Psychotraumatology of Images in Gender Dysphoria

The study proposes a psychodynamic analysis of the traumatic role of mental images, that can be expressed by many conditions; in phenomenology, the psychic relationship is meant as the relationship between subject and object. The analysis is aimed at understanding how representations are relevant.Representations are distinguished as the possibility of intrinsic trauma and as inherently deferred in the conflict between sexual-biological identity and gender-psychological identity; our work aims to highlight how internal images affect adaptation processes.The analysis involves the study of 10 Rorschach protocols of Gender Dysphoria subjects in Male to Female transition; the protocols are analyzed through the studies of N. Raush de Traubenberg, with reference to the Self and Body; a psycho-traumatological and phenomenological analysis of imaginal experiences will be proposed.From the analysis emerges the presence of Self and Body representations affected by a partial and fragmentary prevalence of contents, the presence of psychotraumatic phenomena associated to the processes of introjection and identification of mental representations.The knowledge of the presence of affected representations and psycho-traumatological outcomes would be useful for a psychodiagnostic and psychotherapeutic purpose, intended for the implementation of the adaptation process.


INTRODUCTION
The dynamic of the study aims to highlight the intrapsychic characteristics of the representational world of ten subjects with Gender Dysphoria by attributing and recognizing the right importance to the role of thing-representation.The thing-representations [1] are meant as unconscious images of a multisensory origin that performs their function in the absence of the object.It takes on meaning in the subject's need to represent internment object.Through the link with the word-representation they constitute the tissue of thought.This approach is configured from its origin [2] as the possibility of combining the phenomenon (representation) with the psychic apparatus.
In fact, they could be considered as the basis for the possibility of trauma that hinders the elaboration of identification processes between biological and psychological events.The multidisciplinary approach of clinical psychology responds to the needs of knowledge and comprehension in the areas of mental functioning, whether it is typical or abnormal.The study is about Gender Dysphoria which refers to those who experience the strong and persistent cross-gender identification phenomenon and non-conformities with their sexual identity [3].
From the historical point of view and evolution of the nomenclature, the current version of DSM-V [4] provides a substantial difference compared to the previous edition [5], where the focus is centered on the subject's experience of discomfort.Compared with the previous nosographic inclusions, the present consideration is referring, instead to the condition of dysphoria.The "umbrella" concept of transsexuality from Hirschfeld [6] has been currently abandoned due to growing interest in psychological aspects.
Beyond the nosographic framing, the study of this phenomenon presupposes the consideration of the dynamic components involved in the psychic functioning and experience of the subject [7].The entire phenomenon, in fact, predicts the discrepancy experienced among the components of sexual identity, gender identity and social role [8].We refer to sexual identity based on the biological sex at birth and genetically determined [9].Gender Identity is referred to an identification which produces conscious beliefs [10], a persistent and self-identifying perception with dynamics of the male and female sex [11].The social role can be understood through the function of identity, which is a central theme in expectations, emotional reactions and approaches imposed directly and indirectly by society [12].With regard to this latter phenomenon of social interaction, it is possible to understand a series of phenomena, such as stigmatization, arising from the binary sexual conception [13], an outcome typically reflected in the subjective experience of patients with Gender Dysphoria.The opportunity to study phenomena related to Gender Dysphoria provides the possibility of comprehension of internal dynamics, investigated in this case through interpretative phenomenology.
Multifactorial genesis takes into account the different dynamics involved, such as the presence of trauma, and this leads us to reflect on the peculiar features that this event can take with reference to the phenomenology of Gender.In fact, the mental representation and emotions have a fundamental role.The hypothesis of this study suggests that the psychotraumatic role of images, also considered in an intrinsic sense or traumatic role, could provide harm to more global representations.Therefore, it could be considered as relevant to the existing discrepancy between sexual identity and gender identity, being so powerful it leads the subject to sexual reassignment surgery.
