The Transgender Identity Survey: A Measure of Internalized Transphobia

Abstract

Purpose: We describe the development of a measure of internalized transphobia, defined as discomfort with one's transgender identity as a result of internalizing society's normative gender expectations.

Methods: An item pool was created based on responses from a small clinical sample (N = 12) to an open-ended questionnaire. Expert judges reviewed the items, resulting in a 60-item instrument for empirical testing. We conducted exploratory factor analysis (EFA) by using a community sample of 430 transgender individuals (aged 18–72, mean [M] = 37.4, standard deviation [SD] = 12.0), and confirmatory factor analysis (CFA) by using an online sample of 903 transgender individuals (aged 18–66, M = 31.6, SD = 11.1). Construct validity was examined by using correlations with instruments assessing related constructs administered to the online sample.

Results: EFA resulted in a 52-item instrument with four subscales: Pride, Passing, Alienation, and Shame. CFA, after removal of half of the items, retained the four-factor structure. The final 26-item scale showed excellent internal consistency (0.90) and test–retest reliability (0.93). The factors showed a pattern of association with crossgender identity, gender ideology, outness, felt stigma, self-esteem, and psychological distress consistent with moderate-to-good construct validity.

Conclusion: Internalized transphobia can be conceptualized as four inter-related dimensions: pride in transgender identity (reverse scored), investment in passing as a cisgender person, alienation from other transgender people, and shame. The Transgender Identity Survey reliably assesses this construct, useful in research to understand the impact of minority stress on transgender people's health. It can also be used in clinical practice to assess internalized transphobia at intake and follow-up.

Introduction

Gender norms are deeply embedded in society, and perceived transgressions of these norms are generally met with resistance. This is seen in the ridicule, bullying, and rejection experienced by gender nonconforming children and adolescents,^1–5 and it is reflected in the enacted stigma (actual experiences of discrimination) and felt stigma (perceived rejection and expectations of being stereotyped or discriminated against) reported by transgender people.^6–11 Transgender and gender nonconforming (TGNC) people are a diverse group of individuals whose gender identity and/or expression differs from the sex they were assigned at birth. Transgender individuals may internalize gender norms and expectations, and they may develop shame and self-hatred because of their lack of conformity to culturally established definitions of maleness and femaleness, manhood and womanhood, or masculinity and femininity.^12,13 We began using the term “internalized transphobia,” defined as discomfort with one's own transgender identity as a result of internalizing society's normative gender expectations, to refer to this phenomenon,^14,15 which is analogous to internalized homophobia (internalized negative societal attitudes toward lesbian women and gay men).¹⁶ Since then, an adaptation of the minority stress model^17–19 to a conceptual model for clinical work with TGNC individuals¹² has postulated internalized transphobia as a minority stress process resulting from the internalization of negative attitudes and prejudices from society.²⁰ In this model, internalized transphobia is characterized as self-blame and low self-esteem resulting from gender-related victimization, rejection, and discrimination, leading to a negative self-appraisal of being transgender and, ultimately, self-loathing, which, in turn, affects mental health negatively.¹²

The motivation for developing a measure of internalized transphobia stems from our extensive clinical experience with TGNC populations.^13,21–24 In psychotherapy, internalized transphobia was a frequent theme manifesting itself in at least three ways. First, we observed that individuals may experience intense shame and guilt about being transgender.²⁵ Second, to conform to binary conceptualizations of gender (i.e., one is either a boy/man or a girl/woman) and avoid stigma associated with gender nonconformity, transgender individuals may conceal their feelings about gender and identity from others, by attempting to either conform to their sex assigned at birth or pass as a cisgender member of the other sex.²⁶ Third, we learned that transgender individuals may not want to associate with other transgender individuals because of having internalized society's negative attitudes or to deny or avoid exposure of their own gender variance.^13,27 In contrast with these manifestations of internalized transphobia, transgender individuals may also affirm their gender variance, embrace a gender identity that transcends the gender binary, and surround themselves with other TGNC people to take advantage of the available peer support and empowerment.^{13,15,28–31}

How internalized transphobia manifests itself in a transgender person's life may depend on the social context and may change over the course of their development. For example, a person may experience intense shame toward the self but not have negative attitudes toward others, and over time, become less concerned with concealment, particularly within the social context of the LGBT community.

Although measures exist to assess enacted stigma or transphobia displayed by other people toward transgender people,^32,33 no instruments existed to assess the construct of internalized transphobia. Based on our clinical experience, we expected this construct to include negative attitudes toward one's own and other people's gender nonconformity as well as an emphasis on passing as cisgender. This does not mean that adopting a binary gender expression that leads to concealment of one's transgender identity is, per definition, a manifestation of internalized transphobia. Passing may also serve to affirm a binary gender identity or to protect against discrimination. However, an overemphasis on passing related to the internalization of negative societal attitudes about gender nonconformity would be consistent with the construct of internalized transphobia.^26,34

We developed an instrument to assess this construct in the context of a larger study on gender and HIV risk among a diverse cross-section of the U.S. transgender population.^35–37 Since we started the instrument development process, two other instruments have emerged that include several items assessing aspects of internalized transphobia. An adaptation of a homophobia measure by Diaz et al.³⁸ includes such items as “How many times have you had to pretend that you were not transgender?”³⁹ The Transgender Adaptation and Integration Measure⁴⁰ includes such items as “I get depressed about my gender status” and “Being transgender is part of me. It does not go away.” Neither one of these instruments, however, focuses specifically on a comprehensive assessment of internalized transphobia. Our instrument was designed to focus more exclusively on the internalized aspects of transphobia rather than embedding them within a broader measure of transgender-related stigma and discrimination.

