Transgender Health, Resilience, Inner Well-Being, Vitality, and Empowerment (THRIVE) Scale: Development and Validation of a Novel Gender-Diverse QOL Scale

Abstract

This paper presents the development and validation of the Transgender Health, Resilience, Inner Well-Being, Vitality, and Empowerment (THRIVE) Scale. It offers insights into the well-being of transgender and gender-diverse (TGD) individuals, by considering their unique experiences and challenges. TGD individuals often experience significant health disparities, including mental health issues, substance abuse, physical health problems, and difficulty with providers knowing about their needs. A comprehensive quality-of-life assessment could aid in identifying contributions to poor quality of life (QOL) and knowing which resources are needed to address this effectively. Assessments attempting to address these challenges often have not been studied adequately and/or have limitations of being for one-time use, surgery-focused, lengthy, emotionally taxing, and not inclusive of non-binary individuals’ specific needs. Validated among a sample of TGD individuals (N = 61), the THRIVE scale displayed good internal consistency reliability (α = 0.87), as well as convergent and divergent validity. It had significant negative correlations with measures of psychological symptoms and identity distress and positive correlations with measures of life satisfaction and well-being. The THRIVE scale represents a critical advancement in assessing the QOL of TGD individuals and could be an effective tool for individualized care, research, and conversation with these populations.

1. Introduction

Quality of life (QOL) is a complex construct that envelopes multiple domains such as mental health, physical health, social functioning, well-being, satisfaction regarding living condition or a combination of these factors (Coswosck et al. 2022; Jones et al. 2019). The transgender and gender-diverse (TGD) population often report more frequent social and psychological challenges than their cisgender counterparts. TGD populations do not identify with their gender assigned at birth and many others do not adhere to the binary status of gender. Cisgender populations may acknowledge that gender is not a binary construct; however, their gender identity aligns with their gender assigned at birth (APA 2015; Coleman et al. 2012). With TGD individuals identifying as a gender minority, they are more likely to have greater health disparities and face greater physical, mental, and social challenges. The impact of these challenges on QOL is understudied in this marginalized population (Jones et al. 2019). Unfortunately, there are no tools that can be found in the research that specifically measure QOL among TGD populations. The goal of this study was to develop and validate the Transgender Health, Resilience, Inner Well-Being, Vitality, and Empowerment (THRIVE) scale, with the aim to help in starting conversations with a medical or mental health provider regarding gender-diverse topics and help to personalize care. Furthermore, this does not have the limitations of being lengthy, emotionally taxing, or confusing. When taken repeatedly, this tool could be used to track changes in QOL over time (pending necessary longitudinal validation to maintain accuracy). Other proposed benefits of this scale include measuring QOL pre- and post-intervention, changes in QOL before and after gender-affirming surgery or other procedures, and as a tool for healthcare providers to spark conversation about needs and resources.

Coleman et al. (2012) explain that TGD individuals’ standard of care requires various and specialized forms of gender-affirming healthcare such as psychological, hormonal, surgical, or general health treatments. However, some other TGD individuals have already made self-directed progress regarding their gender identity, which could warrant more nuanced care. It may be difficult for providers to understand specific needs of TGD patients. There is also the potential risk that providers may hyperfocus on health concerns related to gender affirming care. This form of tunnel-vision, also known as “transgender broken arm syndrome,” might indirectly impact healthcare, in turn, impacting QOL (Newman et al. 2021). Providers asking irrelevant questions about gender, gender identity, gender expression, and transitioning when a TGD patient is presenting for a completely separate health issue is more likely to increase negative health outcomes or may come across as invalidating to the patient. Providers should be able to address primary prevention, routine care, and emergency care separate from gender affirming care (Do and Nguyen 2020).