The subjectivity of the image suggests that the study should use refined methods that can evoke symbolic images which can be analyzed and compared to scientific literature.The study of images expected is then compared with the obtained images in our clinical experience.To support phenomenological understanding, it is necessary to suggest a discussion that allows us to classify the components involved.
It is important to clarify that from the phenomenological point of view we see an important difference between perception and representation.This difference will be studied in the phases of transition from perception to representation.The different approaches, based on the interpretive phenomenology, are studied in depth with the complexity of typical and abnormal manifestations.
The particular essence of mental images is considered relevant to psychopathology in their relationship with emotions [14], meaning images can evoke emotions in several different ways.
They have a direct influence on the emotional systems of the CNS, sensitive to sensory signals and perceptive to the ability to come in contact with emotional traits linked to past episodes.Therefore, they become representations related to unconscious dynamics.
Compared to this latter point, the driving force of studying the subjective psychopathological experience is the image considered as a form of knowledge [15].Therefore, since physical phenomena have been experienced by the subject and perceived through the five senses, they become psychic phenomena and representations, belonging to the subject's mind [16].
Through phenomenological psychology image and mind can express their inextricable co-belonging [15].The phenomenology which has the main target of making the person's moods visible and evident [17] distinguishes the representation from perception [18].Thus through the psychoanalytic point of view, it becomes possible to consider it as a thing-representation, related to word-representation, both having an emotional charge.Emotional representation, as a result, translates into perceptual sentiments, processes and modifications (1).In terms of clinical and hermeneutic analysis, projective methods are therefore instruments or stimuli which intend to generate verbal or graphic results, expressive of the subject's mental activity.From a neuropsychological point of view, emotional expenditure aimed at response and gesture can be understood in the view of mentalization.This process combines the deep and ancestral properties of the archicortex with the most recent neocortical activities.This process unifies an emotional adaptive potential to neocortical potentials, whose purpose is symbolic and elaborative.The complexity of functioning and the psychic manifestations come from their inter-retroactive relations.
Morin's [19] concept of inter-retroactivity suggested in the field of complexity, could be considered to show how an effect can retrograde to the cause.It can help us to understand the relationship between mental representation and affectivity.In this case, since the effect is necessary for the cause we could refer to this relationship also in terms of autopoiesis [20].It could be defined as the ability of a complex system to maintain its unity and its organization through the mutual interactions of its components.By accepting the authenticity of complex thinking, it is quite clear that mental representations are not only interretroactive but also autopoietic.This emerging relationship has implications for the framework-person system.
It is intended to clarify that the desirable linearity to deterministic scientific approaches is difficult to reconcile with the variability and the emergencies of the mind.In this sense, as a phenomenon that is continuously evolving, the mind is considered as an emerging set of meanings.It is different from the simple summation of the parts.The psychological duty in the clinical field is decoding to the study of phenomena, directed towards order and knowledge, in line with evolutionary, comprehensive and complex trends.A model of psychic functioning, thought to be appropriate for understanding, allows us to understand the basic relationships between older (archicortex) and more modern (neocortex) structures, whose manifestations need to be understood in a complex way.It is therefore necessary to understand that in the same way that the substance manifests itself through relationships, the relations may have a retroactive effect.This retrospective optic is necessary in order to study manifestations that do not exclude the substance.