In this article, we report on the process of item development and selection, exploratory factor analysis (EFA) to determine scale structure and initial psychometric properties, confirmatory factor analysis (CFA) to validate scale structure and refine the scale, internal consistency and temporal stability, social desirability, and preliminary construct validity. For the latter, we examined correlations, hypothesized based on the minority stress model,^12,19 between internalized transphobia and related constructs (Fig. 1).

FIG. 1.

A priori expected correlations guiding exploration of construct validity.

We expected higher scores on internalized transphobia to be associated with higher scores on crossgender identity and role, reflecting greater identification with the binary gender “opposite” of sex assigned at birth and greater investment in passing.⁴¹ We expected a positive correlation with more traditional gender ideology,⁴² reflecting greater adherence to the gender binary.²⁶ We expected a negative correlation with outness, reflecting greater openness and comfort with being transgender in social contexts perceived as sufficiently safe.¹³ We further expected positive correlations with gender-related stigma, particularly with felt stigma, which, similar to internalized transphobia, is a proximal personal process as opposed to the more distal social stressor of enacted stigma.¹⁹ Finally, we expected negative correlations with self-esteem and positive correlations with psychological distress, recognizing that internalized transphobia is one among many factors that can affect mental health and well-being negatively.^13,43–47

Methods

Participants and procedures

This study was approved by the Institutional Review Board of the University of Minnesota. For each of the samples described in this article, participants who self-identified as transgender, ≥age 18, and living in the United States were eligible. Transgender was used throughout as an umbrella term; participants could further specify their identity in such terms as transsexual, crossdresser, drag king/queen, and transgender or otherwise gender nonconforming. Trained community advisory board (CAB) members obtained consent from Sample 1 participants; Samples 2 and 3 provided consent via the interactive TGStudy website. See Table 1 for demographics.

Table 1.

Demographic Information

	Sample 1	Sample 2a	Sample 2ba	Sample 3
N	430	1229	903	102
Mean age (SD, range)	37.4 (12.0, 18–72)	32.7 (12.0, 18–70)	31.6 (11.1, 18–66)	26.4 (7.9, 18–52)
Gender identity, n (%)
Trans feminine	309 (72.0)	697 (56.7)	457 (50.6)	44 (43.1)
Trans masculine	120 (28.0)	532 (43.3)	446 (49.4)	58 (56.9)
Race/ethnicity, n (%)
White	232 (57.1)	966 (78.6)	698 (77.3)	83 (82.2)
African American	71 (17.5)	34 (2.8)	24 (2.7)	2 (2.0)
Latino	38 (9.4)	20 (1.6)	13 (1.4)	7 (6.9)
Asian/Pacific Islander	32 (7.9)	19 (1.5)	12 (1.3)	3 (2.9)
Multiracial or other	33 (8.1)	190 (15.5)	156 (17.3)	6 (5.9)
Education, n (%)
High school or less	106 (26.0)	164 (13.3)	116 (12.8)	13 (12.7)
At least some college	302 (74.0)	1065 (86.7)	787 (87.2)	89 (87.3)
Marital status, n (%)
Single	263 (62.5)	792 (64.5)	615 (68.2)	88 (86.3)
Married	63 (15.0)	241 (19.6)	140 (15.5)	6 (5.9)
Divorced/separated/widowed	95 (22.6)	195 (15.9)	147 (16.3)	8 (7.8)
Employed, n (%)	N/A	1024 (83.3)	741 (82.1)	81 (79.4)
Income
Median (interquartile range)	N/A	$35.0k (19.0k–60.0k)	$32k (17.5k–52.0k)	$20k (12.0k–45.0k)
% below twice the poverty level		31.7	34.0	53.5
Residence, n (%)
Large metropolitan area	296 (72.7)	495 (40.3)	385 (42.6)	36 (35.3)
Smaller city	65 (16.0)	353 (28.7)	251 (27.8)	40 (39.2)
Small town	23 (5.7)	248 (20.2)	173 (19.2)	13 (12.7)
Rural area/other	23 (5.7)	133 (10.8)	94 (10.4)	13 (12.7)
Used hormones, n (%)	289 (67.5)	611 (49.8)	560 (62.2)	44 (43.6)
Had surgery, n (%)	104 (24.6)	206 (16.9)	199 (22.2)	19 (19.0)
Openly transgender, n (%)	N/A	701 (60.6)	547 (64.0)	62 (66.0)
Mental health provider, ever, n (%)	N/A	907 (82.5)	735 (89.6)	79 (90.8)

Sample 1 was used for EFA, Samples 2a and 2b for CFA and construct validity testing, and Sample 3 for reliability analyses. Sexual orientation was not assessed in Sample 1. Information on sexual orientation for Sample 2 is presented elsewhere.²⁴

The number of participants may not always sum to the total N due to missing data.

^aDuring CFA, a more homogenous subsample was created of participants identifying as transsexual or transgender (as opposed to crossdresser, drag king/queen).

CFA, confirmatory factor analysis; EFA, exploratory factor analysis; N/A, not available, as data on these variables were not collected; SD, standard deviation.

Sample 1. For the EFA, participants (N = 430) were recruited by members of a national transgender CAB (N = 15). Each CAB member received 35 surveys to distribute among their communities in Minneapolis/St. Paul, Chicago, Houston, New York City, Philadelphia, Washington DC, Seattle, San Francisco, and Los Angeles. Participants completed the survey at community meetings supervised by the CAB member, and they were offered $10 compensation. Returning the completed survey implied consent. Of the 525 distributed surveys, 467 (89.0%) were returned. Of these, 430 (81.9% of the total) were complete, deemed valid, and included in the analysis.