A group of researchers found that TGD individuals report significantly poorer well-being. This may be predicted by various social, psychological, and physical health concerns (Aparicio-García et al. 2018). Unfortunately, the demand for TGD competency continues to be overlooked among many health professional education programs (Knudson et al. 2023; Stromberg et al. 2020). This lack of TGD competency has been shown to contribute to the health disparities within the population, compared to cisgender populations. It is necessary for providers to understand the specialized health issues of TGD populations in order to develop intervention programs and improve overall health, well-being, and QOL. Between 2017 and 2020, approximately 1.3 million adults identified as TGD in the United States, and research indicates that this number has remained steady over time (Herman et al. 2022). However, the exact numbers are not known as many people live in stealth for security reasons. The worldwide numbers are even more difficult to estimate as the question has not been asked in the same way in every country. Regardless, the disproportionate ratio of competently trained TGD-related care providers acts as another barrier for TGD patients to access quality healthcare.

Research also indicates that TGD populations are at greater risk of homelessness compared to cisgender populations (Keuroghlian et al. 2015; Miller and Grollman 2015). In many ways, homelessness can produce more negative outcomes in TGD well-being and QOL. TGD individuals who are homeless report higher rates of psychological distress, suicidal ideation, substance use, and violence (Miller and Grollman 2015; Pellicane and Ciesla 2022; Wolford-Clevenger et al. 2017).

Given the broad range of challenges and barriers that TGD populations endure, there is an ongoing debate about how best to learn, understand, and address the needs of this underserved population. Safer (2021) commented that there is little data available on the healthcare needs of TGD individuals. A contributing cause to this minimal data is insufficient communication and inclusion of TGD individuals in research. To conduct research and accumulate data, there needs to be a tool that will accurately conceptualize what TGD QOL looks like for this marginalized group. Without appropriate and culturally relevant tools, measures, or scales to gauge QOL of TGD patients, there is no validated way to inform treatment, thus perpetuating the risk factors and health disparities within this population.

There are measures such as the World Health Organization QOL-Brief Survey (Silva et al. 2021; Thompson et al. 2015), QOL Scale (Burckhardt and Anderson 2003), PedsQL (Zou et al. 2018), Short Form-12 Health Survey (Matthews et al. 2016), and various lengths or adaptations of the Short Form-36 Health Survey (Coswosck et al. 2022; Fredriksen-Goldsen et al. 2014; Pavanello Decaro et al. 2021; Valashany and Janghorbani 2018; Vosvick and Stem 2019) that have been used consistently in QOL and life satisfaction research for TGD populations over the past three decades. However, according to Lindqvist et al. (2016), there is no gold-standard tool for measuring QOL.

Also, Shulman et al. (2017) confirm that there is no known review of various tools, protocols, and survey batteries developed specifically for TGD individuals. The lack of a gold standard tool is not the only limitation to these QOL tools when utilized for the TGD population. As aforementioned, TGD individuals have different life experiences that may impact their physical, mental, and social health which may increase negative QOL outcomes compared to cisgender individuals. Having a QOL tool that is specific to the various health-related challenges among TGD populations will provide better insight into TGD needs for medical treatment and mental health interventions.

There has been a steady increase in TGD research over the past couple decades. Even with this increase in research, there remains a lack of focus on QOL among TGD populations. As medical and psychological standards have started adapting to include more comprehensive assessments for TGD individuals, there are many tools that have yet to be developed and validated. The most commonly utilized QOL tools lack the ability to capture the influence of minority discrimination and prejudice on psychological well-being, social well-being, and physical health. However, healthcare providers should be mindful that QOL may also be related to non-TGD-specific health concerns (Shulman et al. 2017). There is a significant need to shift focus to general psychological aspects of TGD experiences instead of diagnosing a gender identity disorder or concern. Such measures should aim to be brief, broad, repeatable, and include experiences around gender congruence, stigma, discrimination, coping, community connection, social support, and general well-being.

Vosvick and Stem (2019) discuss how well-being and QOL are subjective. That said, QOL measures should be developed to incorporate culturally relevant experiences that may reduce the level of subjectivity with more specialized items. Many researchers discuss the fact that research on QOL in TGD populations is sparse (Shulman et al. 2017; Thompson et al. 2015; Valashany and Janghorbani 2018; Vosvick and Stem 2019). Studies that utilize the aforementioned tools present inconsistent findings around QOL among TGD participants.

