Navigating the World: Understanding Gender Expression through the Experiences of Transgender and Nonbinary People Teresa van Winkle A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy University of Washington 2024 Reading Committee: Molly Altman, Chair Em Rabelais Barbara Cochrane M. Rebecca O’Connor Program Authorized to Offer Degree: School of Nursing ©Copyright 2024 Teresa van Winkle University of Washington Abstract Navigating the World: Understanding Gender Expression through the Experiences of Transgender and Nonbinary People Teresa van Winkle Chair of the Supervisory Committee: Molly Altman School of Nursing Transgender and nonbinary (TNB) people in the United States face daily discrimination and violence due to their minoritized gender resulting in disproportionately high rates of psychological distress including but not limited to depression, anxiety, and suicide. Current research into these experiences focuses on gender, however, this does not provide a complete picture of the lived experiences of TNB people. Gender expression is the external manifestation of not only gender but a multitude of other factors and is influential in how people are perceived and subsequent discrimination and violence. The overarching goal of this study is to ascertain the process of gender expression for TNB people and describe the associated factors. The dissertation is comprised of three distinct but interrelated analyses. The first paper consists of a principle-based concept analysis clarifying the concept of gender expression. Health science literature, along with historical fiction and current writings from Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) authors provided the data for the analysis. The second paper utilizes constructivist grounded theory and dimensional analysis to explore the process of gender expression through interviews with TNB people (n=28). Using the data from Paper Two, the third paper employs situational analysis to map and understand the external influences on the gender expression process. Findings from this study support the need to include gender expression along with gender when conducting research with TNB communities. Additionally, this study proposes a new conceptualization of the Gender Minority Stress Model to better align with TNB experiences. 5 Dedication This dissertation is dedicated to my magnificent child Helen May Dec. May their life be full of joy and happiness as they grow and express their gender in authentic and beautiful ways. “I had absolutely no idea, absolutely none, that there was a thing on the other side of [gender dysphoria]. That there was a gender euphoria. That there was a feeling good about yourself, right about yourself, something that was really amazing. So, I had never, never, never, ever experienced that before.” ~Participant 15 6 Acknowledgements My sincerest gratitude to the twenty-eight people who graciously volunteered their time, insight, and personal journeys with me. I appreciate the joy, sadness, and hope you shared through this work. I never expected to connect and feel so deeply – Thank you from the deepest recesses of my soul. To the members of my committee – Drs. Molly Altman, Em Rabelais, Barbara Cochrane, and Rebecca O’Connor. Thank you, Drs. Altman and Rabelais, for your endless time and support as I navigated Transgender and Nonbinary research and complex methodology. Your endless encouragement was critical to my success. Dr. Cochrane, thank you for your brilliant introduction to nursing theory, insightful questions, and expertise. Dr. O’Connor, thank you for bringing your discrimination and bias expertise to this project. Your feedback was thought provoking and essential. I thank you all for your mentorship throughout this process. This research was made possible by funding from the Research in Nursing and Global Health T32 Training Grant. Thank you, Dr. Pamela Kohler for supporting my research from its conception through the final product. I appreciate the time and feedback you provided through the entire process. To my children – Theodore Robert, Helen May, and Florence Maeve, I love you more than you will ever know. Thank you for your patience and grace especially over the summer of data collection and the final weeks of writing. To my chosen family – Tracy Middlebrook, Nichole Hart, Lois Harris, Lauren Hernandez and Erin Wallace. Thank you for being my family for the past 20+ years. You have been there for me through all of my brilliant decisions including pursuing my PhD during a global pandemic. I appreciate you more than I can express. To my friends – Stephen Mitchell thank you for providing emotional support during the last phases of writing. Bekah Root, I would not have made it without your restorative presence and brilliant yoga classes. Susan Dec, without your support to attending nursing school, none of this would have been possible. 