Sample 2a. For CFA and construct validity testing, we used data from a larger study on gender and HIV risk (TGStudy).^35–37 Participants (N = 1229) were recruited through banners on transgender community websites and messages posted to online mailing lists, journals, and forums. To confirm eligibility, survey validity, and uniqueness, a computerized de-duplication, cross-validation protocol compared each participant's e-mail and IP address, user name, password, date of birth and age, zip code, and completion time with other participants' responses, to identify participants who submitted more than one survey or provided false or unreliable data. Participants were compensated with an online gift certificate of $30.

Sample 2b. For the CFA, we also used a more homogeneous subsample from the TGStudy with participants who identified as transsexual or transgender (N = 903), excluding crossdressers and drag kings/queens.

Sample 3. For examination of reliability and temporal stability, we used data from a pilot test of the TGStudy.⁴⁸ Participants (N = 102) were recruited in a similar manner to those in Sample 2a.

Instruments

The initial item pool for the internalized transphobia measure was developed by asking a small adult clinical sample (N = 12, diverse in age, type of transgender identity, and stage of development) from a transgender care center in the Midwest to complete an open-ended questionnaire about their thoughts and feelings when they felt down or ashamed of being transgender versus when they felt good or proud. Content analysis of responses resulted in 108 items.

A panel of 4 expert judges with extensive clinical experience with TGNC people (first, fifth to seventh authors) selected 60 items based on face validity, clarity, brevity, and uniqueness. Each item consisted of a statement followed by a 7-point Likert scale ranging from (1) strongly disagree to (7) strongly agree. The overall instruction for the “Transgender Identity Survey” (TIS) was: “The following questions are about how you have felt in the last 3 months about being transgender. Please indicate to what extent you agree/disagree” (Appendix A). Items were scored so that higher scores reflect more transphobic, negative attitudes.

Along with the newly created items, adapted items from the Internalized Homonegativity Inventory⁴⁹ and the Lesbian Internalized Homophobia Scale⁵⁰ were administered to Sample 1. These items were changed to measure discomfort with gender identity rather than sexual orientation. Finally, the 13-item Marlow-Crowne Social Desirability Short Form C⁵¹ was included; higher scores on this scale indicated greater need to appear in ways likely to win social approval. Throughout the course of instrument development, we met with our CAB to obtain their feedback, which contributed to the final wording of items and interpretation of factors and subscales.

The online survey administered to Samples 2a, 2b, and 3 included the 52-item TIS resulting from the EFA and augmentation of factors 3 and 4 (see Results for further details) as well as measures for the constructs in Figure 1. Crossgender identity was assessed by using a 26-item scale.⁴¹ Items such as “When I wear women's/men's clothing I do not consider it cross dressing because my true gender is feminine/masculine” were rated on a 4-point scale from false to true. Higher scores indicated stronger crossgender identification. Internal consistency was 0.97; test–retest reliability was 0.85 (n = 16). Crossgender role was assessed by using an 18-item scale.⁴¹ Items such as “I have developed a passable style of speaking as a woman/man” were rated on a 4-point scale from false to true. Higher scores indicated a greater degree of crossgender presentation. Internal consistency was 0.95; test–retest reliability was 0.82 (n = 18). Gender ideology was assessed by using a 24-item scale adapted from Taywaditep.⁴² Participants were asked to indicate their agreement with such statements as “A man should always try to project an air of confidence even if he really doesn't feel confident inside” (7-point Likert scales, “strongly disagree to strongly agree”). Higher scores indicated more traditional gender ideology. Internal consistency was 0.91; test–retest reliability was 0.88 (n = 19).

Outness was assessed by a 4-item scale asking participants to what degree they were open (out) with their transgender identity in their personal/social life, with immediate family (partner, children), family of origin (parents, brothers, sisters), and coworkers or classmates (7-point Likert scales, “none of the time” to “all the time”). Internal consistency was 0.80; test–retest reliability was 0.90 (n = 10). Enacted stigma was assessed by 10 items asking participants whether they had experienced various forms of discrimination because of their transgender identity or gender presentation,³² for example, “Have you ever been verbally abused or harassed and thought it was because of your transgender identity or gender presentation?” (yes/no). Internal consistency was 0.74; test–retest reliability was 0.79 (n = 20). Felt stigma, defined as perceived rejection and expectations of being stereotyped or discriminated against, was assessed with a 10-item adaptation of the Stigma Consciousness Scale.^15,52 Respondents indicated to what extent they agreed with statements such as “Most people have a lot more transphobic thoughts than they actually express” (7-point Likert scales, “strongly agree” to “strongly disagree”). Higher scores reflected higher levels of felt stigma. Scores were summed, then divided by the number of completed items to arrive at a scale score that reflected the original metric of the Likert scale. Internal consistency was 0.77; test–retest reliability was 0.70 (n = 19).

Self-esteem was assessed by using the 10-item Rosenberg Self Esteem Scale.⁵³ Higher scores indicated higher self-esteem. Internal consistency was 0.93; test–retest reliability was 0.97 (n = 20). Finally, psychological distress was assessed by using the 18-item short form of the Brief Symptom Inventory (BSI-18).⁵⁴ In addition to a total score representing overall psychological distress (the Global Severity Index), the BSI-18 contains three 6-item subscales for depression, anxiety, and somatization (i.e., symptoms of cardiovascular, gastrointestinal, and other physiological systems observed in presentations of anxiety and depression). For each item, respondents indicated on a 5-point Likert scale how much a particular symptom had bothered them during the past 7 days ranging from (1) not at all to (5) extremely. Items include “Feeling hopeless about the future” (depression), “Feeling tense or keyed up” (anxiety), and “Nausea or upset stomach” (somatization). Internal consistency was 0.94 for the total scale and 0.91, 0.89, and 0.82 for the subscales of depression, anxiety, and somatization, respectively. Test–retest reliability (n = 20) was 0.72 for the total scale and 0.73, 0.70, and 0.66 for the depression, anxiety, and somatization subscales, respectively.