Scale Development

The THRIVE scale aims to be a brief and uniform measure, able to be repeatedly administered by clinicians treating gender-diverse individuals to monitor changes in QOL and resource needs. The tool was originally created with a research team including LGBT+ care coordinators, and the transgender veteran point of contact for the participating Veteran’s Administration (VA). The tool was also based on answers from a quality improvement survey asking providers at a metropolitan VA about the QOL for their transgender veteran patients. This scale was formally being titled TRANSVERSE: Transgender Veteran QOL Scale. TRANSVERSE was then reviewed by 20 veterans receiving care at the VA in focus groups. The tool draft shown to the participants included 16 items and 5 themes derived from previous literature review: self-satisfaction/pride, social support, safety, sex-characteristics/physical, and specific veteran care. A semi-structured interview format was used to collect feedback from participants. The tool was shown in sections, when researchers requested initial thoughts from each veteran, allowing for discussion among focus group participants. Each veteran was asked to compare the TRANSVERSE draft to previously used tools at the VA and relative VA care, rating it on a scale from 1 to 10 (1—worse than current care to 10—perfect). Overall, feedback regarding TRANSVERSE was positive, with the average score being a 7.8 response.

The previous study demonstrated high acceptance of the tool within the TGD veteran community (Essa et al. 2022). This scale was then restructured for the general TGD population after considering data from previously completed focus groups. To better understand the QOL within this community, a TGD QOL Survey was developed through collaborative efforts with focus groups of TGD veterans, ensuring its relevance and inclusivity. After focus groups were completed, the THRIVE scale was adapted for this study to improve it and be more inclusive of all individuals identifying as TGD rather than just those within the veteran community. In this current study, participants took the THRIVE scale as well as other indicators of identity and QOL, and answered opinion-based questions on the THRIVE scale to explore further validation of the measure.

In summary, a research study on creating a TGD quality-of-life assessment in a population-informed format is critical to fill the existing gap in knowledge and promote social justice. By recognizing and addressing the unique challenges faced by gender-diverse individuals, we can improve the care of the at-risk population of gender-diverse individuals.

2. Materials and Methods

2.1. Participants

The sample consisted of 61 participants. The mean age of participants was 28.20 years (SD = 11.33). As can be seen in

Table 1. Demographic characteristics of participants (N = 61).

Characteristic:	N	%
Sex Assigned at Birth
Male	13	21.3
Female	44	72.1
Intersex	2	3.3
Did not answer	2	3.3
Race/Ethnicity
White, non-Hispanic	45	73.8
Hispanic or Latino/a	7	11.5
Black, non-Hispanic	3	4.9
Asian or Pacific Islander	3	4.9
Mixed or Other	10	16.4
Education Level
College graduate	32	52.5
Some college	15	24.6
High school graduate	9	14.8
Did not finish high school	5	8.2
Sexual Orientation
Heterosexual	5	8.2
Homosexual	8	13.1
Bisexual	23	37.7
Pansexual	13	21.3
Asexual	5	8.2
Other	16	26.2

Note: Totals are not 100% for every characteristic due to rounding or “select all that apply” questions (ethnicity, sexual orientation).

, the sample was close to three-quarters White, non-Hispanic, and just over half were college or trade school graduates. Close to three quarters of the participants were also assigned female gender at birth.

Gender identification was measured using two different methods. First, participants were asked to describe their gender identification in an open-ended text box. Many chose to skip this question, and of those who did answer, the terms used were so varied that it was not clear they were using a consistent classification system, and others gave vague answers such as “not sure, it’s complicated”. To create a more standardized method, participants were asked to rate the degree to which they identified with being male, female, and other gender (see

Table 2. Participant gender identification by sex assigned at birth.

