Abstract
Transgender and gender diverse (TGD) youth report significant health disparities compared to cisgender youth,
including gender-based victimization, greater mental health symptoms (e.g., anxiety, depression, internalized
stigma, suicide), and disproportionately higher rates of health risk taking behaviors (e.g., hazardous alcohol use,
cigarette use, illicit drug use). Use of accurate and relevant terminology that distinguishes among individuals
with diverse sexual and gender identities is critical to identifying TGD youth who are at heightened risk for such
health disparities. In response to NOT-OD-23-046, the proposed administrative supplemental study seeks to:
(a) test terminology for measuring current gender identity as part of the two-step process and suggest timely
and relevant modifications, and (b) explore changes in TGD and cisgender youths’ interpretations of gender
terminology and gender identification over time. The supplemental study will build on Co-PIs Hequembourg’s
and Livingston’s ongoing R01 (AA028810-01A) study of the acute daily and longitudinal effects of peer
victimization (PV) on sexual minoritized adolescents’ (i.e., lesbian, gay, bisexual, queer, + or LGBQ+) risky
alcohol use and identification of protective factors. The proposed supplement will bolster and expedite the
inclusion of sexual minoritized TGD youth (n = 75) for comparison with sexual minoritized cisgender youth
(n=75) in the parent study. Gender identity will be assessed using the two-step process in surveys administered
in two timepoints (baseline and 6-months) with these participants (N = 150). Additionally, two qualitative
cognitive interviews (baseline, 6-months) will be conducted with a subsample of cisgender youth (n = 25) and
TGD youth (n = 25) randomly selected from the survey participants to achieve the following aims: Aim 1 is to
examine TGD and cisgender youths’ (n = 50, 25 each group) perceptions of the 2-step answer options and
suggest modifications using a cognitive interviewing approach. Sources of confusion or ambiguity in the two-
step answer options and suggestions for relevant modifications (i.e., “intersex,” “non-binary”) will be
explored. The centrality of youths’ gender identity in their self-concept and its role in their perceptions of the
two-step gender assessment options also will be examined. Aim 2 is to describe the implications of the two-
step process in research with TGD sexual minoritized adolescents who are at a transitional developmental
period featuring fluid gender (and sexual) identities. Descriptive patterns of gender identification measured
over two time points using the two-step method will be captured via longitudinal surveys (baseline, 6-
months) of TGD and cisgender youth (n = 75 each group). Cognitive interview (at 6-months) will explore
youths’ perceptions (n = 25 each cis and TGD) of the effectiveness of two-step questions for capturing changes
over time as well as patterns of gender identification among TGD and cisgender youth. A revised version of
the two-step gender identity assessment will be developed based on participant feedback in the first
interview; modifications will be explored for appropriateness with TGD LGBQ+ youth in interview 2.
