Mental Health: Global Challenges Journal
https://www.sciendo.com/journal/MHGCJ ISSN 2612-2138
Exploring Nursing Students' Attitudes Toward
Transgender Individuals and Dehumanization of
Transgender People: The Role of Psychological
Characteristics
Evangelos C. Fradelos
1
, Vissarion Bakalis
2
, Aikaterini Toska
1,
Maria Saridi
1
, Evridiki Kaba
3
Foteini
Tzavella
4
, Kyriakos Souliotis
5,6
1
Laboratory of Clinical Nursing, Department of Nursing, University of Thessaly, Larissa Greece
2
Department of Nursing, University of Thessaly, Larissa Greece
3
Department of Nursing, University of West Attica, Athens Greece
4
Department of Nursing, University of Peloponnese, Tripoli Greece
5
Department of Social and Education Policy, Korinthos, Greece
6
Health Policy Institute, Athens, Greece
Address for correspondence: Evangelos C. Fradelos, University of Thessaly.
Gaiopolis Campus, Larissa - Trikala Ring Road, 41500, GREECE
Email: efradelos@uth.gr
This work is licensed under a Creative Commons Attribution License International CC-BY 4.0.
©Copyright: Fradelos et al., 2025
Publisher: Sciendo (De Gruyter)
DOI: https://doi.org/10.56508/mhgcj.v8i1.252
Submitted for publication: 11
September 2024
Revised: 21 January 2025
Accepted for publication: 24
January 2025
1
Mental Health: Global Challenges Journal
https://www.sciendo.com/journal/MHGCJ ISSN 2612-2138
Introduction
The term "transgender" refers to individuals
whose gender identity does not align with the sex
they were assigned at birth. This term can
encompass a wide range of gender identities and
expressions, from individuals who have undergone
medical sex reassignment procedures to
individuals who self-identify with a different gender
identity without any changes to their bodies.
According to research by Collin and colleagues
(2016), the perception of what it means to be
transgender depends on the definition adopted,
with significant variations in prevalence rates
depending on the methodology. Also, as pointed
out by Buck (2016), misconceptions and a lack of
understanding of the concept of gender identity can
lead to prejudice and discrimination.
The discrimination and dehumanization that
transgender people face are particularly intense,
both in society and in health services. According to
research, transgender people are often targeted by
microaggressions, objectification, and
discrimination, which lead to the loss of their
humanness through the rejection of characteristics
that are considered uniquely human, such as
emotional sensitivity and moral conscience
(Kcomt, 2019; Haslam, 2006; Cascalheira & Choi,
2023). In the context of health services, this
dehumanization manifests itself in the indifference
to the subjectivity and needs of patients, but also in
the objectification of them as passive recipients of
treatment. At the same time, these experiences
lead to increased internalized negativity, shame,
and mental health problems, which are often
associated with poorer mental health (Cascalheira
& Choi, 2023; Safer et al., 2016). Transgender
individuals face higher rates of anxiety, depression,
and suicidal ideation due to societal stigma and
discrimination. Experiences of rejection, workplace
bias, and inadequate healthcare contribute to
chronic stress and psychological distress. Minority
stress theory explains how cumulative
discrimination leads to poor mental health
outcomes. A systematic review highlights that
transgender people are at significantly increased
risk of mental health disorders compared to
cisgender individuals (Budge et al., 2013).
Addressing these issues requires strengthening
legislative protections and raising awareness
among health professionals to provide
comprehensive and humane care.
Nursing students' attitudes towards transgender
people vary, but most studies show that they are
characterized by a lack of knowledge (Fradelos et
al.,2022), prejudices, and stereotypical
perceptions, which affect them in providing
provision of quality care. According to the study by
Derbyshire and Keay (2023), many students show
confusion about gender and gender identity, with
many agreeing with statements such as "the
male/female dichotomy is natural" and "a person
can never change their gender". Furthermore, they
exhibit higher levels of implicit bias compared to
other health professional groups, while education
about trans health remains limited. Similarly,
research by Day and Nicholls (2019) highlights that
students use language that heteronormatively
treats trans people, positioning them as “other” and
reinforcing social stereotypes, while there is a lack
of understanding of the complexities of trans
identity. The findings highlight the need for targeted
education that will reduce bias and enhance
inclusive health care (Albani et al, 2022; Day &
Nicholls, 2019; Derbyshire & Keay, 2023).