Results

Exploratory factor analysis

EFA with Varimax rotation resulted in 15 factors with eigenvalues greater than 1.0.⁵⁵ Application of scree criteria⁵⁶ resulted in six factors explaining 47% of the variance. The rotated factor structure was used to assign items to factors; only items with a factor loading >0.45 were retained. Factor 5, consisting of only two items and deemed uninterpretable, was removed. For each of the remaining factors, internal consistency was calculated; alphas were high for Factors 1 and 2, modest for Factors 3 and 4, and poor for Factor 6, which led us to remove the latter consisting of four items to improve reliability (see Table 2 for the remaining 39 items).

Table 2.

Exploratory Factor Analysis Structure with Item Loadings and Internal Consistencies

Items	Factor loadings
	1	2	3	4
Factor 1 (Eigenvalue = 12.2; 20.3% of variance; Cronbach's alpha = 0.89): Pride
Being transgender makes me feel special	0.78	0.05	0.04	−0.07
I am proud to be a transgender person	0.77	−0.05	−0.06	−0.26
Being transgender is a gift	0.76	−0.04	0.13	−0.17
I am like other people but I am also special because I am transgender	0.69	0.16	−0.06	−0.10
Being perceived as transgender by others is okay for me	0.66	−0.27	−0.34	0.04
I am paving the way for the acceptance of other transgender people who will come after me	0.65	0.13	−0.16	0.03
I am comfortable revealing to others that I am transgender	0.63	−0.17	−0.29	−0.05
I am comfortable with the reality that I am transgender	0.61	−0.08	−0.19	−0.39
I don't mind being perceived as transgender	0.60	−0.30	−0.38	0.04
I have no problem talking about my transgender identity to almost anyone	0.59	−0.14	−0.12	−0.20
The ability to combine the best of both genders makes me feel like a better person	0.57	−0.03	0.00	−0.11
I'd rather have people know everything and accept me as transgender	0.55	−0.17	−0.33	0.04
I feel comfortable being out in public with other transgender people	0.51	−0.17	−0.46	0.01
I am very comfortable with who and what I am as a transgender person	0.47	0.01	−0.01	−0.41
Factor 2 (Eigenvalue = 5.7; 9.5% of variance; Cronbach's alpha = 0.90): Passing
I would like to be read as a cisgender woman or man	−0.07	0.78	−0.09	0.01
It's much better to pass as female or male than to be recognized as transgender	−0.15	0.77	0.18	0.00
I want to be able to go out in public and pass as a cisgender female or male	−0.14	0.76	−0.13	0.05
It's nice when I am seen as 100% female or male	0.01	0.74	−0.13	−0.02
I really want to pass	−0.06	0.73	−0.06	0.12
Passing is a standard to measure my success	0.00	0.70	0.30	0.03
If I look the part, talk the talk, and walk the walk of a woman or man, it will allow others to accept me	0.06	0.64	0.13	−0.04
Passing means I have accomplished looking the way I feel inside	0.16	0.63	0.12	−0.04
I consider my situation as being born with a birth defect	−0.02	0.61	0.07	0.09
I cannot be happy unless I am perceived as a cisgender woman or man	−0.15	0.61	0.31	0.08
Being read (recognized as transgender) makes me try harder to pass	−0.02	0.60	0.11	0.09
Passing is my biggest concern	−0.11	0.59	0.40	0.10
For me, passing is everything	−0.13	0.53	0.37	0.05
I envy people who are not transgender	−0.17	0.46	0.08	0.33
Factor 3 (Eigenvalue = 3.2; 5.4% of variance; Cronbach's alpha = 0.63): Alienation
I feel uncomfortable around other transgender people	−0.11	0.12	0.58	0.08
I feel a lot of shame when I am around other transgender people	−0.19	−0.03	0.55	0.16
If I enjoy my birth anatomy sexually, I must not be transgender	−0.03	0.10	0.53	0.11
I never reveal myself as transgender	−0.40	0.15	0.49	−0.07
I'm not like other transgender people	0.16	0.09	0.49	−0.11
I hate the look of a woman dressed in men's clothes	−0.22	0.13	0.48	0.06
Factor 4 (Eigenvalue = 2.8; 4.7% of variance; Cronbach's alpha = 0.76): Shame
Being transgender makes me feel like a freak	−0.13	0.01	−0.03	0.73
Often, I feel weird like an outcast or a pervert	−0.23	0.06	0.05	0.70
I often ask myself: How could I do this to my parents, family and/or children	−0.02	0.02	0.05	0.60
Because I am transgender, I often wish I were dead	−0.24	0.14	0.14	0.59
I often ask myself: Why can't I just be normal?	−0.19	0.32	0.21	0.52

Factors 3 and 4 were then augmented with adapted items (10 and 5 items, respectively) from the Internalized Homonegativity Inventory⁴⁹ (items 3, 5, 7, 8, 14, 18, and 20) and the Lesbian Internalized Homophobia Scale⁵⁰ (Connection with Community items 1, 3, and 5, Public Identification item 13, and Attitudes toward Others items 3, 5, 6, and 8), selected on face-validity by expert judges consistent with the factors' interpretation in an effort to improve reliability. Two more items showing poor item-total correlations were removed, resulting in a 52-item scale. The resulting Cronbach's alphas were 0.83 for the total scale and 0.89, 0.90, 0.81, and 0.87 for Pride, Passing, Alienation, and Shame, respectively. Table 3 presents the correlations among these four subscales and social desirability. The correlation between the total scale and social desirability was not significant (r = 0.07, df = 426).