	“I identify with being a female/woman/girl”
Sex Assigned at Birth	Strongly Disagree	Disagree	Somewhat Disagree	Unsure/ Neutral	Somewhat Agree	Agree	Strongly Agree	Total
Male	1	0	0	0	0	3	9	13
Female	19	6	5	2	3	1	7	43
Intersex	0	0	0	0	1	0	1	2
	“I identify with being a male/man/boy”
Sex Assigned at Birth	Strongly Disagree	Disagree	Somewhat Disagree	Unsure/Neutral	Somewhat Agree	Agree	Strongly Agree	Total
Male	7	3	0	0	0	2	0	12
Female	8	3	1	6	9	6	9	42
Intersex	2	0	0	0	0	0	0	2
	“I identify with being another gender”
Sex Assigned at Birth	Strongly Disagree	Disagree	Somewhat Disagree	Unsure/Neutral	Somewhat Agree	Agree	Strongly Agree	Total
Male	6	1	0	1	1	1	2	12
Female	6	3	3	4	5	13	9	43
Intersex	1	0	0	0	0	0	1	2

).

2.2. Materials

Demographic: a demographic questionnaire inquiring about gender identity, sex assigned at birth, sexual orientation, age, ethnicity, and education level.

Transition Satisfaction: a single question, “How satisfied do you feel with where you are at with your transition into your gender identity?”, using a 5-point scale with response options ranging from 1 to 5 (1 = very unsatisfied, 2 = unsatisfied, 3 = unsure/neutral, 4 = satisfied, 5 = very satisfied). This item was included to measure the degree to which participants were satisfied with their transition into their gender identity.

Transgender Health, Resilience, Inner Well-Being, Vitality, and Empowerment (THRIVE) Scale (Essa et al. 2022): this measure is a 17-item self-report, 5-point scale with response options ranging from 1 to 5 (1 = never, 2 = rarely, 3 = some of the time, 4 = most of the time, 5 = always). This scale was designed to measure the QOL among diverse gender populations. The scale has statements such as “I am satisfied with my connections and engagement in the general community” and “I am comfortable with how I express my gender identity in public.”

Brief Symptom Inventory 18 (Derogatis 2001): an 18- item self-report 5-point Likert scale of distress (1 = not at all, 2 = a little bit, 3 = moderately, 4 = quite a bit, and 5 = extremely). This survey is designed to determine the typical symptomatology of individuals with psychological concerns and their level of psychological distress. The test lists symptoms such as “feeling no interest in things.” The BSI was reported to have an average internal consistency of symptoms ranging from 0.71 to 0.85. In the current study, Cronbach’s alpha was found to be 0.90.

Satisfaction with Life Scale (Diener et al. 1985: a 5-item Likert-type scale that assesses satisfaction with the respondent’s life as a whole. Responses range from 1 to 7 (1 = strongly disagree, 2 = disagree, 3 = slightly disagree, 4 = neither agree nor disagree, 5 = slightly agree, 6 = agree, and 7 = strongly agree). The scale includes statements such as “So far I have gotten the important things I want in life.” In the current study, Cronbach’s alpha was found to be 0.88.

Warwick–Edinburg Mental Well-Being Scale (Stewart-Brown et al. 2011): this scale assesses an individual’s mental well-being. This measure is a 14-item survey that asks participants to respond to statements about feelings and thoughts that they have some of their experiences over the past two weeks, such as “I’ve been dealing with problems well”. Questions are based on a 5-point scale (0 = none of the above, 1 = rarely, 2 = some of the time, 3 = often, 4 = all of the time) in regard to the degree that best describes their frequency of experience for each statement. Stewart-Brown et al. (2011) reported a Cronbach alpha of 0.89 and high test–retest reliability of 0.83. In the current study, Cronbach’s alpha was found to be 0.92.

Identity Distress Scale (Berman et al. 2004): this scale assesses an individual’s level of distress and discomfort in the process of identity development. It is a 7-item survey that asks participants “To what degree have you been upset, distressed, or worried over any of the following issues in your life: sexual orientation and behavior? (e.g., feeling confused about sexual preferences, intensity of sexual needs, etc.).” Responses are based on a 5-point scale (1 = none at all, 2 = mildly, 3 = moderately, 4 = severely, 5 = very severely) in regard to degree of distress. Berman et al. (2004) reported an internal consistency of 0.84 for the average distress rating. In the current study, Cronbach’s alpha was found to be 0.83.