Nursing students’ attitudes toward transgender
people are influenced by several factors, with
education playing a central role. Research
suggests that curricula often lack sufficient
information about the needs of the transgender
community, leading to students being inadequately
prepared to provide quality care. Lack of
knowledge about issues such as psychological
support, management of transgender patients, and
their medical needs reinforces prejudices and
stereotypes (Gentil et al., 2023). Furthermore, the
lack of specialized educational tools and clinical
scenarios limits students’ ability to fully understand
the challenges transgender people face in the
healthcare system (Mizock & Lundquist, 2016).
At the same time, personal contact and clinical
experience play an important role. When students
can meet and care for transgender people, they
form more positive and well-informed views about
the needs of this group (Jecke & Zepf, 2024). On
the other hand, the lack of such experiences often
leads to uncertainty and insecurity when providing
care, which highlights the importance of adapting
educational programs (Roy & Clark,2024; Jecke &
Zepf, 2024). By incorporating interactive seminars,
partnerships with transgender organizations, and
internship opportunities, educational institutions
can reduce prejudice and enhance students’
cultural sensitivity (Stewart & O’Reilly, 2017).
Personality traits and empathy play a central
role in shaping nursing students’ attitudes toward
transgender people individuals. Individuals with
high emotional stability, openness to experience,
and a heightened level of social responsibility tend
to express greater acceptance of diversity.
Empathy, as the ability to understand and share the
feelings and experiences of others, is a catalyst for
reducing prejudice. Studies show that educational
programs aimed at enhancing empathy can
significantly reduce negative attitudes toward
LGBTQ+ individuals, including transgender
individuals (Ozturk & Demirden, 2023).
Beyond theoretical knowledge, experiential
learning plays an equally important role.
Educational interventions based on experiential
exercises, such as participating in virtual scenarios
or personal contact with trans people, enhance
empathy and reduce discrimination. At the same
Mental Health: Global Challenges Journal
https://www.sciendo.com/journal/MHGCJ ISSN 2612-2138
time, promoting openness through diversity
courses helps reduce internalized bias that can
affect professional behavior. Lack of empathy, on
the contrary, can reinforce stereotypes and lead to
phenomena of professional distancing, which
negatively affects the quality of care for
transgender people (Adams, 2019). Therefore,
educational institutions should emphasize the
cultivation of empathy and sensitivity towards
diversity through targeted interventions that
enhance both interpersonal skills and knowledge.
Although nursing students’ attitudes towards
LGBTQI+ people have been studied (Fradelos et
al., 2022; Cornelius & Carrick 2015), attitudes
specifically towards transgender people remain
unexplored in the Greek academic space. Lack of
focus on the trans community indicates a
significant gap in the relevant literature.
Furthermore, in Greece, there are no valid and
reliable tools to measure attitudes towards trans
people or to assess transphobia, which limits
scientific understanding and the possibilities for
intervention to reduce prejudice.
Purpose
The purpose of the study is to investigate
nursing students' attitudes toward transgender
individuals as well as to examine the role of
demographic, personality, and cognitive
characteristics in shaping attitudes toward
transgender individuals and their dehumanization
by nursing students. In addition, the study aims to
weigh and culturally adapt the Genderism and
Transphobia Scale.
Methodology
Study setting and participants
This study employed a cross-sectional design. 294
Nursing students from two nursing departments
were recruited.
Data collection
Data were collected via an anonymous
questionnaire consisting of five parts:
A sheet containing social and demographic
characteristics.
The Genderism and Transphobia Scale (GTS)
is a psychometric instrument developed by Hill and
Willoughby (2005) to measure prejudice,
discrimination, and negative attitudes toward
transgender individuals and those who do not
conform to traditional gender norms. The
instrument is designed to assess different aspects
of transphobia and radical gender bias. The GTS
includes a total of 32 statements that cover a wide
range of behaviors, perceptions, and feelings
toward transgender individuals. Participants are
asked to rate their level of agreement or
disagreement with the statements, usually on a 7-
point Likert scale (from 1 = I strongly disagree to 7
= I strongly agree). This scale consists of two
factors: Transphobia/genderism and Gender-
bashing.