MATERIAL AND METHODS
The study presents the analysis of Rorschach's [21] representations of 10 subjects with Gender Disphoria.The study is then extended to more global representations, such as the Self and Body [22,23], and to particularly significant representations exemplifying the psychotraumatic perspective, studied through a phenomenological interpretative and psychodynamic approach.
The above mentioned representations are thoroughly compared with the state of the art literature.What is known in the literature as Expected Images will be compared to Expressed Images from our patients.The need for adherence to the method expresses view that would reduce the misunderstanding, in acquiring the factual data [18].Such a need for us-is carried out by the Rorschach method [21] and in the analysis of the dream.They enable us to develop and order knowledge adhering to the method by which they were acquired [24].In this sense the need for adaptation is met, as in the Projective Methods: assumes its value in the quality of the response and in what it expresses.Abstinence and rejection are also significant to the proper answer offered by the mind, as the significance of the impossibility of promoting the adaptive process of mentalization.
For psychotherapy, approaching the image may suggest a further form of understanding the subject's behavior.Compared to direction and origin, phenomenology suggests that even in cases where experience seems to be the explicit etiopathogenesis, the complex effects are as understandable as deeply-rooted in the past.The opportunity to capture subjectivity is supported by a horizontal a method based on pareidolia's phenomenology [18].It could be considered as an external sensory stimuli combined with elements reproduced in a unit so that direct ones cannot be distinguished from those reproduced.
The tradition of the Rorschach method, which has been in clinical practice for almost a century, is for us hermeneutical, inclusive, and analytical.Therefore, the image can provide us with those archaic elements that co-exist in psychopathological momentum, giving us the character of existence to the phenomena [25].
A methodology that suggests to us not only single representations linked to the diagnostic meaning, but to a more global approach, refers to the works of Nina Rausch de Traubenberg [22,23].

The Study of the Representation of the Self and the Affective Dynamics of Body Image [22, 23]
-Rausch de Traubenberg's Self-Representation Grid [22], thanks to our specific use of the first column, allows us to study hierarchically the responses to their content.
In the specific case, the hierarchical order in the Human World, Animal World, and Inanimate World allows us to find out how the subject is represented.Human representations are qualitatively better and need more energy in their major and massive investment to elicit a response starting from their own internal representations.
-The Grid of Affective Dynamics and the Body Image [23], allows us an analysis of body representation through the contents of Rorschach based on image quality, in which the best possibility is integrity.The categories provided by the grid refer to the determining qualities of the answer: -Integrate, for images that appear as complete representations, providing clear indications of a good quality answer; -Reached / Attested, for those representations that, although starting from a partial tendency, reach an integrity that must take the origin into account the; -Partial, whose expressiveness remains linked to the lack of entirety with the related diagnostic implications; -Fragmentary, understandable not only as not integrated, but as a part of a set whose function or existential sense cannot ignore the integrative contact between the parts, in the specific cases separated as in spaltung.
The prevalence of partiality and fragmentation on the integrity of the image would be consistent with the phenomenon described above.
The paper proposes a centralized analysis of the dynamics of global Self-Representation dynamics, the dynamics of the Representation of the Body and the study of individual answers.It is linked to the diagnostic meaning of the tables and the intrinsic phenomenology in comparison with the knowledge in the literature.In this regard, the study of psychotraumatology at Rorschach suggests different determinants and content elements, typical of traumatological images.

As Suggested Before, the Role of the Effects Created by the Traumatic Images Could be Considered as a Key Variable in Understanding Clinical Conditions, Continuing to Disturb the Individual in the Self-experience During the Entire Life [26]
The studies of Gravenhorst [27], in the evolutionary field, suggest that the following elements are particularly relevant to detect traumatic experience at Rorschach: 1) Low number of responses, which do not invalidate the diagnosis, and as associated with traumatic experiences.
2) F% within the expected range, indicating Ego efforts to be objective and logical.
3) F+%.Low as a non-operative function of the Ego, with the failure of recognition and adaptation function.4) MD (multiple determinants) increased as a crisis indicator.5) Conflicts (conflict index related to Erlebnistypus) increased, indicating not only crisis, but intense conflicting charge, with the possibility of imbalance or risk.VI, responses referring to the traumatic experiences associated with sexuality.

6) In Table
7) Skeletal content, as a melancholy element.
8) Disturbances associated with responses of blood content, that may appear in people who have experienced other traumatic situations such as accidents or wars.9) Direct sexual responses, due to the failure of the suppression mechanism.
13) Presence of the following special phenomena known as MOR (premorbid content), to identify a damaged, destroyed, broken or dead object.
On the basis of the clinical experience and the literature proposed, the phenomenology will provide us a clearer significance of Gender Dysphoria.The meaning and the sense that subjects need to improve their state of health, should not be just related to an analysis.The discussion will express the results and data in a way that would expand what is necessary for each style of existence and a general knowledge.