Table 3.

Correlations Among the Initial Four Subscales of the Transgender Identity Survey and Social Desirability (N = 430)

Transgender Identity Survey Subscales	1. Pride, r (df)	2. Passing, r (df)	3. Alienation, r (df)	4. Shame, r (df)	5. Social desirability, r (df)
1. Pride	1	−0.23 (428)***	−0.45 (428)***	−0.49 (428)***	−0.14 (426)**
2. Passing	−0.23 (428)***	1	0.40 (428)***	0.38 (428)***	0.11 (426)*
3. Alienation	−0.45 (428)***	0.40 (428)***	1	0.41 (428)***	0.10 (426)*
4. Shame	−0.49 (428)***	0.38 (428)***	0.41 (428)***	1	0.25 (426)***

^*p < 0.05, ^**p < 0.01, ^**p < 0.001.

Confirmatory factor analysis

Instrument development and cross-validation of the survey's structure proceeded through examination of individual item distributions and CFA by using Sample 2a. Items on which little variance was observed were eliminated (e.g., “In general, I believe that transgender people are more immoral than other people are.”) For the CFA, we used maximum likelihood estimation, and items with the highest EFA factor loadings served as marker variables. After initial analyses indicated a poor model fit (Table 4), we re-examined individual items by using an item correlation matrix. Items with high intercorrelation were retained, whereas those with little variation or correlation with other items were removed, resulting in a 26-item revised scale. Internal consistency for the revised scale (using Sample 2a) was 0.88, 0.90, 0.73, and 0.89 for Pride, Passing, Alienation, and Shame, respectively, and 0.92 for the total scale.

Table 4.

Summary of Results from Confirmatory Factor Analysis

Model	Fit indices
	df	CFI	NNFI	RMSEA	90% CI of RMSEA
Four factor-original	458	0.85	0.84	0.098	0.096–0.100
Four factor-revised	293	0.94	0.93	0.094	0.091–0.097

CFI, Confirmatory Factor Index; CI, confidence interval; NNFI, Non-normed Fit Index; RMSEA, Root Mean Square Error of Approximation.

Next, a CFA of the 26-item revised scale was run with the reduced sample of transsexual and transgender participants (Sample 2b). For these two identities, internalized transphobia might have greater relevance and consistency in meaning because their transgender status is likely more central to their identity. Results indicated a moderate fit for this revised four factor model using the Root Mean Square Error of Approximation criteria, an acceptable-to-good fit using Confirmatory Factor Index criteria, and an acceptable fit using Non-normed Fit Index criteria (Table 4).^57,58 The pattern of relationships between subscales and the item make-up of each subscale is shown in Figure 2.

FIG. 2.

Factor structure of internalized transphobia as measured by the Transgender Identity Survey (N = 903). The items are shortened to fit the graphic. For full items, please see Appendix A. TG, transgender.

Reliability and temporal stability

Internal consistency and test–retest reliabilities of the final TIS version (Appendix A) were assessed by using Sample 3. Randomly selected participants were asked to complete the same survey again 7 days later (n = 20), and test–retest reliability was assessed by computing correlation coefficients between Time 1 and 2 scores. With the exception of the 3-item Alienation subscale, reliabilities were good to excellent (Table 5).

Table 5.

Descriptive Statistics, Internal Consistency, and Test–Retest Reliabilities for Scale and Subscale Scores

Subscale	Mean (SD) (N = 102)	Coefficient alpha (N = 102)	Test–retest correlation coefficient (n = 20)
Total scale	3.78 (1.03)	0.90	0.93
Pride	4.16 (1.48)	0.91	0.95
Passing	3.83 (.88)	0.88	0.86
Alienation	4.08 (1.51)	0.66	0.78
Shame	3.57 (1.36)	0.87	0.84

Scores on the total scale and the four subscales could range from 1 to 7.

Construct validity

Using Sample 2b, Pearson's Product Moment Correlation Coefficients were calculated between scores on the TIS and measures of related constructs depicted in Figure 1 (Table 6). Correlations with crossgender identity were significant and, for the most part, in the expected direction. The correlation between Passing and crossgender identity was the largest. Correlations with crossgender role were smaller and more mixed: a positive, small-to-medium correlation for Passing (as expected), and negative but small correlations for Alienation and Shame. The association between internalized transphobia and gender ideology was positive and of medium size, particularly for Passing.

Table 6.

Correlations Between Transgender Identity Survey Total Scale and Subscale Scores and Selected Measures of Construct Validity (N = 903)