To evaluate the dehumanization of transgender
individuals, a modified and culturally adapted
Greek version of the Dehumanization Scale was
utilized (Fradelos et al., 2022). "Human
Uniqueness" refers to characteristics that
differentiate humans from other animals, including
attributes such as delicacy, politeness, self-control,
and advanced cognitive abilities. "Human Nature"
encompasses universal and fundamental human
traits such as sensitivity, autonomy, kindness, and
cognitive flexibility. When individuals are denied
"Human Uniqueness," they are often compared to
animals and described as puerile, immature,
impolite, irrational, or backward. Conversely, the
denial of "Human Nature" traits leads to
comparisons with inanimate objects or machines,
rendering individuals emotionless, rigid, passive,
and lacking in feelings or agency. The scale
consists of seven-point items, with eight
statements in total. For example, one item is "they
are open-minded and can think things through",
where "1" indicates total disagreement and "7" total
agreement. Higher scores reflect stronger
dehumanizing tendencies, whereas lower scores
suggest the absence of such tendencies. The scale
measures two forms of dehumanization:
animalistic dehumanization (assessed by four
items) and mechanistic dehumanization (also
assessed by four items) (Bastian & Haslam, 2010).
The Ten-Item Personality Inventory (TIPI),
developed by Gosling et al. (2003), is a concise
self-report measure containing ten items that
assess personality according to the Big Five
Factors Model, as proposed by Costa and McCrae
(McCrae & Costa, 1987). Each dimension of the
Big Five is represented by one item reflecting the
positive pole and another reflecting the negative
pole. Participants rate how each trait applies to
them using a seven-point scale. This scale has
demonstrated strong convergent validity, test-
retest reliability, and a high degree of agreement
between self-ratings and observer ratings
(Myszkowski et al., 2019). The scale has been
used in Greek students by Fradelos et al. (2022).
The Toronto Empathy Questionnaire (TEQ),
developed by Spreng et al. (2009), is a brief self-
report instrument designed to assess empathy as
an emotional process. The TEQ comprises 16
items that evaluate the behavioral, emotional,
cognitive, and physiological dimensions of
empathy across a wide spectrum of individuals
(Novak et al., 2021). The TEQ has been used in
numerous countries, languages, and psychological
contexts (Roth & Altmann, 2021). Furthermore, the
TEQ has been validated in Greece, with a
satisfactory Cronbach’s α coefficient of 0.72
(Kourmousi et al., 2017).
Mental Health: Global Challenges Journal
https://www.sciendo.com/journal/MHGCJ ISSN 2612-2138
The translation and cultural adaptation
process of the Genderism and Transphobia
Scale
Adhering to WHO's guidelines, the translation
and cultural adaptation of the Genderism and
Transphobia Scale involved several stages.
Initially, two independent bilingual translators, both
healthcare professionals, translated the English
version into Greek. These translations were then
merged and revised by a third translator to create
a single Greek version. This Greek version was
then translated into English by two separate
individuals who were proficient in English. The
resulting English versions were combined into a
single version and translated in Greek by a third
translator. This final Greek version was
administered to ten nursing students, and the
cognitive interview method was employed. During
this process, students shared whether they
encountered any confusing or challenging aspects.
Generally, nine out of the ten students reported no
such issues.
Statistical analysis
Descriptive and inferential statistics were are
applied to this study. The data was examined using
descriptive statistics (frequency, mean values, and
standard deviations) and inductive statistics to
address all the research questions. Analyses of
variance (ANOVA), independent t-tests, spearman
and Pearson correlation, regressions, internal
consistency (Cronbach's coefficient), and
confirmatory factor analyses were carried out using
SPSS26.0 and JASP. The significance level was
set to a p-value ≤0.05.
Ethics
This study received approval from the Ethics
Committee of the Department of Nursing of the
University of Thessaly University in Thessaly
(approval number 689DN/08.06.2023).
Furthermore, the study adheres to the principles
outlined in the Helsinki Declaration (2013) and
complies with the national ethical standards
established by the relevant national and
institutional committees overseeing human
experimentation. The anonymity of participants
was ensured using self-selected codes. Informed
consent was obtained from all participants before
their involvement in the study
Results
Table 1 presents the demographic
characteristics of the sample. Most participants
were women (78.6%), while men constituted 20.1%
and non-binary individuals constituted 1.4% of the
sample. The mean age of the participants was
23.09 years (SD ± 9.1). Regarding the year of
academic studies study, 36.7% of the nursing
students were in their 4th year, 28.9% in their 2
nd
,
and 15% in their 1
st
year of studies, respectively.
while the percentages for the 2nd and 1st years
were 28.9% and 15% respectively. Most students
Mostly, were single (53.1%), while 30.3% stated
that they were in a relationship. Regarding the
place of residence, 73.1% lived in urban areas,
13.9% in semi-urban, and 12.9% in rural areas,
.70.7% identified themselves as heterosexual,
while 15.6% chose not to answer about their sexual
preference. The education of the participants’
parents varied greatly with the mother and father of
the participants mostly having university or
secondary education. Finally, 93.9% of the
participants had not attended seminars on the care
of LGBTQ+ people.
