Comparison of the Effectiveness of Shame-Awareness Therapy and Cognitive-Behavioral Therapy on Self-Regulation Behaviors and Psychological Symptoms in Adolescent Girls with Gender Dysphoria

Introduction

Adolescence and young adulthood are considered some of the most critical periods of life due to the significant personality and physiological changes they entail, which constantly challenge the individual to adapt to new situations (Schroek, 2019). The term "gender dysphoria" in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) refers to a distress that may arise from the incongruence between an individual’s experienced or expressed gender and their assigned sex. Although not all individuals experience distress from this incongruence, many do if they do not receive appropriate physical interventions, such as hormone therapy or surgery. It is noteworthy that this term was previously referred to as "gender identity disorder" in the fourth edition of the DSM (American Psychiatric Association, 2013).

Self-regulation is a process through which an individual monitors their behavior, judges it against their own standards, goals, and criteria, and adjusts their behavior based on the outcome of that judgment (McAllister et al., 2018). Bandura (2005) asserts that self-regulation is crucial for health improvement and control. He suggests that individuals are continuously guided by their behavior. Therefore, accurate monitoring and regulation of behavior towards achieving health can be effective, and its absence may lead to health problems. Humans guide their behavior by controlling and regulating their challenging goals, mobilizing resources, and striving to achieve them. In fact, any deficiency in self-regulation can make an individual vulnerable to stress and psychological disorders such as depression and anxiety (Bandura, 2005).

Various therapeutic approaches have been adopted to treat depression, anxiety, and stress in patients with gender dysphoria, among which cognitive-behavioral therapy (CBT) is one of the psychological interventions. CBT is a form of psychotherapy that helps patients understand the thoughts and feelings influencing their behavior. CBT is currently used to treat a wide range of disorders, including phobias, addiction, depression, and anxiety (Beck, 2013). CBT is generally short-term and focuses on helping patients address a specific problem. During therapy, the individual learns how to identify and change destructive or disturbing thought patterns that negatively influence behavior (Beck, 2013).

Another emerging therapeutic method in psychology is shame-awareness therapy. Shame is defined in the Merriam-Webster Dictionary as a painful feeling arising from the consciousness of guilt, shortcoming, or impropriety, which can alternatively lead to disgrace or dishonor. In psychological terms, shame is referred to as anger directed at oneself (Erikson, 1950) or feeling bad about oneself (Tangney, Wagner, Hill-Barlow, Marshall, & Gramzow, 1996). Nathanson (1993) described the "compass of shame" as an indicator of four typical sets of instructions for managing the painful experience of shame. A single shaming incident can be sufficiently traumatic to cause more harm than a series of repeated but milder experiences. Indeed, other studies have shown that any significant and traumatic shaming event in the past, especially those occurring in childhood, can make individuals more prone to feelings of shame than others (Edmond Ng, 2021). Research on the impact of cognitive-behavioral therapy, shame-awareness, body image, self-esteem, and psychological symptoms is limited, but related studies can be mentioned. For example, cognitive-behavioral therapy was investigated for improving negative body image in individuals with this disorder in the study by Cash (2004). Lima (2007) and Barker (2008) explored the relationship between shame-awareness and explicit and implicit self-esteem and narcissism.

Findings by Mohammadi and Sajadi Nejad (2007) indicate a relationship between self-esteem and body image dissatisfaction. Asgari and Shabaki (2010) found in a study that students with high and low body image differed significantly in terms of quality of life, life satisfaction, sexual role attitudes, and self-esteem. Therefore, understanding cognitive-behavioral therapy and shame-awareness in relation to body image and self-esteem in adolescent girls with gender dysphoria is essential. Given the prevalence of psychological distress among adolescent girls with gender dysphoria and its negative effects on their self-esteem and body image, it seems that providing psychological services in the form of therapeutic strategies such as cognitive-behavioral therapy or shame-awareness can be beneficial in enhancing self-esteem and psychological symptoms in adolescent girls with gender dysphoria. Accordingly, the main objective of this study is to answer the question: Does cognitive-behavioral therapy and shame-awareness therapy affect self-regulation behaviors and psychological symptoms in adolescent girls with gender dysphoria?

