative affectivity, psychoticism, and detachment (Thimm, 2010; Ehsan & Bahramizadeh, 2011; Brudek et al., 2023).

In addition to the stated diathesis, this study identifies several key stressors, and each is likely to increase the chance of EMS formation. Among these are interpersonal problems, abuse, trauma, depressive symptoms, and minority stressors. Interpersonal problems, frequently manifested in the form of poor parental relationships, may exist in a causal relationship with EMS development (Başer Baykal & Erden Çınar, 2023), and EMSs and interpersonal problems may perpetuate each other. Emotional, sexual, and physical abuse have also been identified as contributing factors to EMS development, though scholars disagree over the role of physical abuse in EMS formation. Trauma is often related to psychological dysfunction with EMSs as a mediating variable, indicating that trauma exhibits a level of direct impact on EMS formation. Depressive symptoms exhibit the potential to result in EMSs, as is outlined in Hankin & Abramson’s (2001, as cited in Calvete et al., 2013) cognitive vulnerability-transactional stress theory which finds support from Calvete et al.’s (2013) study of adolescents. Additionally, minority stress is a unique and multifaceted stressor highlighting the distal (external) and proximal (internal) stressors transgender women commonly face due to their specific minority status. As noted at relevant points in the study, transgender women experience many of the identified diatheses and stressors at higher rates than their cisgender counterparts. Lastly, several of the works examined by this study identify EMSs as a mediator between a diathesis/stressor and a psychological consequence, indicating EMS formation exhibits predictive validity toward a multitude of disorders. The applied model can be visualized in Fig. 1.

Figure 1. Diathesis-stress Model of EMS Formation in Transgender Women

Note: Own work. An individual does not need to experience every diathesis or stressor to experience EMS formation. *There is scholarly debate over whether physical abuse contributes to EMS formation.

The applied model both builds upon and strengthens the minority stress proposal that gender minorities experience unique stressors related to psychological consequences. However, this research is limited to the extent it examines resilience factors, a key component of modern minority stress theory literature (Meyer, 2015) largely because the diathesis-stress model does not address resilience factors. Further study should evaluate the potential impact of resilience factors on EMS development. Expansions of the traditional model should also be considered; as Kendler et al.’s (2002) study on phobia development observed, the diathesis-stress model is not applicable to every psychological abnormality. Belsky and Pleuss’s (2009) differential susceptibility model may expand this study by considering both positive and negative environmental influences. Lastly, while the model identifies a greater number of stressors than diatheses, this finding should not be confused with greater predictive validity. Further research is needed to determine which diatheses and stressors exhibit the greatest predictive power of EMSs.

As outlined by minority stress theory, transgender women experience unique stressors pertaining to their specific sociocultural minority status. Such stressors may exacerbate the impact of already-present diatheses, encouraging the formation of EMSs. However, by improving legal, clinical, and social acceptance of the LGBTQ+ community, EMS formation in transgender women may be mitigated—improving mental health outcomes for queers and allies alike.

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