Measure of construct validity	Correlations with…
	Total scale	Pride	Passing	Alienation	Shame
	r (df), 95% CI	r (df), 95% CI	r (df), 95% CI	r (df), 95% CI	r (df), 95% CI
Crossgender identity	0.34 (836)***, 0.28–0.40	−0.16 (838)***, −0.22 to −0.09	0.59 (838)***, 0.55–0.64	−0.10 (835)**, −0.17 to −0.04	0.17 (840)***, 0.10–0.23
Crossgender role	0.02 (836), −0.05 to 0.09	0.04 (838), −0.02 to 0.11	0.24 (838)***, 0.17–0.30	−0.10 (835)**, −0.16 to −0.03	−0.09 (840)**, −0.16 to −0.03
Gender ideology	0.32 (820)***, 0.26–0.38	−0.19 (822)***, −0.26 to −0.12	0.42 (822)***, 0.36–0.48	0.06 (819), −0.01 to 0.13	0.18 (824)***, 0.11–0.25
Outness	−0.33 (840)***, −0.39 to −0.27	0.40 (843)***, 0.35–0.46	−0.06 (842), −0.13 to 0.00	−0.24 (840)***, −0.30 to −0.18	−0.25 (845)***, −0.32 to −0.19
Social/personal	−0.41 (845)***, −0.47 to −0.36	0.49 (848)***, 0.44–0.54	−0.17 (847)***, −0.23 to −0.10	−0.25 (845)***, −0.31 to −0.18	−0.26 (850)**, −0.33 to −0.20
Immediate family	−0.15 (704)***, −0.22 to −0.08	0.16 (707)***, 0.08–0.23	−0.01 (705), −0.09 to 0.06	−0.16 (704)***, −0.23 to −0.08	−0.14 (708)***, −0.21 to −0.06
Family of origin	−0.02 (821), −0.09 to 0.05	0.07 (824)*, 0.00–0.14	0.15 (823)***, 0.08–0.22	−0.12 (821)**, −0.19 to −0.05	−0.08 (826)*, −0.15 to −0.01
Friends	−0.29 (830)***, −0.35 to −0.23	0.32 (833)***, 0.26–0.38	−0.13 (832)***, −0.20 to −0.07	−0.195 (830)***, −0.26 to −0.13	−0.197 (835)***, −0.26 to −0.13
Work/school	−0.37 (758)***, −0.43 to −0.31	0.43 (761)***, 0.37–0.49	−0.16 (759)***, −0.23 to −0.09	−0.18 (757)***, −0.25 to −0.11	−0.25 (761)***, −0.32 to −0.18
Enacted stigma	−0.02 (840), −0.09 to 0.04	0.10 (843)**, 0.03–0.16	−0.03 (842), −0.10 to 0.03	0.03 (840), −0.03 to 0.10	0.053 (845), −0.01 to 0.12
Felt stigma	0.14 (833)***, 0.07–0.21	−0.02 (836), −0.09 to 0.05	0.03 (835), −0.04 to 0.10	0.07 (833)*, 0.00–0.14	0.28 (838)***, 0.21–0.34
Self-esteem	−0.32 (806)***, −0.38 to −0.25	0.18 (808)***, 0.02–0.24	−0.04 (808), −0.11 to 0.03	−0.28 (805)***, −0.34 to −0.22	−0.46 (810)***, −0.51 to −0.40
Psychological distress	0.21 (806)***, 0.15–0.28	−0.08 (808)*, −0.15 to −0.01	−0.02 (808), −0.09 to 0.05	0.29 (805)***, 0.22–0.35	0.34 (810)***, 0.28–0.40
Depression	0.28 (806)***, 0.21–0.34	−0.12 (808)***, −0.19 to −0.06	0.06 (808), −0.01 to 0.13	0.27 (805)***, 0.20–0.33	0.39 (810)***, 0.33–0.45
Anxiety	0.17 (807)***, 0.10–0.231	−0.05 (809), −0.12 to 0.02	−0.05 (809), −0.12 to 0.02	0.28 (806)***, 0.21–0.34	0.29 (811)***, 0.23–0.35
Somatization	0.08 (807)*, 0.01–0.15	−0.03 (809), −0.10 to 0.04	−0.08 (809)*, −0.15 to −0.01	0.19 (806)***, 0.12–0.26	0.18 (811)***, 0.11–0.24

^*p < 0.05, ^**p < 0.01, ^***p < 0.001.

Correlations between internalized transphobia and outness were negative; correlations between the overall TIS and the Alienation and Shame subscales were of small-to-medium size. The correlation with Pride was positive and of medium size. Looking at the various domains of outness, all correlations with Pride were positive, with being “out” in one's social/personal life and at work/school showing large associations. Passing had small negative correlations with social/personal, friends, and work/school outness and a small positive correlation with being out to family of origin. Alienation had a small-to-medium, negative correlation with social/personal outness and small negative correlations with being out to family, friends, and at work/school. Shame had medium negative correlations with social/personal and work/school outness, and small negative correlations with being out to family and friends. Contrary to our expectations, the TIS did not correlate with enacted stigma other than showing a small positive correlation with Pride. The correlation of the overall TIS with felt stigma was significant but small; for Shame, it was of medium size. Higher levels of internalized transphobia and Shame were related to higher levels of felt stigma.

Correlations between internalized transphobia and self-esteem were negative. The correlation with the overall TIS score was of medium size. The correlation with Shame was substantial, whereas the correlations with Pride and Alienation were small-to-medium. Consistent with the minority stress hypothesis, correlations between internalized transphobia and psychological distress were positive, particularly for Shame and Alienation, which showed correlations of medium size with depression and anxiety.

Social desirability

Social desirability was examined by using Sample 1. The total score of the final TIS showed a significant, small-to-medium positive correlation (r = 0.25, df = 426, p < 0.001) with social desirability measured by the Marlow-Crowne Social Desirability Short Form C,⁵¹ sharing 6% of the variance. Thus, internalized transphobia was positively associated with the need to appear in ways that are likely to win social approval. The subscales of Alienation and Shame showed positive correlations (r = 0.20, df = 426, p < 0.001 and r = 0.29, df = 426, p < 0.001) with social desirability, of small and medium size, respectively, whereas Pride showed a small negative correlation (r = −0.14, df = 426, p < 0.01) (higher scores on this subscale indicated greater pride). Passing was not significantly related to social desirability (r = 0.08, df = 426).

