Abstract Evidence demonstrates that transgender and gender diverse (TGD) persons are at dramatically elevated risk for HIV and a number of other detrimental health outcomes largely as a result of pervasive exposure to gender- based stigma and discrimination. Such prejudicial treatment is internalized by TGD persons as “identity non- verification,” a well-established behavioral mechanism in Identity Theory which has yet to be broadly adopted by researchers studying TGD populations. This study would develop the first multidimensional measure of TGD persons' gender identities using Identity Theory's established metrics (e.g., identity standards, reflected appraisals, salience / prominence / commitment ratings) and mechanisms (e.g., identity non-verification, identity corrective responses). The study would occur in two stages, beginning with a Development Stage in which in-depth interviews are carried out with a purposively sampled group of TGD persons evenly split by age, HIV status, and gender identity (N = 24 participants each) over the course of six months followed by a period of six weeks to analyze the interview data and formulate initial dimensions of the gender identity measure. Six weeks of cognitive debriefing interviews (n = 6) would then confirm the face validity of the new measure and allow for fine-tuning of items. This would conclude the Development Stage and would commence the Testing Stage (N = 150), in which the reliability and validity of the new measure could be established, and a test of how identity non-verification is associated with critical health outcomes can be carried out. A deeper and more granular understanding of how TGD persons see themselves, how they believe other people see them, and how differences between these two constructs are associated with HIV-related outcomes and risks (including exposure to HIV and uptake/adherence to ART or PEP/PrEP) could generate new hypotheses, better research questions, and new methods of intervening in one of the populations most affected by HIV in the US.

Project Narrative The proposed study would create a multidimensional measure of gender identity specific to transgender and gender diverse persons, establish the reliability and validity of this new measure, and estimate associations between instances of identity non-verification and participants' HIV-related (and other critical) health outcomes. Twenty-four in-depth interviews with a diverse sample of TGD persons will generate dimensions of a nuanced and culturally appropriate measure of gender identity, while a sample of 150 TGD persons will be enrolled and administered the newly created assessment to establish psychometrics and associations with important health cofactors, including HIV.