Table 2.

Characteristics of Included Studies

Study	Design	NIH QAT rating	Sampling	Gender identification method	Sample characteristics	Health outcome	Summary of relevant findings	Measure of social/legal gender affirmation
Glynn et al.21	Cross-sectional	Good	Purposive sampling in community spaces and venues Two rounds; second to “increase size and diversity of the sample”	Self-identification as transgender or transsexual woman	573 trans women with a history of sex work from San Francisco, CA  41% Black, 21% white, 19% Asian/Pacific Islander, 19% Latina	Mental health: Depression Self-esteem Suicidal ideation	Social, psychological, and medical gender affirmation were significant predictors of lower depression and higher self-esteem. There was no association with suicidal ideation.	Social gender affirmation: Satisfaction with Family Social Support Scale; 5 items rated on 3-point scale; sample: “During the last 30 days, how much more help would you have liked from family members to help you do things?”
Nuttbrock et al.28	Cross-sectional	Poor	Not reported	Not reported	43 trans women sex workers from New York City metro  33% Hispanic, 49% African American (rest of sample not described)	Mental health: Depressive symptoms	There was a high prevalence of gender affirmation from partners, but it was not associated with depressive symptoms. There was a negative association between gender affirmation from friends and gender affirmation from parents with depressive symptoms.	Gender affirmation: Degree to which specific people (family, friends, etc.) “[see] female attire as a natural part of who they are a person.”
Fisher et al.30	Cross-sectional	Poor	Online sampling through Facebook and e-mail lists; national	Not reported	90 trans men and 60 trans women, 14–21 years old, with cisgender male sexual partners  5.3% African American/black, 6.0% American Indian/Alaska Native, 4.0% Asian, 11.3% Hispanic/Latino, 88.7% non-Hispanic white, 7.3% other	HIV prevention: Willingness to participate in PrEP research	Most participants reported that at least one of their caregivers (primary or secondary) was somewhat to very accepting of their trans identity, although this was not associated with willingness to participate in PrEP research. Participants identified access to trans affirming counseling during PrEP research as a factor that would facilitate their involvement.	Assessed family disclosure and acceptance of gender and sexual orientation identities; measure was not described. Listed “being able to talk to research staff who are affirming of my gender identity” on checklist of potential facilitators to PrEP study participation.
Goldenberg et al.31	Cross-sectional	Good	Purposive sampling across 14 U.S. cities through community-based agencies	Gender identity not the same as sex assigned at birth	110 Black trans and gender nonconforming youth  68.18% transfeminine, 10.00% transmasculine, 21.82% gender diverse	Health care utilization: Delaying primary care	Not delaying health care was associated with having gender affirmation needs met in bivariate analysis. In adjusted models, experiencing gender affirmation in health care settings was associated with decreased odds of delaying/not using health care. Gender affirmation in health care modified the relationship between anticipated stigma and probability of delaying or not using primary care.	Gender affirmation occurring in health care: 8 items related to need for and 8 items related to access to gender affirmation in health care; 4-point scale; sample “It is important to me that my preferred name and gender pronouns are always used at the places where I receive health care, including in the waiting room.”