Discussion

Our findings indicated that internalized transphobia can be conceptualized as four dimensions that measure pride in transgender identity (reverse scored), investment in passing as a cisgender woman or man, alienation from other transgender people, and shame. Pride reflected a positive affective reaction to one's transgender identity and thus related negatively to the other transphobia dimensions. Both Pride and Passing, in different ways, could be interpreted as a reaction to the negative dimensions of shame and alienation stemming from stigma attached to gender nonconformity. Those who score high on Pride may have reacted to stigma by connecting with a community of similar others and relabeling shared nonconformity as positive,²⁹ which has been shown to buffer the negative influence of stigma on mental health.^15,28 Alternatively, they may have reacted with an emphasis on passing in an attempt to avoid enacted stigma by conforming to the gender binary.^14,24,26

The Passing subscale should be interpreted with caution; investment in passing may or may not be a manifestation of internalized transphobia. An overemphasis on passing may reflect internalized stigma attached to gender nonconformity. However, it may also be a positive way to affirm gender identity or an act of resistance (i.e., opposing stigma, discrimination, and oppression).⁵⁹ Moreover, a lack of investment in passing may reflect a nonbinary identity, independent of one's internalized transphobia. Alienation appears analogous with “horizontal internalized homophobia” (negative attitudes and divisions within the peer group of lesbian women and gay men),⁵⁰ and it involves feeling different from, and embarrassed by, other transgender individuals. Individuals who score high on this dimension would be precluded from benefiting from the support that peers might provide, thus feel isolated and alone and possibly more susceptible to affective and other mental health concerns. Finally, Shame (feeling defective, not belonging) seems the most direct manifestation of internalizing society's normative gender expectations and the social stigma attached to nonconformity. Each of the subscales can be used separately to measure aspects of internalized transphobia as well as pride in identity and the importance of passing for a given individual or group.

Our first attempt to confirm the TIS factor structure indicated a poor fit. The problem appeared to be related to (1) a need to delete items that showed little variability or had poor item-total correlations, and (2) differences between Samples 1 and 2a in gender identity, race/ethnicity, and geography. Once scales were re-configured, the revised CFA model tested in a more homogeneous sample had a moderate-to-good fit. The final subscales showed good to excellent internal consistency and test–retest reliability, with the exception of the 3-item Alienation subscale.

The CFA confirmed that the four dimensions of internalized transphobia are not independent. Pride was negatively associated with Shame, Passing, and Alienation (Fig. 2). Pride and Shame are opposing constructs and one would expect those with pride in identity to experience less alienation from their community. Passing may be influenced by lack of Pride, but Passing and Pride were not opposite ends of one dimension (i.e., one can be both proud and invested in passing). Alienation and Shame had a strong, positive association; those with high shame would be expected to most likely alienate themselves from other transgender individuals. Passing was moderately associated with Shame but not with Alienation, indicating that individuals invested in passing as cisgender, while likely struggling with shame, are not necessarily alienated from other transgender people. They may be open about being transgender in certain settings (e.g., within the transgender community) and may experience a level of pride.

Our examination of construct validity indicated that the TIS measures dimensions of internalized transphobia, and differs from other scales measuring related constructs (Fig. 1). Gender identity and role⁴¹ refer to one's identification and experience as a member of the other gender rather than to attitudes toward one's own gender nonconformity. Gender ideology refers to attitudes about masculinity, femininity, and the relationships between men and women, whereas internalized transphobia concerns the appraisal of one's own transgender identity.

The TIS's assessment of self-acceptance and self-esteem is specific to being transgender rather than self-esteem more generally. Nevertheless, the TIS total score was positively associated with crossgender identity and gender ideology, and negatively associated with outness. Individuals with stronger crossgender identification and a more traditional gender ideology, therefore, appear more vulnerable to internalized transphobia. However, the associations between Passing and crossgender identity and ideology may indicate that this dimension, in addition to internalized transphobia, reflects a desire to validate one's crossgender identity. Pride was associated with being out in one's social life and to friends and coworkers, whereas Shame was most associated with felt stigma. Alienation showed a small, negative association with outness to friends, consistent with the construct of feeling isolated from other transgender people. Our finding that internalized transphobia was not associated with enacted stigma and only had a small association with felt stigma suggests that internalized transphobia is a minority stress process that is distinct from actual or anticipated rejection and discrimination.¹²

We do need to acknowledge that the threat of rejection, discrimination, and violence is real,^6–11 and it may make even the most proud transgender person pause in being open about their identity to just anyone. The relationship between Shame and self-esteem suggests that gender-related shame includes negative self-esteem, but it is not limited to that (sharing 21% of the variance). As expected, internalized transphobia showed a small-to-medium positive relationship with psychological distress, particularly for depression.²⁷

With the exception of Passing not showing a significant correlation, the TIS scores showed small correlations with social desirability. Participants may have over-reported internalized transphobia in an effort to meet social expectations. Social desirability was associated with negative self-evaluation on the part of transgender individuals, which is consistent with our conceptualization of internalized transphobia as a minority stress process. Because transgender identity has been perceived as socially undesirable, higher levels of internalized transphobia can be expected among transgender individuals with a strong desire to meet social expectations.

Limitations

Our conceptualization of transgender identity development and coming out was grounded in clinical experience with primarily Caucasian individuals living in the United States.¹³ We initially turned to a clinical sample to generate items, which were refined by experts working at a center providing gender-affirming care. As such, the instrument may reflect a greater problem-focus and applicability to primarily Caucasian individuals in transition (from male to female or female to male) than if we had initially developed our tool with a broader, more diverse community sample. The EFA data were collected from a convenience sample recruited by CAB members in urban communities (Sample 1). For CFA and construct validity, data were collected from an online sample of TGNC people across the country (Samples 2 and 3).³⁵ The degree to which these samples were representative of the transgender population as a whole is not clear.