7 Table of Contents Abstract…………………………………………………………………..……………………………….3 Dedication…………………………………………………………………..…………………………….5 Acknowledgments………………………………………………………..……………………………..6 Table of Contents………………………………………………………………………………………..7 Chapter One…………………………………………………………..………………………………….8 Introduction…………………………………………..…………………………………………...9 Specific Aims……………………………………….…………………………………….……..14 References…………………………………….…………………………………………….….17 Chapter Two……………………………………...……..………………………………………………20 Abstract…………………………………………….……………………………………………21 Introduction……………………………….……………………………………………………..23 Data Sources………………………….………………………………………………………...25 Overview of Concept……………………….…………………………………………………..28 Discussion……………………………………………………………………………………….35 References………………………………………………………………………………………39 Chapter Three…………………………………………………………………………………………..42 Abstract………………………………………………………………………………………….43 Introduction……………………………………………………………………………………...45 Methods………………………………………………………………………………………….46 Results…………………………………………………………………………………………..50 Discussion……………………………………………………………………………………….59 References………………………………………………………………………………………64 Chapter Four……………………………………………………………………………………………66 Abstract………………………………………………………………………………………….67 Introduction……………………………………………………………………………………...69 Methods………………………………………………………………………………………….71 Results……………………..……………………………………………………………………75 Discussion…….…………………………………………………………………………………93 References………………………………………………………………………………………97 Chapter Five…………………………………………………………………………………………….99 Conclusion………………..……………………………………………………………………100 Implications……………….……………………………………………………………………102 References……………...……………………………………………………………………..107 8 Chapter One Navigating the World: Understanding the Gender Expression 9 Introduction Transgender and Non-Binary (TNB) individuals make up approximately 2% of the US population with ample research highlighting the mental health consequences of discrimination such as depression, anxiety, and suicide as well as daily discrimination faced by this community.1,2 Disparities and discrimination exist even within the TNB community, perpetrated through transnormativity, an expectation of assimilating into binary gender roles.3-5 Individuals who do not express their gender in socially expected ways face discrimination, violence, bullying, and victimization.2,6-9 Over the last decade, the adverse mental health outcomes experienced by TNB communities are abundant in the scientific literature. Among respondents to the 2015 US Transgender Survey (N=27,715), 39% of were currently experiencing psychological distress.2 TNB individuals are 3.9 times as likely to be diagnosed with an anxiety disorder.10 Roughly 40% of TNB individuals experience depression,2,11 with even higher rates among those who are nonbinary.12 Depression increases with anticipated rejection13 and suicide increases with non-affirmation of gender.14,15 It is often gender expression, defined as the external situational and contextual construct within which one interacts with the world (as opposed to the often internal constructs of gender), that triggers violence and discrimination.2,13 How one presents to the outside world is personal and contextual. When identities are different from the dominant culture, be that ethnicity, disability, race, gender, or any other category employed to marginalize and oppress a community, those in the minoritized community have a much more complex process determining how they want to present themselves. In TNB communities, identity concealment (attempts to hide one’s identities) or revelation (sharing one’s identities) through gender expression is highly contextual, complex, and not well understood. TNB individuals must consider how to express their gender for everyday activities to mitigate risks of harm. Research has repeatedly found that discrimination, violence, and rejection are related to both gender and gender expression as separate concepts;16 however, 10 research has failed to address the complexity of identity management through gender expression and its short- and long-term effects on health. This additional stress, of which identity management is a part, has been linked to poor mental health outcomes such as anxiety, depression, and suicide through the Gender Minority Stress Model.13,14,16,17 However, the actual process through which this occurs is unclear.13,14 Background Sexuality, Gender, and Gender Expression Sexuality is an umbrella term used to capture a multidimensional array of attractions and activities. Frequently the term sexuality, or the cisheteronormative term sexual orientation, is employed to describe sexual activity. However, it is fraught with problems based on cisheteronormative and moralistic assumptions of negatively perceived sexual activities and choices of sexual partners, who might also be outside of heteronormativity in other