RESULTS
As suggested in the previous discussion, the results proposed by studying the 10 Rorschach Protocols of Gender Dysphoric patients, will consider the expressed images.The same results will be discussed below related to (Table 1): Self-Representation Grid, for each protocols and mean values; Grid of Affective Dynamics of the Body, and in terms of the phenomena of responses to individual protocols; The predominance of object-content responses suggests, as supported by the studies of Rausch de Traubenberg, that the representations of the Self of our subjects in analysis are currently inflicted (Table 2).The high fragmentation of the images and the presence of partiality suggests that the current state of the body image interferes with the affective and representational dynamics of subjects.This is to say that the role of object-relations and fragmentation can be considered as intervening in the process of projection of internal representations.This phenomenon produces a weak bodily function, in line with the dynamics of Gender Dysphoria useful to understand the discrepancy between Sexual Identity and Gender Identity.

Psychotraumatology of Images
The Open Psychology Journal , 2018, Volume 11 229 Below are the significant responses to the indexes suggested.
The Table 3 and 4 report the answers given to the Rorschach test's tables.

Psychotraumatology of Images
The Open Psychology Journal , 2018, Volume 11 231 Data analysis suggests the quality of the responses obtained at Rorschach by the ten Gender Dysphoric examined patients.Specifically, the analysis focused on the total number of responses, F determinants, F+ responses and type of Erlebnistypus.

DISCUSSION
The property of images, to become more global and more complex in Self and Body representations, suggests to us to analyze them in relation to the protocols of the assisted patients.In the present case, two dimensions of representation are particularly interesting and specifically related to the phenomenon of Gender.The most relevant facts are the evolving identity processes, in agreement or discrepancy [28].The study of the Self-representation, supported by the tradition of Rausch de Traubenberg's studies, shows in fact the underlying prevalence of responses belonging to the inanimate world domain (57.7%) compared to the little more mature and integrative representations of the animal world (32.2%) and finally the less represented in the human world (10%, 1%).These dynamics, could suggest a strong indication of how the affective investment is relevant.The prevalent low emotional-affective investment related to inanimate and even animal domaines instead of directing more affective energy to human representations, provides a clear indication of their compromised representation state.
The second dynamic considered as the Body Representation, is a central element in Gender Dysphoria: the discrepancy between the biological and genetically determined sexual identity and the psychic gender identity, takes on an intervention that is quite definitive, far from the psychological matrix of discomfort.The resolution of the conflict, in fact, usually involves the use of surgical sex reassignment.The physic state has a powerful role within the subject's mind, in phantasmatic terms phenomenologically representative.The dynamics of the body's representation show that fragmentation (29,1%) and object partiality (10,1%) go beyond the attempts to reach integrity (24,4%) and the integrity of the image (37.3%).This condition of suffering, seen through the powerful discrepancy, allows us to understand the phenomenon.Such understanding may well be considered as the target of clinical psychology here expressed.
The contents suggested refer to psychotraumatology studies through the Rorschach method, they can provide information about the traumatic role of the images, here considered as inherently overwhelming.
Below the evidence of the phenomena related to the protocols through the conversion into its psychotraumatological outcomes (Gravenhorst, 2002): As suggested by the studies reported, these indices allow us to evaluate the psychotraumatic role of the image, whether it is related to the condition of Gender Dysphoria.They are implicitly guaranteed the current persistence of discrepancy between sexual-biological identity and psychological identity.The concrete presence of these phenomena is accompanied by several other indices, as shown above.With particular reference to them, we note a good production in terms of productivity, with an average response of 15; the presence of a total number of formal responses, which stands at 52% on average, and good responses that stop at 34.5%; type I and II Erlebnistypus, is often in conflict, especially in 8 cases out of 10, as a conflicting index and not in agreement between internal / external needs and hence considered to be an index of increased conflict.
Our clinical experience would be a proposal of study based on images that could be extended to all the areas of psychological clinic contact.
Clinical Psychology can consider the image as a purpose of knowledge (13), for its physiological nature that is inexhaustible through the word.It allows us to work far from a mere and unique phenomenological description, producing a complex study.
Precisely in terms of complexity it is then necessary to approach as much as possible the evolving model.The term transsexualism already contains an etymological root that suggests its teleological function.In these terms, it would be interesting to extend the knowledge to clarify the primary functional differences, as in this case, the image may assume a traumatic and secondary face.Thus the nonconformity between the physical and the psychological identity generates complexes.It accentuates the consciousness around the nucleus dominated by the word trans.From the dialectical interretroaction (18), understood as a peculiar interchange for the modification and evolution it would be possible to evolve in terms of health.The power of the sex reassignment surgery could not therefore only be understood as the cognitive outcome of a cogitatio oriented to any desire.We are referring to the outcome of an intrinsic necessity for genderdysphoric subjects to solve a discrepancy.That has often come to us since childhood through cross gender identities and role-sharing, and mostly managed by images and affective-emotional basics.From the power and potentiality of the images, the understanding of the complex articulations between desire and representations, desire and somaticism, and the retroactive evolution of both intrapsychic realities, is the result of a desire to an adaptation.