Methods and Materials

Study Design and Participants

The present study is a quasi-experimental study with a pre-test and post-test design involving two intervention groups. The statistical population of the research includes all girls who sought treatment at various healthcare centers in the city of Zahedan due to concerns about gender identity. These centers include forensic medicine, the unit supporting patients with gender dysphoria within the Welfare Organization, specialized psychology and psychiatry clinics, and general surgery specialists operating in this field. To select the sample, visits were made to the main clinics and counseling centers across Zahedan, and 36 adolescent girls were selected based on entry criteria. According to Cohen's table, to examine and compare the two groups, considering the minimum required test power, a medium effect size, and a 0.05 error probability, 12 participants per group were considered, and the allocation of individuals to the three groups, as well as the type of intervention in the groups, was done randomly. Thus, the sample size of 36 participants (12 for each of the experimental and control groups, with each group consisting of an equal number of adolescent girls with gender dysphoria) was selected through purposive sampling after meeting the entry criteria. The entry criteria included no concurrent psychological interventions, absence of specific physical illnesses, adolescent girls aged 12-18 years, parental consent to participate in therapy sessions, no psychiatric medication use, and a psychiatrist's confirmation of gender dysphoria for all girls with the condition. Exclusion criteria included missing more than two sessions and unwillingness to continue participation.

Measures

Psychological Symptoms

The Depression, Anxiety, and Stress Scale was developed by Lovibond and Lovibond in 1995 to measure depression, anxiety, and stress and consists of 21 items. The DASS-21 includes three subscales, each comprising seven items, with the final score for each subscale being the sum of the corresponding items (see Table 1). The scoring method ranges from 0 (does not apply to me at all) to 3 (applies to me very much). Since DASS-21 is the short form of the original 42-item scale, the final score for each subscale should be doubled. The severity of symptoms can then be determined by referring to the corresponding table. Lovibond and Lovibond (1995) reported a validity of 0.77 for the DASS-21. The Cronbach’s alpha obtained in this study was 0.81.

Self-Regulation

To measure self-regulation, the Brown, Miller, and Lawendowski (1999) Self-Regulation Questionnaire was used. This questionnaire contains 63 items and is designed to assess self-regulation processes through self-report. The questionnaire measures seven components: receiving appropriate information, evaluating information and comparing it to norms, directing changes, seeking options, planning, executing the plan, and evaluating the effectiveness of the program. Scores on this questionnaire range from 63 to 315. Brown, Miller, and Lawendowski (1999) reported the reliability of the questionnaire through test-retest and Cronbach’s alpha as 0.94 and 0.91, respectively, for alcohol users. They also established concurrent validity with alcohol consumption measures and found a negative and significant correlation between self-regulation and alcohol consumption in a specific situation. A score of 239 or above on this questionnaire indicates high self-regulation, 214-238 indicates moderate self-regulation, and a score of 213 or below indicates low self-regulation capacity. The Cronbach’s alpha obtained in this study was 0.85.

Measures

Shame-Awareness Therapy

Shame-awareness therapy is designed to help individuals recognize and process feelings of shame that may be contributing to psychological distress. The intervention aims to increase self-awareness and emotional understanding, ultimately helping individuals manage their feelings of shame more effectively. The therapy consists of 13 sessions, each focusing on different aspects of shame, its sources, and its impact on relationships, culture, and daily life. The intervention is structured to progressively build on each previous session, leading to a comprehensive understanding and management of shame by the end of the program.

Session 1: Introduction and Pre-Assessment

In this initial session, the goal is to establish a connection among group members and introduce the concept of shame-awareness therapy. The session begins with a group introduction, followed by the setting of ground rules and session guidelines. The participants are then guided through exercises designed to promote self-awareness and mutual understanding. A pre-assessment is conducted to establish a baseline for each participant’s current state of self-regulation and psychological symptoms.

Session 2: Understanding Shame and Useful Shame

This session focuses on differentiating between harmful and useful forms of shame. Participants explore the general inadequacies of the body and the manifestation of shame in their behaviors. The session highlights how certain levels of shame can be constructive, particularly in maintaining healthy relationships.

Session 3: Functions of Shame

Participants delve into the various functions of shame, including how shame-centric individuals perceive their world. The session also addresses the consequences of a lack of shame, such as destructive behaviors, and explores the concept of shame spirals.

Session 4: The Deficiency and Absence of Shame

This session examines the role of shame in anger, denial, and perfectionism. It also looks into how individuals with excessive shame tend to withdraw and how a lack of insight into shame can lead to shameless behavior.

Session 5: Sources of Shame

Participants explore the origins of shame, particularly those stemming from early childhood experiences. The session discusses the long-lasting impact of shaming experiences during upbringing and how these feelings of shame influence family dynamics.