ways. For the purpose of this paper, sexuality will be defined as “multifaceted, including elements of attraction, sexual behavior, erotic-affectional behavior and fantasies, emotional attachments, self-identification, and current relationship status”.18 Sexuality is also highly fluid,18-20 further complicating the creation of a stable or concrete definition. Labelling sexuality poses significant difficulty in research. When one asks about participants’ ‘sexuality’, what information are they truly seeking? How people label their sexuality is varied and the criteria used to determine the label can be based on current partners, inclusive to any potential partner, or evolve situationally.18 Additionally, labels are influenced by peers, communities, and social stigma.18,21 Because of the contextual and social nature of sexuality labelling, labels do not necessarily indicate attraction or sexual activity. When considering sexuality, it is critical to determine what information is relevant and ask the individual about the specific details of interest rather than broad labels. Gender is an intrinsic and personal quality that cannot be determined by looking at someone.22 This personal process involves gender awareness, exploration, and integrating into 11 one’s understanding of self.23 The cisheteronormative term gender identity is commonly used in lieu of gender, often as a means of othering. Gender, as defined by the Oxford English Dictionary, is “one’s internal, deeply held sense of” self that aligns to “a class of things or beings distinguished by having certain characteristics in common. Gender includes a plethora of identities, including but not limited to, bigender, men, nonbinary, gender queer, women, and so on. There are also people without gender (agender). No single element or clustering of elements predicts a person's gender; instead, gender just exists or forms through self-reflection and self-understanding.4,24 Conceptual understandings of gender are largely influenced by the culture and society within which one exists. The Christian colonial concept of gender, which is based on primary and secondary sex characteristics and determines “social standing, the roles that are open to you, the attributes and interests and expressions that are allowed and expected of you,”25 is what is most seen in the western health science literature. Understanding gender must be done through the cultural and social norms, and the deconstruction of those norms, within which an individual is existing. Gender expression, as currently understood, is how one chooses to convey their gender (or lack thereof) to the outside world26 and how one is perceived by the outside world.8 Gender expression, like gender and sexuality, is fluid and dynamic, influenced by multiple factors such as context, social expectations, social gender roles, gender, sexuality, and previous experiences.23,26-28 Existing along and outside of continuums of both masculine and feminine,9 expression can be comprised of either, both, or neither feminine and/or masculine attributes. The independent constructs of sexuality, gender, and gender expression interact and influence each other such that they cannot be viewed without consideration of the others.29 Due to the fluid nature of all the constructs,20 they cannot be viewed separately or as one exerting more influence over the other, rather they need to be considered as complex and dynamic relationships.29 Further obfuscation of the relationships among sexuality, gender, and gender 12 expression is due to the limitations in data collection within these constructs. Sexuality can shift with gender expression adaptations or gender transition in multiple ways, such as how some people’s attractions change with gender affirming hormone therapy may consequently lead to changes in how they describe their sexuality. When someone transitions, they may change their sexuality labels to align with their new gender expression.29,30 The frequent conflation of gender and sexuality related concepts in the scientific literature requires clarification and delineation of the concept of gender expression in order to begin to understand the complexity of TNB experiences. Existing Conceptual Models The Minority Stress Theory (MST) was developed to explain the high lifetime adverse mental health outcomes for gay, lesbian, and bisexual individuals resulting from discrimination, bias and violence. The MST theorizes that distal stressors, "objective events and conditions" lead to proximal stressors and "subjective personal processes.” Along this continuum, Meyer identifies the distal to proximal chain as follows: (a) external, stressful events and conditions (chronic and acute), (b) expectations of such events and the vigilance this expectation requires, and (c) the internalization of negative social attitudes.35 Meyer posits that this additional stress due to their minority sexuality status accounts for the mental health disparities compared to the heterosexual population.35 The Gender Minority Stress Model (GMSM) is an expansion of the MST. In 2012, The MST was adapted into the GMSM to reflect the experiences of the transgender community, describing the concealment of gender as a proximal stress factor contributing to adverse mental health outcomes such as depression and suicide.16,17 Gender concealment, along with internalized transphobia and negative expectations are the person specific contributors to the experience of gender minority stress in the TNB community. 