Kuper et al.32	Cross-sectional	Good	Recruitment not described; survey was online; national	Self-identification as a gender identity other than or in addition to their sex assigned at birth	1896 trans people ages 14–30  89.7% White, 5.5% black or African American, 5.5% American Indian or Alaska Native, 9.2% Hispanic or Latino, 5.4% Asian or Pacific Islander, 1.7% Arab or Middle Eastern  21.9% assigned male at birth, 78.1% assigned female at birth	Mental health: Suicide attempt Suicidal ideation Suicide risk	Gender-related support and gender-related expression ability were associated with decreased odds of past-year suicide attempt, past-year suicidal ideation, and current suicide risk, but was not significant in adjusted models.	Gender-related support: 4 items; α=0.82; sample: “People in my life have been accepting of my gender identity/expression.” Gender-related expression ability: 3 items; α=0.79; sample: “I have been able to openly dress and style myself the way that I want.” Each rated on a 4-point scale; measures developed based on qualitative interviews and confirmatory factor analysis
Le et al.33	Cross-sectional	Poor	Purposive sampling: peer referral, social media, community organizations, health clinics	Self-identification as any gender other than that typically associated with an assigned male sex a birth	301 trans female youth ages 16–24 from San Francisco, CA  44.2% female, 32.9% transgender, 22.9% genderqueer/fluid/questioning  36.5% white, 21.9% Latina, 13.0% African American, 6.3% Asian, 7% other race, 15.3% mixed	Mental health: Psychological distress	A greater proportion of participants who reported that their parents were their primary source of social support reported parental acceptance than those who reported a different primary source of social support.	Parental acceptance: 10 dichotomous items; acceptance defined as endorsement of 6+; sample: “Did any of your parents or caregivers ever talk about your trans identity with you?”; α=0.775
	Cross sectional	Poor	N/A, used electronic health records	Not reported	180 electronic health records from trans patients at a clinic serving people ages 12–29 in Boston, MA  63.04% FTM, 36.96% MTF,  23.91% racial/ethnic minority, 76.09% white non-Hispanic	Smoking	Gender affirmation was not associated with current or lifetime cigarette smoking.	Gender affirmation: number of following items in electronic health record: Family support for transgender identity Legal name change Legal gender identification change Involvement with transgender organizations
Pariseau et al.35	Mixed methods	Fair	Recruited from “an interdisciplinary gender clinic serving transgender youth”; procedures not reported	Not reported	54 patients ages 8–17 at a gender clinic in Boston with at least one caregiver	Mental health Depressive symptoms Anxiety symptoms Internalization and externalization of problems	Past acceptance from the primary caregiver was associated with decreased odds of depressive symptoms, anxiety symptoms, and internalizing problems. Acceptance from siblings was associated with decreased odds of externalizing problems and thoughts of suicide.	Gender acceptance: Applied a coding system to clinical interviews. Coded for parental past and current gender acceptance and sibling current gender acceptance.
Pollitt et al.36	Cross-sectional	Fair	Recruited from three U.S. cities; procedures not described	Two-step method	129 trans and genderqueer youth ages 15–21  10.1% Asian/Pacific Islander, 24.8% black, 27.1% white, 26.4% Multiracial, 11.6% no race reported  34.1% trans woman, 31.0% trans man, 10.9% different gender—assigned sex male, 24.0% different gender—assigned sex female	Mental health: Depressive symptoms Negative suicidal ideation Self-esteem Positive suicidal ideation (i.e., wanting to continue to live)	Among participants who had a chosen name, use of the chosen name at home, school, and work was associated with decreased likelihood of depressive symptoms and negative suicidal ideation and increased odds of higher self-esteem. Use of the chosen name at home was also associated with positive suicidal ideation.	Chosen name use: one item about whether participant had a “preferred name different from the name they were given at birth” & whether they were able to go by this preferred name at home, school, work, and with friends. Family acceptance of gender identity: single item rated on a 4-point scale
Reisner et al.37	Cross-sectional	Good	Purposive sampling of youth engaged in care at an Adolescent Medicine Trials Unit site from 14 U.S. cities	Two-step method cross-classifying sex at birth and current gender identity	181 transgender youth ages 16–24 from 14 U.S. cities  76.8% transfeminine, 23.2% transmasculine  69.1% people of color	HIV prevention: Engagement in counseling or programs with HIV prevention content HIV treatment HIV care continuum	Social gender affirmation in HIV-related medical care predicted involvement in primary prevention for seronegative youth, but was not associated with care continuum for seropositive youth.	Social gender affirmation in health care: single item; “In the past 12 months, how supported have you felt in your gender identity or gender expression at place(s) where you accessed HIV-related services?”