Session 6: Shame-Inducing Relationships

This session focuses on recognizing and managing shame-inducing relationships in everyday life. Participants learn to identify signs of shaming in their interactions and how power dynamics can perpetuate feelings of shame.

Session 7: The Role of Shame in Culture

The influence of culture on shame is explored, particularly how success orientation and societal emphasis on appearance can contribute to shame. The session also discusses the phenomenon of organizational shaming.

Session 8: Shame-Inducing Thoughts

Participants learn to recognize shame-inducing thoughts that lead to withdrawal, criticism, and self-hatred. The session provides strategies for addressing these negative thought patterns.

Session 9: Healing Shame Injuries

This session is dedicated to identifying solutions to shame-related issues. Participants gain awareness of their shame triggers and learn strategies to heal from shame-related injuries.

Session 10: Overcoming Shame

In this session, the focus is on overcoming shame through acknowledgment, self-reflection, and behavioral changes. Participants learn to recognize denial, withdrawal, arrogance, and aggression as defense mechanisms against shame and how to move beyond these behaviors.

Session 11: Healing Shame in Families

Participants explore strategies for healing shame within family systems. The session emphasizes the importance of creating supportive relationships both within the family and in professional environments.

Session 12: Managing Shame in Daily Relationships

This session teaches participants how to manage shame in their daily interactions by fostering calmness, respect, and self-worth. Practical exercises help reinforce these concepts.

Session 13: Review and Post-Assessment

The final session reviews all the concepts covered throughout the therapy, provides practice opportunities, and conducts a post-assessment to measure progress. The session concludes with reflections on personal growth and future steps.

Cognitive-Behavioral Therapy (CBT)

Cognitive-Behavioral Therapy (CBT) is a structured, short-term psychological intervention that focuses on altering negative thought patterns to improve emotional regulation and develop personal coping strategies. This intervention comprises 12 sessions, each addressing specific cognitive and behavioral issues. Through this process, participants learn to identify, challenge, and change destructive thoughts and behaviors, ultimately enhancing their ability to manage stress, anxiety, and depression.

Session 1: Introduction and Pre-Assessment

The initial session introduces participants to the CBT framework and establishes group rapport. The session involves explaining the structure of the sessions, setting group rules, and understanding each participant's initial mental state through a pre-assessment.

Session 2: Thoughts, Feelings, and Behaviors

This session explores the distinctions between thoughts, feelings, and behaviors. Participants learn to identify cognitive distortions (thinking errors) and are introduced to techniques for recognizing and addressing automatic negative thoughts.

Session 3: Cognitive Restructuring

The session focuses on the cognitive restructuring technique, where participants learn to identify, evaluate, and modify distorted thoughts. They practice changing their thoughts and assess the impact of these changes on their emotions and behaviors.

Session 4: Behavioral Chains and New Behaviors

Participants learn about the concept of behavioral chains and how new behaviors can be introduced and reinforced. The session provides strategies for creating and maintaining positive behavioral changes.

Session 5: Assertiveness Training

This session teaches the concept of assertiveness and its types. Participants explore the benefits of assertive behavior and the negative consequences of passive or aggressive behaviors. Practical exercises help participants develop assertiveness skills.

Session 6: Impulsivity, Self-Control, and Mood Regulation

The focus of this session is on understanding and managing impulsivity. Participants learn self-control techniques and cognitive strategies to regulate their mood positively.

Session 7: Stress Management and Problem-Solving

Participants are introduced to various coping strategies for managing stress. The session distinguishes between problem-focused and emotion-focused coping strategies and discusses ways to enhance self-esteem.

Session 8: Self-Esteem Enhancement

This session defines self-esteem and explores the impact of low self-esteem. Participants are provided with strategies to improve self-esteem and practical exercises to reinforce these concepts.

Session 9: Gender Concepts and Expression

Participants are educated about gender concepts and the impact of societal beliefs on gender identity. The session includes identifying and challenging irrational beliefs related to gender and learning healthy ways to express gender identity.

Session 10: Catastrophic Thinking and Cognitive Reframing

This session addresses the identification of catastrophic thoughts and associated physical reactions. Participants learn relaxation techniques and practice reframing ineffective self-talk into productive thoughts.

Session 11: Imaginal Exposure and Gradual Confrontation

Participants engage in imaginal exposure exercises, where they process traumatic experiences and practice gradual confrontation of distressing situations. Coping strategies are developed and rehearsed.

Session 12: Review and Post-Assessment

The final session consolidates the skills learned throughout the therapy. A post-assessment evaluates progress, and participants are encouraged to reflect on their journey and discuss future goals.