2.3. Procedure

Recruitment flyers were published on multiple social media sites and distributed around the Central Florida area, with a link to an anonymous survey battery which included the above-mentioned scales. Participation was limited to individuals who identified as TGD, a criterion that was clearly stated in recruitments materials. To ensure alignment with this inclusion criteria, flyers were posted in online spaces specifically intended for TGD individuals and in physical community locations known to provide support for broader LGBTQ+ populations. Although specific sites are not named to protect participant anonymity, these spaces were selected based on their established reputation for serving this community including support groups and peer-based services. This targeted recruitment strategy helped to ensure that the sample was composed of individuals identifying as TGD.

3. Results

Data analysis was performed using IBM SPSS Statistics (Version 29). The mean score for participants on the THRIVE scale was found to be 3.41 (SD = 0.65), where the minimum score was found to be 2.12 and a maximum score of 5.00. The THRIVE scale showed significant negative correlations with measures of psychological symptoms and identity distress; however, the scale also showed significant positive correlations with measures of life satisfaction and well-being (See

Table 3. Correlation matrix of measured constructs.

Measures	Mean	Standard Deviation	Median	Range	1.	2.	3.	4.
1. THRIVE	3.41	0.65	3.41	2.88	-	-	-	-
2. Psychological Symptoms	2.21	0.87	2.17	3.61	−0.55 *	-	-	-
3. Identity Distress	2.28	0.69	2.14	3.00	−0.54 *	0.51 *	-	-
4. Life Satisfaction	3.01	1.02	3.00	4.00	0.63 *	−0.48 *	−0.57 *	-
5. Well-Being	3.10	0.70	3.08	3.92	0.64 *	−0.58 *	−0.43 *	0.54 *

* p < 0.001.

).

Results also showed a strong positive correlation between the THRIVE scale and age, r = 0.43, p = 0.001. There were no significant differences across ethnicities. A one-way analysis of variance (ANOVA) showed significant differences between participant sexual orientation and THRIVE scale scores, F_{(5, 53)} = 4.93, p < 0.001, η² = 0.32. Sidak post hoc tests found that the mean score of participants who identified as heterosexual (M = 4.50, SD = 0.44) was significantly greater than all other sexuality groups, including homosexual participants (M = 3.66, SD = 0.69, p = 0.018, 95% CI [0.15, 1.53]), asexual participants (M = 3.65, SD = 0.29, p = 0.030, 95% CI [0.09, 1.61]), participants who identified with “other” sexualities, (M = 3.30, SD = 0.60, p = 0.010, 95% CI [0.19, 2.21]), pansexual participants (M = 3.22, SD = 0.47, p = 0.010, 95% CI [0.21, 2.35]), and bisexual participants (M = 3.20, SD = 0.60, p = 0.003, 95% CI [0.31, 2.28]).

There were no significant differences between any of the non-homosexual groups nor was there any differences found in scores based on sex assigned at birth or education level.

Satisfaction with gender identity transition also indicated significant differences in THRIVE scale scores F_{(4, 55)} = 7.62, p < 0.001, η² = 0.36. Participants who reported “very satisfied” (M = 4.02, SD = 0.61) scored significantly higher in QOL compared to those who reported “unsure/neutral” (M = 3.14, SD = 0.36, p = 0.007, 95% CI [0.17, 1.58]), “unsatisfied” (M = 3.50, SD = 0.53, p = 0.004, 95% CI [0.22, 1.60]), or “very unsatisfied” (M = 2.35, SD = 0.25), p = 0.006, 95% CI [0.35, 2.98]. There were no significant differences between participants who reported “very satisfied” and “satisfied.”

Furthermore, a reliability analysis was conducted for the THRIVE scale consisting of 17 items. The overall Cronbach’s alpha was 0.87, indicating good internal consistency. The item–total statistics showed that all items had a corrected item–total correlation above 0.30, showing moderate to strong correlation with the total score. Squared multiple correlation values are also greater than 0.30 for all items. This indicates that each item aligns well with the underlying construct of TGD QOL and that each item is consistent with the other items in the scale. Results also showed a decrease in Cronbach alpha values if any item of the scale was to be deleted. The results are reported in

Table 4. THRIVE item and item–total Statistics.