Russell et al.38	Cross-sectional	Fair	Recruited from three U.S. cities; procedures not described	Not reported	129 trans and genderqueer youth ages 15–21  38% MTF, 38% FTM, 7% MTDG, 17% FTDG  24% white, 8% Asian, 33% black, 28% multiracial, 7% not reported	Mental health: Depressive symptoms Suicidal ideation Suicidal behavior	Chosen name use in more contexts predicted fewer depressive symptoms, less suicidal ideation, and less suicidal behavior.	Chosen name use: one item about whether participant had a “preferred name different from the name they were given at birth” and whether they were able to go by this preferred name at home, school, work, and with friends.
Wilson et al.39	Cross-sectional	Good	Peer referral, respondent-driven sampling, and social media outreach	Identifying as any gender other than that associated with their assigned male sex at birth	216 sexually active trans female youth without HIV from San Francisco  16.7% genderqueer, 31.9% transgender, 44.4% female, 6.9% other  5.6% Asian, 13.4% African American, 23.1% Latina, 15.3% mixed, 34.3% white, 8.3% other	Mental health: PTSD Mental health symptoms (Brief Symptom Inventory) Depression Stress related to suicidal thoughts	Youth with higher parental acceptance of their transgender identity reported significantly lower odds of PTSD compared to those with lower parental acceptance. There was no relationship for mental health symptoms, depression, and stress related to suicidal thoughts.	Parental acceptance of transgender identity: “Parental acceptance was measured by developing 10 questions based on research from the Family Acceptance Project.”
Barr et al.40	Cross-sectional	Fair	Purposive sampling through community and university organizations and social media; national Two rounds; second round devoted to people of color	Two-step method; included all participants who reported a gender identity different than their assigned sex at birth	571 trans adults  36.6% female, 38.0% male, 25.4% nonbinary  79.5% white, 9.5% multiracial, 3.7% black, 4.2% Latino, 1.6% Asian, 0.8% other	Mental health: Psychological well-being	Transgender community belongingness mediates the relationship between strength of transgender identity and psychological well-being.	Transgender community belongingness: 9 items; 5-point scale; some relate to social gender affirmation (“There are places in the trans community where I feel understood and accepted”) and some do not (“There are places within the trans community where I can get support”)
Bockting et al.41	Cross-sectional	Fair	Online sampling; national; quotas to recruit equal numbers of transsexuals, cross-dressers, drag queens and kings, and “other” transgender people	Self-identification as transgender	1093 trans adults ages 18–65  57.5% trans women, 42.5% trans men  79.4% white, 5.1% Latino, 2.4% African American, 1.6% Asian/Pacific Islander, 1.0% Native American, 7.0% Multiracial, 3.5% other	Mental health: Mental health symptoms	Family and peer support were significantly associated with decreased odds of mental health symptoms. Peer support moderated the relationship between enacted stigma and mental health symptoms in such a way that high peer support removed the association between enacted stigma and mental health symptoms.	Family support: “How supportive do you feel your family of origin (parents and/or siblings) is regarding your transgender identity?” and “How supportive do you feel your immediate family (partner, children) is regarding your transgender identity” 7-point scale; α=0.88 Peer support: “What portion of your social time is spent with transgender people?” and “How often have you felt like you were the only transgender person in the area where you live?” 7-point scale; α=0.87
Crosby et al.42	Cross-sectional	Poor	Community-based outreach in Atlanta, GA, including venue-based sampling and word-of-mouth referrals from transgender advocates	“Having been assigned male at birth and self-identifying as either a transgender woman, female, or other gender non-conforming identity”	77 Black trans women	Mental health: Mental health outcomes (Brief Symptom Inventory)	Social, but not medical gender affirmation was associated with a lower likelihood of mental health outcomes.	Social gender affirmation composite: 5 items: 1. Legal name change 2. Legal photo ID with gender marker changed 3. Do not avoid thinking about gender identity 4. in a relationship 5. Reporting finding sex to be blissful