Data analysis

To analyze the data obtained from the above questionnaires, descriptive statistics were used to calculate frequency, percentage, mean, standard deviation, and standard error of the data. Then, inferential statistics were applied to perform multivariate analysis of covariance (MANCOVA) using SPSS 22 software.

Findings and Results

The results indicate that 44.4% of the target population is between 12 to 14 years old, and 22.3% are between 17 to 18 years old. The majority of the target population, 41.6%, are enrolled in the first stage of secondary education. Based on the collected data and analysis using statistical software, the most important central indices of the research variables are presented in Table 1.

Initially, the Shapiro-Wilk test was conducted to determine whether the data were normally distributed, which informed the decision to use parametric or non-parametric tests. The results of the Shapiro-Wilk test for the research variables indicated that the distribution of variables was likely normal. To examine the impact of shame-awareness therapy and cognitive-behavioral therapy on the psychological symptoms and self-regulation behaviors of adolescent girls with gender dysphoria, an analysis of covariance (ANCOVA) was conducted. The results of Levene’s test indicated homogeneity of variance for body image scores across groups. There was no significant difference in the regression slope of the dependent control variable between the two groups. The ANCOVA analysis focused on the residual scores of the dependent variable; the presence of a slope difference in the residual scores would render the dependent variable's status illogical and meaningless. The interaction of independent and covariate variables was non-significant, suggesting that the assumption of homogeneity of the regression slope was met.

As observed in Table 2, there are significant differences in psychological symptoms and self-regulation behaviors among the three intervention groups: shame-awareness therapy, cognitive-behavioral therapy, and the control group. To compare the effectiveness of shame-awareness therapy and cognitive-behavioral therapy with the control group on psychological symptoms and self-regulation behaviors, and to compare the experimental groups with each other, a Bonferroni post hoc test was conducted. The results are presented in Table 3.

The Bonferroni post hoc test results in Table 6 show that the mean psychological symptoms in the shame-awareness therapy and cognitive-behavioral therapy groups are significantly lower than those in the control group. Significant differences in mean psychological symptoms between the shame-awareness therapy and cognitive-behavioral therapy groups were found in the anxiety and stress components. This indicates that shame-awareness therapy and cognitive-behavioral therapy reduced psychological symptoms compared to the control group, with shame-awareness therapy being more effective than cognitive-behavioral therapy in reducing anxiety and stress. The mean self-regulation behaviors in the shame-awareness therapy and cognitive-behavioral therapy groups were significantly higher than in the control group, but there was no significant difference between the two experimental groups. This suggests that both shame-awareness therapy and cognitive-behavioral therapy increased self-regulation behaviors compared to the control group, with no difference between the experimental groups.

Discussion and Conclusion

The results show that the mean psychological symptoms in the shame-awareness therapy and cognitive-behavioral therapy groups are significantly lower than in the control group. Significant differences in mean psychological symptoms between the shame-awareness therapy and cognitive-behavioral therapy groups were found in the anxiety and stress components. This indicates that shame-awareness therapy and cognitive-behavioral therapy reduced psychological symptoms compared to the control group, with shame-awareness therapy being more effective than cognitive-behavioral therapy in reducing anxiety and stress. The mean self-regulation behaviors in the shame-awareness therapy and cognitive-behavioral therapy groups were significantly higher than in the control group, but no significant difference was observed between the experimental groups. This suggests that both shame-awareness therapy and cognitive-behavioral therapy increased self-regulation behaviors compared to the control group, with no difference between the experimental groups.

No previous research has directly compared the effectiveness of shame-awareness therapy and cognitive-behavioral therapy in improving self-regulation behaviors in individuals with gender dysphoria. However, the findings of this study are consistent with previous research by Ali Mahdi (2023), Khoshab et al. (2020), and Zabihollah Zadeh et al. (2019), which separately examined the effectiveness of these therapies on related variables. The study's findings demonstrate that shame-awareness therapy and cognitive-behavioral therapy positively impacted all seven stages of self-regulation. In the acceptance stage, which is the first stage of self-regulation, individuals receive information about their current state from the environment. This information can attract individuals' attention to themselves and serve as motivation to initiate self-regulation. Additionally, a significant increase in the execution stage indicates that the experimental group members were able to engage in the implementation of their plans.