CONCLUSIONS
The relevance of internal images among the ten cases examined is in line with the typical dynamics of mental functioning.The images were managed by their quality, and projection of emotions.Early conflicts known since the beginning of this research, are then studied in depth through methods that allow us to comprehend the abnormal meaning of the phenomena.The most important outcomes such as partiality, fragmentation, defensive attitudes and intrapsychic conflicts, have emerged thanks to the Rorschach method.These phenomena, which were studied in the peculiarities of the cases, and articulating in an inclusive phenomenological view, enable us to understand the role of inner images in the process of adaptation.The psychotraumatic dynamics properly given were considered as implicitly

Table 1 . Representation of the Self.
As seen from the data, human representations, typically mature and adaptive, are depicted by inanimate representations.It suggests psychic suffering underneath unsuccessful responses.

Table II :
Defensive rigidity expressed by Choc to Red; Table III: Blood; Table VI / VIII: Undergone Actions

Table II :
Fragmentation, Blood; Table III Blood; Table VIII: Defensive Rigidity, Aggressiveness Defensive rigidity, Direct Sexual Response; Tav II Blood, Direct Sexual Response; Table VI: Defensive rigidity; Table VI: Direct Sexual Response; Table VII Direct Sexual Response; Table X: Defensive Rigidity, Direct Sexual Response, Direct Sexual Response, Direct Sexual Response

Table III :
Direct Sexual Response; Table IV: Fragmentation, Direct Sexual Response; Table IX Failed Suppression Table VI Premorbid content, devitalized; Table VII Defensive rigidity; IX Failed Suppression; Table X Failed Suppression Protocol VI Table III Aggressiveness; Table IV Premorbid content devitalized; VII Defensive rigidity; Table VIII: Defensive rigidity; Failed Suppression, Defensive Digression; Table II Failed Suppression, Defensive Rigidity; Table III Skeleton content, fragmentation; Table IV Failed Suppression; Table VIII: Fragmentation; Table IX Failed Suppression;

Table IV :
Failed Suppression; IX Defensive rigidity

Table II :
Defensive rigidity; Table IV: Defensive rigidity, Direct Sexual Response; Table VI Direct Sexual Response; VIII Defensive rigidity, Direct sexual response; Table IX: Defensive Rigidity, Direct Sexual Response, Direct Sexual Response

Table I :
Failed Suppression; Table II: Color Answer; Table III: Blood, Safety Seeking, Defensive Rigidity, Defensive Rigidity, Failed Suppression; IV: Failed Suppression; Table V Melancholic Content; Table VI Defensive rigidity, Defensive rigidity; Table VIII: Failed Suppression; Table IX: Failed Suppression, Defensive Rigidity;