13 Figure 1. The Gender Minority Stress Model16 The GMSM, as it stands, fails to account for the multidirectional influence of the distal and proximal factors. The relationships of the distal and proximal factors are not clear.19 The unidirectionality of the model also fails to account for changes in experience over time, generational experiences, and the impact and knowledge gained from the lived experience over a lifetime.19,36 Meyer does acknowledge the modifying effect minority stress has on the overall stress process, leaving room for multiple oppressed identities.35 Gaps in Knowledge Significant evidence demonstrates the heavy burden of adverse mental health outcomes in the TNB population.2,8,17,29,33,35,37-39 The current GMSM fails to capture the complexity of intersecting experiences, identities, and factors such as geographical location (rural or urban), racial and ethnic identities, or socioeconomic position, power dynamics, heterosexism, transphobia, and transmisogyny on the level of stress experienced by different members of the TNB community. Additionally, binary assumptions are abundant in the model despite the acknowledgment in the original conceptional framework that not everyone conforms to binary genders or gender. The specific influences, interactions, and impact of the proximal factor, 14 concealment, have not been explored sufficiently within the context of the GMSM. No studies have examined the process of gender expression through the lens of identity and situational context and the impact on mental health in TNB populations.13 Based on the GMSM, the process of gender expression plays a role in the increased stress and associated comorbidities in this population. However, it is unknown how the distal stress factors influence identity concealment as an aspect of gender expression. The overarching goal of this dissertation is to elucidate the bounds, the process, and the experience of gender expression for TNB individuals to better understand pathways to improve mental health outcomes for these individuals. Specific Aims To better understand the sources of stress and depression among TNB individuals, the process of living in the world, i.e. navigating social settings and the impact of managing identity, need to be ascertained. Through this dissertation the experiences of TNB people will be explored through gender expression with specific focus on community understanding of gender expression, the process of gender expression, and the situational context within which gender expression resides. The aims of the dissertation, each represented by chapters, are as follows: Aim 1: To identify the current use of gender expression in the health science literature and to articulate a theoretical definition of gender expression in the context of TNB communities. Chapter 2, “Gender Expression: An Adapted Principle-Based Concept Analysis,” creates a theoretical definition and understanding of gender expression to capture the nuanced experiences of individuals existing outside of cisheteronormative gendered societal expectations. Using an adapted Principle-Based Concept Analysis41 framework, the scientific literature, historical writings and current social media writings were analyzed to create a comprehensive definition of gender expression congruent with TNB communities’ experiences over the past several decades. This theoretical definition builds the basis for the subsequent lines of inquiry. 15 Aim 2: Describe the experience and process of navigating gender expression for TNB individuals, including identifying factors influencing gender expression in various contexts and social situations. Chapter 3, “Operationalizing Gender Expression: Implications for Data Collection,” uses dimensional analysis to identify and explore the factors involved in gender expression. Data collection occurred via 28 in-depth interviews with TNB individuals about their process of gender expression. As analysis progressed, interviews probed the identified dimensions and focused on the explanatory relationships between the dimensions. The resulting constructs allow for operationalization of gender expression for use in future data collection and research. Aim 