Fuller and Riggs43	Cross-sectional	Poor	Purposive sampling through social media and community organizations; national	Not reported	345 trans adults  31.6% male, 25.2% nonbinary, 24.6% female, 13.0% another gender, 5.5% agender  75.7% White, 4.3% black, 3.5% Hispanic, 3.2% American Indian or Alaskan Native, 5.5% Asian or Pacific Islander, 7.8% other	Mental health: Psychological distress	Gender-related family support was negatively correlated with psychological distress.	Gender-related family support: “How supportive has your family of origin been of your trans and/or gender diverse identity?”; 4-point scale
Hill et al.44	Cross-sectional	Poor	Venue-based sampling through the Transgender Legal Defense and Education Fund Name Change Project in New York, NY	Identifying as a transgender woman, trans woman, transgender female, or MTF transgender/transsexual person	65 trans women of color  52.3% Black/African American, 7.7% Pacific Islander, 46.2% Hispanic/Latino	Health care utilization: Delaying medical care Nonprescribed Hormone Use	Legal name change was associated with higher monthly income, stable housing, and postponement of care due to gender identity, nonprescribed hormone use, and verbal harassment from family.	Legal name change: single-item dichotomous measure
Kidd et al.45	Cross-sectional	Poor	Online sampling; national	Participants gave open-ended descriptions of gender identity Self-identification as transsexual, cross-dresser, drag queen or king, or other (“My transgender identity doesn't fit any of the above categories”) Participants reported “the degree to which they felt like a woman or a man” and sex assigned at birth	631 transfeminine and 473 transmasculine adults  Sample primarily white	Smoking	In bivariate analysis, gender marker change was associated with decreased odds of smoking in the past 3 months. This was retained for transfeminine participants in multivariable models, but not for transmasculine.	Legal document gender marker change: Determined by comparing participants' sex assigned at birth and their response to the question “According to your current birth certificate, what is your legal sex?”
Nuttbrock et al.46	Cross-sectional	Fair	Online and community-based sampling	“Medical assignment as ‘male’ at birth with a later conception of one's self as not ‘completely male’ in all situations or roles”	571 trans women from New York City metro, ages 19–59  43.9% Hispanic, 26.8% non-Hispanic white, 21.6% non-Hispanic black, 7.6% other	Mental health: Major depression	Gender affirmation was associated with decreased likelihood of major depression across the life course.	Transgender identity affirmation: Percentage of time “relationship partners acted upon disclosures of transgender identity in a positive or affirming way” and the percentage of time these individuals “treated them the way they wanted to be treated with regard to gender.” Rated on a 6-point scale for each of six different types of relationships: parents, siblings, fellow students, friends, coworkers, and sex partners.
Poteat et al.47	Mixed methods	Fair	Purposive sampling at community-based organizations, health care centers, and social media First round of recruitment occurred in Baltimore; Washington, DC, was added to increase sample size	Assigned male at birth and identifies as a female/woman or transgender	201 Black and Latina trans women ages 19–82 from Baltimore or Washington, DC  62.2% Black/African American, 17.4% multiracial, 11.0% other race, 9.5% Indigenous  26.9% Latina/Hispanic	HIV prevention: PrEP willingness	Legal gender affirmation was associated with lower odds of PrEP willingness in adjusted models.	Legal gender affirmation: single-item measure of the extent to which identification documents list their desired name and gender marker
Reisner et al.48	Cross-sectional	Poor	Convenience sampling online and in person; Boston, MA	Two-step method based on sex assigned at birth and current gender identity	171 trans men who have sex with men  81.5% white, 7.5% Hispanic, 2.9% black, 6.9% multiracial, 1.2% other  51.4% binary; 48.6% nonbinary	HIV prevention: Sexual risk STIs Number of sexual partners Condomless sex	Syndemics (drinking, poly-drug use, depression, anxiety, CPA/CSA, IPV) were associated with increased odds of all sexual risk outcomes. Syndemics were associated with sexual risk only for participants who had social gender affirmation. Social gender affirmation was associated with increased odds of lifetime STI diagnoses, having 3+ sexual partners, and decreased odds of condomless sex.	Social gender affirmation: single-item dichotomous measure; “Do you live full time in your identified gender?”