THRIVE Items	Item and Item–Total Statistics
	Item Mean	Item Standard Deviation	Corrected Item–Total Correlation	Squared Multiple Correlation	Cronbach’s Alpha if Item Deleted
I find it liberating to accept and express my gender identity	4.30	0.78	0.44	0.48	0.85
2. I am comfortable with how I express my gender identity in public	3.79	0.94	0.45	0.57	0.85
3. I worry how other people may react to my gender identity and expression *	2.58	1.05	0.56	0.49	0.85
4. I am satisfied with my gender expression	3.79	0.86	0.49	0.56	0.85
5. I am satisfied with how my voice reflects my gender identity	3.05	1.20	0.44	0.36	0.85
6. I am distressed by a gap between my gender identity and my physical body *	2.75	1.20	0.54	0.69	0.85
7. I am satisfied with my connections and engagement in the general community	3.25	0.95	0.55	0.72	0.85
8. I am satisfied with my connections and engagement in the LGBTQ+ community	3.28	1.05	0.57	0.77	0.85
9. I worry about being harassed or physically harmed due to my gender identity *	2.88	1.14	0.46	0.48	0.85
10. I feel safe using public restrooms	3.16	1.30	0.39	0.45	0.86
11. I use coping methods that concern other people *	3.67	1.04	0.48	0.43	0.85
12. I have people I trust to support me	4.12	1.00	0.59	0.60	0.85
13. I accept my family boundaries and relationships as they are	3.63	1.11	0.42	0.40	0.86
14. I am concerned about being able to maintain a satisfying intimate relationship *	3.28	1.33	0.39	0.61	0.86
15. I worry about my ability to meet my gender-related goals due to financial costs such as legal name changes or gender-affirming procedures *	3.00	1.44	0.37	0.50	0.86
16. I am satisfied with my progress in meeting my gender-related goals	3.40	1.05	0.61	0.66	0.85
17. I am supported by treatment providers regarding my gender-related care	3.26	1.28	0.47	0.47	0.85

* Denotes reverse-coded items.

.

An exploratory factor analysis was conducted with varimax rotation and principal axis factoring extraction method as its specifications using SPSS 29 and showed a five-factor structure for the THRIVE scale. However, upon closer inspection, factor one accounted for 32.4% of variance of the overall measure, with an eigenvalue of 5.51. Considering the standard cutoff of 40% or greater for unidimensional factor structures, an argument could be made that the THRIVE factor structure may function well as a single factor, given a larger sample size. Furthermore, individual factor loadings for all items support a single factor structure for the THRIVE. Although all of the items cross-loaded onto multiple factors, factor loadings were found to be higher on factor one for all 17 items. Factor loadings were within acceptable bounds of 0.50 or greater for all items on factor one as well, with only three items loading at 0.40 (THRIVE 15), 0.44 (THRIVE 13), and 0.41 (THRIVE 10). When compared to other factor loadings, these items loaded much greater on factor one.

A multiple linear regression was conducted to analyze which measured variables (e.g., identity distress, psychological symptoms, well-being, and life satisfaction) would significantly predict QOL scores. Results revealed that the model showed a significant model fit, F_{(4, 48)} = 13.36, p < 0.001, R² = 0.53. Furthermore, results indicated that identity distress and psychological symptoms did not account for any variance in THRIVE scale scores; however, both well-being and life satisfaction combined accounted for 52% of the total variance in THRIVE scale scores. As can be seen in

Table 5. Regression analysis to predict THRIVE Scale quality-of-life scores.

Predictor Variables:	β	t	p
Identity Distress	−0.16	−1.22	0.227
Psychological Symptoms	−0.10	−0.82	0.419
Life Satisfaction	0.28	2.15	0.036
Well-Being	0.36	2.81	0.007

Significant p values are in bold.

, life satisfaction and well-being were found to be a significant predictors of QOL.