Table 1. Demographic characteristics of the sample
Variable
Group
Frequency
Percentage
Gender
Female
231
78.6
Male
59
20.1
non-binary
4
1.4
Age (mean±SD)
23.09(9.1)
Year of Study
1st
44
15
2nd
85
28.9
3rd
19
6.5
4rth
108
36.7
5th <
38
12.9
Marital Status
In relationship
89
30.3
Single
156
53.1
Other
30
10.2
Married
19
6.5
Area of Residence
Urban (>10.000)
215
73.1
Mental Health: Global Challenges Journal
https://www.sciendo.com/journal/MHGCJ ISSN 2612-2138
Descriptive Analysis
Table 2 presents the descriptive statistics of the
study. The mean values for the different
dimensions examined varied range over a wide
range. Specifically, the Mechanistic and Animalistic
dehumanization scales presented similar mean
values (10.715 and 10.696 respectively) with high-
reliability coefficients (Cronbach's alpha = 0.849
and 0.817). Of Regarding the personality
dimensions, Extraversion had a mean of 7.48 with
a standard deviation of 2.803, while Agreeableness
and Conscientiousness presented means of
10.401 and 10.799 respectively. However, the
reliability for some of these dimensions such as
Agreeableness (0.260) and Emotional Stability
(0.210), was low. The total score in the Empathy
(TEQ) scale had a mean of 48.500 with a standard
deviation of 5.677, while the dimensions of Gender
Bashing and Transphobia/Genderism showed
higher fluctuations, with mean values of 11.456 and
56.228, respectively, and high reliability
(Cronbach's alpha = 0.865 and 0.961,
respectively).
Bivariate Analysis
The results of the ANOVA analysis revealed
significant differences in the scores for the Gender
bashing and Transphobia genderism categories of
the GTS scale between genders. The Gender
bashing category showed a mean value of 10.225
(SD = 4.214) for female participants, a mean value
of 16.576 (SD = 9.534) for male participants, In the
Gender bashing category, female participants had
a mean value of 10.225 (SD = 4.214), males
16.576 (SD = 9.534), while non-binary
individuals/others had the lowest mean value of
7.000 (SD = 0.000). The difference between
females and males was statistically significant (p <
.001), as was the difference between males and
non-binary individuals/other (p = 0.004). In the
Transphobia genderism category, female
participants had a mean score of 51.641 (SD =
26.560), male participants had a mean score of
75.831 (SD = 36.337), and non-binary/other
individuals had a mean score of 32.000 (SD =
5.715). Differences between females and males (p
< 0.001) and between males and non-binary
individuals (p = 0.010) were also statistically
significant, indicating the influence of gender on the
relevant attitudes. ANOVA analysis revealed
statistically significant differences in Mechanistic
dehumanization scores by gender (F(2. 288) =
5.261, p = 0.006). The mean score was higher for
men (M = 12.310, SD = 5.500) compared to women
(M = 10.380, SD = 4.534) and non-binary
individuals (M = 6.750, SD = 4.193). The
differences confirm the existence of variation in
perceptions according to gender. Similarly, in the
Animalistic dehumanization scale, the ANOVA
analysis also showed significant differences
Rural (<2000)
38
12.9
Semi-urban (2000 10.000)
41
13.9
Sexual Preference
Heterosexual
208
70.7
I don’t want to answer
46
15.6
Homosexual
24
8.2
Other
4
1.4
Bisexual
12
4.1
Mothers Educational status
Postgraduate
36
12.2
University
109
37.1
Highschool
108
36.7
J. Highschool
14
4.8
Elementary
21
7.1
Illiterate
6
2
Mothers Educational status
Postgraduate
20
6.8
University
102
34.7
Highschool
97
33
J. Highschool
31
10.5
Elementary
39
13.3
Illiterate
5
1.7
Have you attended an LGBTQ+ care course?
No
276
93.9
Yes
18
6.1