Sample 1 was diverse in race/ethnicity and to a lesser extent in education, whereas Samples 2 and 3 were predominantly White and highly educated, which may limit the applicability of the TIS. Differential vulnerabilities and resiliencies exist related to the intersection of multiple marginalized identities (e.g., transgender and Black), which may affect how transphobia is internalized and expressed.^60–63 Further development of the TIS requires independent replication with trans feminine and trans masculine people of diverse backgrounds. Although our samples included gender nonconforming individuals, transgender identities continue to evolve and instruments tailored specifically to the identities and experiences of, for example, nonbinary individuals, are needed urgently. The Gender Minority Stress and Resilience measure⁶⁴ includes items from the TIS in which “transgender identity” was replaced with “gender identity or expression” to account for greater diversity. Other changes in item wording are needed to keep pace with evolving standards of cultural competency.⁶⁵

During CFA, we modified subscales to replicate a four-factor structure, and even after that, absolute model fit remained limited. This may call into question the robustness of this factor structure. However, replication of an Italian translation of the TIS found an adequate fit with the exception of item 26 (“I'd rather have people know everything and accept me as transgender”).⁶⁶ Our validity analyses were based on variables available in a database of an HIV prevention study not specifically designed to assess the TIS's construct validity. The associations may be spurious and/or due to some third, unmeasured construct. Further validation studies are needed to position and evaluate the TIS in the context of existing instruments measuring stigma, transgender identity, gender nonconformity, and related self-esteem, and a direct comparison is needed with other instruments that assess aspects of internalized transphobia.^39,40 Further research is also needed to illuminate the various reasons for passing and its relation to internalized transphobia.

Clinical utility

The TIS may have utility in clinical settings to assess internalized transphobia as a minority stress process, potentially informing interventions to alleviate internalized transphobia and promote health and well-being.⁴⁷ For example, individual psychotherapy may reduce shame⁶⁷ and group therapy or access to community resources may decrease alienation,^68,69 which would be expected to have a positive impact on symptoms of depression and anxiety.^15,44 The TIS could be re-administered at follow-up to evaluate progress in alleviating shame, increasing self-acceptance and pride, and fostering a sense of comfort and belonging among other transgender individuals. Future research is needed to test this utility and establish norms, so that clinicians and patients can evaluate how feelings about being transgender compare with those of the larger population and whether or not they reach a clinical threshold.

Conclusion

The TIS reliably measures internalized transphobia and its four dimensions of Pride, Passing, Alienation, and Shame. We found positive associations between the TIS and measures of gender identity, role, and ideology, consistent with the definition of internalized transphobia as stemming from the internalization of prevailing binary conceptualizations of gender, which for many transgender individuals fails to account adequately for their lived experience.^26,70 Confronting internalized transphobia often involves working toward acceptance of ambiguity in gender identity and role, challenging traditional ideology.^13,24,71 Future research should explore the causes and correlates of each of the four dimensions of internalized transphobia, furthering our understanding of minority stress and its impact on identity development and health. For example, in an Italian sample, shame and alienation were found to mediate the relationship between enacted stigma (anti-transgender discrimination) and depression, whereas only alienation mediated the relationship between enacted stigma and anxiety.⁴⁶

Future research should move beyond cross-sectional designs to understand the impact of internalized transphobia on identity development and health longitudinally. This should include generational differences in internalized transphobia (cohort effects) as well as how internalized transphobia and its impact on health may change over time (age effects).⁷² A better understanding of internalized transphobia and its role in minority stress and coping will aid in the development of effective interventions to reduce the health disparities found among transgender populations.^73–75

Appendix A. Transgender Identity Survey

The following questions are about how you have felt in the last 3 months about being transgender. Please indicate to what extent you agree/disagree.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree/Disagree	Somewhat Agree	Agree	Strongly Agree
1	2	3	4	5	6	7

• 1.Being transgender makes me feel special and unique.
• 2.Being perceived as transgender by others is okay for me.
• 3.I sometimes resent my transgender identity.
• 4.Being transgender makes me feel like a freak.
• 5.I feel isolated and separate from other transgender people.
• 6.I have no problem talking about my transgender identity to almost anyone.
• 7.Being transgender is a gift.
• 8.When I think of being transgender, I feel depressed.
• 9.For me, passing is everything.
• 10.I cannot be happy unless I am perceived as a cisgender woman or man.
• 11.Being read (recognized as transgender) makes me try harder to pass.
• 12.I am like other people but I am also special because I am transgender.
• 13.Passing is my biggest concern.
• 14.When I think about being transgender, I feel unhappy.
• 15.Often, I feel weird like an outcast or a pervert.
• 16.I often ask myself: Why can't I just be normal?
• 17.It's much better to pass as female or male than to be recognized as transgender.
• 18.I sometimes feel that being transgender is embarrassing.
• 19.I am proud to be a transgender person.
• 20.If I look the part, talk the talk, and walk the walk of a woman or man, it will allow others to accept me.
• 21.Passing is a standard to measure my success.
• 22.When interacting with members of the transgender community, I often feel like I don't fit in.
• 23.I envy people who are not transgender.
• 24.I'm not like other transgender people.
• 25.I am comfortable revealing to others that I am transgender.
• 26.I'd rather have people know everything and accept me as transgender.

Key to subscales: Pride consists of items 1, 2, 6, 7, 12, 19, 25, and 26, and they are reverse scored when computing the total scale score as a measure of internalized transphobia. Passing consists of 9, 10, 11, 13, 17, 20, and 21. Alienation consists of 5, 22, and 24. Shame consists of 3, 4, 8, 14, 15, 16, 18, and 23.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

The research on which this article is based was funded by grants from the National Institute on Drug Abuse (R01 DA015269, Walter O. Bockting, PI) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01 HD057595, Walter O. Bockting, PI).