Participants rated aspects of the THRIVE scale on a five-point scale, (1 = not at all, 2 = a little bit, 3 = moderately, 4 = quite a bit, 5 = extremely). There were five questions: “How well does this measure capture your QOL related to being a gender-diverse individual?”, “How helpful do you feel this measure would be at starting conversations with a provider about gender-diverse care?”, “How emotionally draining was this measure?”, “How time-consuming was this measure?”, and “How confusing was this measure?”. The answers indicate that participants believed that the THRIVE scale was not confusing (µ = 1.53), and able to capture their QOL related to being gender-diverse (µ = 3.36). Participants also reported that the THRIVE scale was helpful in starting conversations with healthcare providers about gender-diverse care (µ = 3.41) and was neither emotionally draining (µ = 1.46) nor time-consuming (µ = 1.43).

4. Discussion

Findings from the current set of studies indicate that THRIVE scale is a psychometrically sound instrument that assesses TGD QOL. Although there are scales that assess QOL, there is not a scale that assesses QOL based on the unique experiences reported by TGD individuals. The scale is not designed to be a diagnostic tool; rather, it was developed for healthcare professionals and researchers to assess the mental and physical health of TGD individuals. The THRIVE scale represents a critical advancement in assessing the QOL of TGD individuals. Its development through inclusive focus groups ensures that it accurately captures the unique challenges and experiences faced within the community. The high reliability indicated by Cronbach’s alpha reinforces the survey’s consistency and validity.

The findings align with the findings of Bidzan-Bluma et al. (2020), who outline that life satisfaction is a subjective, personal evaluation of one’s life as a whole, whereas QOL refers to general well-being which typically is less fluid than life satisfaction; however, both can be measured on a continuum. This indicates that QOL is strongly related to well-being and life satisfaction. It also shows that QOL is multidimensional and consists of well-being and satisfaction; however, these only account for a combined 52% of QOL. This indicates that QOL may also consist of other facets, particularly among TGD communities, that may require further exploration and research. These findings resemble that of Medvedev and Landhuis (2018) who found that subjective well-being measures accounted for 80% of the variance in the Oxford Happiness Questionnaire (Hills and Argyle 2002), psychological well-being, subjective well-being, and QOL based on the WHO scale. Similarly, there were strong, moderate correlations between these constructs. Given that there are no existing TGD QOL measures, utilizing well-established measures of these two constructs sufficiently indicate the strength and reliability of the THRIVE scale.

Furthermore, research has primarily looked at QOL among sexual minority-identifying communities. Currently, the sociopolitical climate has been shown to negatively impact physical and mental health among these individuals, such that structural barriers like targeted legislation may play a role in TGD QOL (Stuckey 2025). The development and use of the THRIVE scale will further research in this area by showing the potential role that structural barriers may have on TGD QOL. This scale will also allow clinicians to measure the QOL among TGD clients to better inform treatment and preventative strategies.

Findings also indicate that THRIVE scale scores among TGD participants were strongly related to satisfaction with gender identity transition. Those who reported higher levels of satisfaction also reported the highest levels of QOL compared to participants who reported neutral or lesser satisfaction with gender identity transition. This resembles the findings of van Leerdam et al. (2023), who found that TGD individuals who sought out gender-affirming care showed improvement of gender- and body-related dysphoria, psychological well-being, and QOL; however, the effects were low to moderate. The researchers reported that this was likely attributed to a lack of quality assessment tools pertaining to TGD QOL. In contrast to the findings of van Leerdam et al. (2023), by utilizing a scale designed to consider TGD QOL (i.e., The THRIVE scale), this study found moderate to high effect sizes in life satisfaction and well-being. This is likely due to the development and use of the THRIVE scale, thus addressing the limitations of previous research.

THRIVE scale scores were also correlated with age. The observed trend of higher satisfaction levels among older participants may be understood through the lens of Erikson’s (1968) theory of psychosocial development, particularly the stage of identity versus role confusion. According to Erikson, the successful resolution of identity conflicts typically occurs during adolescence and early adulthood, but for transgender and gender-diverse (TGD) individuals, this process may extend into later stages of life due to societal pressures and barriers to self-expression. As people age, they often have more time, experience, and autonomy to explore, affirm, and integrate their gender identity, leading to greater self-acceptance and psychosocial stability. Older TGD individuals may have reached a point of identity resolution that fosters increased comfort with their gender expression and overall life satisfaction, reflecting a more developed and affirmed sense of self. Ribeiro-Gonçalves et al. (2024) suggest that LGB older adults have developed resilience and adaptive strategies to manage sexual stigma which is negatively correlated to well-being. The same is likely true for TGD individuals.