Overall, while individuals consistently create plans for themselves, some struggle to execute these plans, particularly individuals with gender dysphoria. As such, shame-awareness therapy and cognitive-behavioral therapy have successfully influenced the execution of pre-determined plans in the experimental group. It appears that these therapies impacted the execution phase of the self-regulation process and the persistence in achieving goals by modifying thoughts and beliefs related to self-efficacy and motivation. Furthermore, shame-awareness therapy and cognitive-behavioral therapy were effective in the intermediate stages of self-regulation, which involve resolving conflicts between the current and ideal states and planning to achieve the ideal state. For the intermediate stages of self-regulation, additional skills in executive strategies and cognitive constructs, beyond mere belief in abilities, may be required. It seems that supplementary training programs, such as teaching goal-setting and planning strategies alongside shame-awareness therapy and cognitive-behavioral therapy, could be beneficial.

While no previous research directly compares the effectiveness of shame-awareness therapy and cognitive-behavioral therapy in improving self-regulation behaviors in individuals with gender dysphoria, the findings of this study align with previous studies by Yousefi (2020), Avasti and Salehi (2020), Rezaei et al. (2020), Pirayeh, Mohseni, and Ghanei Farid (2017), Latifian (2017), and Oost, Schuling, and Graven (2021). These studies suggest that shame-awareness therapy and cognitive-behavioral therapy are effective in reducing clinical symptoms of anxiety, stress, and depression, which are prominent features of individuals with gender dysphoria. Cognitive-behavioral therapy emphasizes the usefulness of thoughts and cognitions in guiding emotions and promoting positive moods, which contribute to achieving favorable outcomes. The approach asserts that motivated individuals perform well, view events differently, and do not perceive failure negatively, considering it an important factor for achieving results. Individuals can improve their motivation and behaviors by controlling their thoughts.

Given the numerous stimuli that individuals with gender dysphoria frequently encounter, motivation significantly impacts their improvement. When motivation decreases, individuals experience severe anxiety and stress, which cognitive-behavioral techniques can mitigate by preparing individuals psychologically. Tannay, Loutan, and Bernstein (2012) conducted extensive and comprehensive studies to review the effectiveness of shame-awareness therapy and cognitive-behavioral therapy in reducing anxiety and stress, finding that these programs effectively reduce stress and anxiety. Therefore, by helping individuals better understand themselves and experience a non-judgmental attitude, shame-awareness therapy and cognitive-behavioral therapy increase individuals' awareness of their relationships and improve their social interactions, thereby positively influencing interpersonal behaviors.

In summary, shame-awareness therapy and cognitive-behavioral therapy in individuals increase awareness of conditions, which in turn reduces anxiety and stress. Moreover, these interventions address common sources of anxiety, stress, and depression in this group of adolescents, promoting more conscious responses to stressful and anxiety-inducing situations. The concepts taught in these sessions reduce the negative effects of stress and anxiety, and creating lists of irrational thoughts and desires aids in better understanding the thoughts that trigger anxiety.

Limitations & Suggestions

This research was conducted on individuals with gender dysphoria in Zahedan, so caution is advised when generalizing the results to other populations. Additional limitations include the small sample size and the use of self-report questionnaires to measure research variables, which can introduce response biases. It is recommended that this research be conducted on male participants as well. It is also suggested that this research be conducted across different age groups, and the results compared. Given that many individuals with gender dysphoria seek counseling services, it is recommended that psychologists specializing in psychological treatments be stationed in these centers to assist individuals in achieving successful treatment outcomes. For individuals with gender dysphoria who struggle with body image issues, shame-awareness therapy and cognitive-behavioral therapy should be considered a priority. Given the stronger effectiveness of shame-awareness therapy compared to cognitive-behavioral therapy in cases of anxiety and stress, shame-awareness therapy is recommended. However, considering that successful treatment should cover all aspects of the individual, using both therapies in combination could be beneficial in empowering individuals, if feasible and welcomed by the client. The results suggest that shame-awareness therapy and cognitive-behavioral therapy can be used to enhance self-esteem, allowing individuals to build on areas that contribute to increased self-esteem.

Acknowledgments

We would like to express our appreciation and gratitude to all those who cooperated in carrying out this study.

Declaration of Interest

The authors of this article declared no conflict of interest.

Ethical Considerations

The study protocol adhered to the principles outlined in the Helsinki Declaration, which provides guidelines for ethical research involving human participants.

Transparency of Data

In accordance with the principles of transparency and open research, we declare that all data and materials used in this study are available upon request.

Funding

This research was carried out independently with personal funding and without the financial support of any governmental or private institution or organization.

Authors’ Contributions

All authors equally contributed in this article.