Rosen et al.49	Cross-sectional	Fair	Convenience sampling at HIV and transgender-related community events, social and community-based organizations, and word of mouth	Assigned male sex at birth and identified as female, woman, or transgender	201 Black and Latina trans women with HIV, ages 15+, from Baltimore or Washington, DC  62.2% Black/African American, 17.4% multiracial, 11.0% other race, 9.5% Indigenous  26.9% Latina/Hispanic	HIV treatment: Treatment interruptions	Medical, but not legal gender affirmation was associated with HIV treatment interruptions in bivariate and multivariable models.	Legal gender affirmation: single-item measure of the extent to which identification documents list their desired name and gender marker
Sevelius et al.50	Cross-sectional	Fair	Purposive sampling at community and clinic sites across 4 U.S. cities; sites organized own recruitment procedures; examples: community outreach, word of mouth, referrals from service providers	Assigned male at birth and identify as transgender or female	858 trans women of color  49% Hispanic/Latina, 42% black, 8% other race  From San Francisco, New York, Los Angeles, and Chicago	HIV treatment: Viral suppression	Gender affirmation and health care empowerment mediated the relationship between transgender-related discrimination and viral suppression such that participants who reported transgender-related discrimination were more likely to be virally suppressed if they also reported higher levels of gender affirmation and health care empowerment.	Gender affirmation: Access to gender affirmation in health care: 12 items rated on a 5-point scale; sample: “During your last HIV medical appointment, how welcoming was your medical care provider's waiting room for trans women?”; α=0.88 Need for gender affirmation: 5 items rated on 5-point scale; sample: “How important is it that strangers call you ‘she’ when talking to you?”; α=0.87 Satisfaction with gender affirmation: 5 items rated on 5-point scale; sample: “How satisfied are you with your current level of femininity?”; α=0.87
Sevelius et al.51	Cross-sectional	Fair	Purposive sampling by street outreach, venue-based sampling, and snowball sampling in San Francisco, CA	Assigned male sex at birth and identify as female, transgender, or a gender identity other than male	59 trans women on ART for HIV, living in San Francisco  62.7% Black/African American, 6.8% white/Caucasian, 10.2% Hispanic, 20.3% other	HIV treatment: Antiretroviral therapy adherence Viral load	Higher importance of gender affirmation was associated with ART adherence in multiple models, but not with HIV viral load.	Gender affirmation: Importance of gender affirmation: 5 items rated on 5-point scale; sample: “How important is it that strangers call you ‘she’ when talking to you?”; α=0.86 Satisfaction with current gender expression: 5 items rated on 5-point scale; sample: “How satisfied are you with your current level of femininity?”; α=0.91
Stanton et al.52	Cross-sectional	Good	Purposive sampling at event venues, through snowball and respondent-driven sampling, and online	“All respondents who did not identify as cisgender”	402 trans and gender nonconforming adults  30% Black, 12% Hispanic/Latino/a, 6% Asian/Pacific Islander, 5% Native American, 23% white, 19% Multiracial, 6% other  21% male, 21% female, 32% MTF transgender, 18% FTM transgender, 35% other	Mental health: Psychological well-being	Family support positively predicted well-being, but was not significant when controlling for demographic and health behavior covariates.	Family support: “As a lesbian, gay, bisexual, or transgender person, how much do you now feel supported by your family?” 6-point scale

ART, antiretroviral therapy; CSA/CPA, childhood sexual abuse/childhood physical abuse; FTDG, female-to-different-gender; FTM, female-to-male; IPV, intimate partner violence; MTDF, male-to-different-gender; MTF, male-to-female; NIH QAT, National Institute of Health Quality Assessment Tool; PrEP, pre-exposure prophylaxis; PTSD, post-traumatic stress disorder; STI, sexually transmitted infection.