The data indicates that the THRIVE scale has high internal and external validity, would be helpful in starting conversations with a provider regarding gender-diverse topics, and does not have the limitations of being lengthy, emotionally taxing, or confusing. With results continuing in this direction, the THRIVE scale could be an effective tool for individualized care, research, and conversation with TGD populations. This scale is also the first of its kind, allowing for future research to expand on the use of this tool in various healthcare settings.

This study is not without its limitations. It is cross-sectional research and therefore, the findings might not generalize to a broader population, even among TGD populations. Future research endeavors should consist of validating the scale among intersectional TGD identities such as broader racial identities, ethnic identities, broader age range, participants who may come from restrictive legislative states, education level, and socioeconomic status. This could also be performed through utilizing the measure in healthcare settings that treat TGD individuals, potentially showing the role healthcare stigma may play on TGD QOL.

The study included a small sample of participants and therefore the findings should be considered through this lens. Cross-sectional research is highly sensitive to sample size. This limitation could be explained by TGD individuals being a hard-to-reach population because of the historical pitfalls of non-inclusive research. It is recommended that future research aims to study this scale in a larger sample of TGD participants, although the necessary size would depend on a power analysis based on the scope of the hypotheses being tested.

One notable limitation of the current study is the slight lack of generalizability due to some characteristics of the sample population. The majority of participants were assigned female at birth, and many reported lower levels of formal education, which does not accurately represent the full diversity of the TGD community. Recruitment efforts were primarily conducted through convenience sampling in spaces specifically designed to support the queer community, including those that cater to individuals experiencing economic hardship or homelessness. While these community-based locations and online groups provided access to a hard-to-reach population, they also likely skewed the sample toward individuals with specific socioeconomic challenges. As a result, the findings may disproportionately reflect the experiences of TGD individuals navigating systemic barriers related to income, housing instability, and access to education. This sampling approach, while practical for reaching marginalized individuals, limits the extent to which these results can be applied to broader, more demographically diverse TGD populations.

Despite attempts to determine gender identity by using both qualitative open-ended questions and quantitative Likert scale questions, it was not always possible to determine who identified as transgender as opposed to gender-diverse. For instance, when several people assigned female at birth described their gender identification as “male” they could be either transgender or gender-diverse. Also, a few people assigned female at birth answered strongly agree to the statement “I identify with being female”, suggesting they were cisgender; however, this seems unlikely as there was no compensation for taking the survey to provide an alternative motivation when the recruitment materials, consent form, and directions clearly stated that it was only for TGD individuals. More likely, it could be a dual identification as some of these people also agreed with the statement “I identify with being male”. Further, some non-binary and genderfluid people fluctuate, identifying as male some days and female on other days (Tyminski 2024). Future studies may want to use an interview method to better tease out the distinctions in gender identification.

Another limitation was using a single question to determine satisfaction. Disatisfaction can have many different reasons. For example, some people may have delays in treatment or complications, while others may have regret, and these are very different reasons to be dissatisfied with different implications. Future studies should probe for the reasons for any dissatisfaction.

Although steps were taken to reduce biases in self-report responses such as validity checks, qualitative feedback questions about the scale, and the recruitment of a public community sample, there are other factors that may have influenced response results such as social desirability. Future research should also consider where participants are in terms of stage of transition, the role of legislation on QOL and familial and peer support, as well as the stigma associated with TGD healthcare.

5. Conclusions

The THRIVE scale marks a significant step forward in understanding and addressing the needs of TGD individuals. Through its development and validation with focus groups, internal analyses, and statistical techniques, the survey offers a comprehensive assessment of the QOL within the TGD community. Its implementation can lead to improved support systems, better policies, and increased well-being for gender-diverse individuals. Further research is encouraged to explore the larger scale population testing, utilizing THRIVE scale to measure treatment needs and outcomes in healthcare settings, longitudinal studies following the THRIVE scale over time, and collateral reports from significant others, including clinical interviews.