3: To describe the impact of contextual and situational influences on the process of gender expression, the directionality of these relationships, and the impact on psychological wellbeing. Chapter 4, “Revisiting the Gender Minority Stress Model: The Impact of the Sociocultural Milieu and Gender Expression,” revisits the GMSM after conducting situational analysis to understand the process and context of gender expression. Analysis of interview transcripts focused on the factors influencing the process of gender expression. After analysis, the results were juxtaposed onto the GMSM, providing support for the existing constructs and creating a new conceptualization for understanding the experience of TNB people. Conclusion This study provides a foundational understanding of gender expression from the perspective of TNB individuals. Epistemic injustice had kept these voices largely out of the research literature thus justifying the need for a critically oriented, constructivist methodology from which to construct a new understanding. An adapted principle-based concept analysis and a constructivist grounded theory approach provided the structure from which to begin exploring gender expression. The results of this study provide a community-driven definition of gender expression, distinctly separate from gender and sexuality, a process through which gender 16 expression is manifested, and a proposed expansion of the GMSM to better capture the complexity of experiences TNB individuals navigate every day. 17 References 1. Hobster K, McLuskey J. Transgender patients’ experiences of health care. British Journal of Nursing. 2020;29(22):1348-1353. 2. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 U.S.Transgender Survey.: Washington, DC: National Center for Transgender Equality; 2016. 3. Bradford NJ, Rider GN, Catalpa JM, et al. Creating gender: A thematic analysis of genderqueer narratives. International Journal of Transgenderism. 2019;20(2-3):155-168. 4. Darwin H. Doing Gender Beyond the Binary: A Virtual Ethnography. Symbolic Interaction. 2017;40(3):317-334. 5. Richards C, Bouman WP, Seal L, Barker MJ, Nieder TO, T’Sjoen G. Non-binary or genderqueer genders. International Review of Psychiatry. 2016;28(1):95-102. 6. Dimberg SK, Clark DA, SpaniermanL.B., VanDaalen RA. "School shouldn’t be something you have to survive”: Queer women’s experiences with microaggressions at a Canadian university. Vol 68. Journal of Homosexuality2021. 7. Mathers LAB. Bathrooms, Boundaries, and Emotional Burdens: Cisgendering Interactions Through the Interpretation of Transgender Experience. Symbolic Interaction. 2017;40(3):295-316. 8. Gower AL, Rider GN, Coleman E, Brown C, Mcmorris BJ, Eisenberg ME. Perceived Gender Presentation Among Transgender and Gender Diverse Youth: Approaches to Analysis and Associations with Bullying Victimization and Emotional Distress. LGBT Health. 2018;5(5):312-319. 9. Hamilton KM, Park LS, Carsey TA, Martinez LR. “Lez be honest”: Gender expression impacts workplace disclosure decisions. Vol 23. Journal of Lesbian Studies2019. 10. Pinna F, Paribello P, Somaini G, et al. Mental health in transgender individuals: a systematic review. International Review of Psychiatry. 2022;34(3-4):292-359. 11. Connolly MD, Zervos MJ, Barone CJ, Johnson CC, Joseph CL. The Mental Health of Transgender Youth: Advances in Understanding. J Adolesc Health. 2016;59(5):489-495. 12. Newcomb ME, Hill R, Buehler K, Ryan DT, Whitton SW, Mustanski B. High Burden of Mental Health Problems, Substance Use, Violence, and Related Psychosocial Factors in Transgender, Non-Binary, and Gender Diverse Youth and Young Adults. Archives of Sexual Behavior. 2020;49(2):645-659. 13. Pellicane MJ, Ciesla JA. Associations between minority stress, depression, and suicidal ideation and attempts in transgender and gender diverse (TGD) individuals: Systematic review and meta-analysis. Clin Psychol Rev. 2022;91:102113. 14. Gosling H, Pratt D, Montgomery H, Lea J. The relationship between minority stress factors and suicidal ideation and behaviours amongst transgender and gender non- conforming adults: A systematic review. J Affect Disord. 2022;303:31-51. 15. Drabish K, Theeke LA. Health Impact of Stigma, Discrimination, Prejudice, and Bias Experienced by Transgender People: A Systematic Review of Quantitative Studies. Issues in Mental Health Nursing. 2022;43(2):111-118. 16. Hendricks ML, Testa RJ. A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the Minority Stress Model. Professional Psychology: Research and Practice. 2012;43(5):460-467. 17. Testa RJ, Habarth J, Peta J, Balsam K, Bockting W. Development of the Gender Minority Stress and Resilience Measure. Psychology of Sexual Orientation and Gender Diversity. 2015;2(1):65-77. 18. Callahan CJ, McGuire JK. Sexual orientation labelling: Relational processes of trans identity development. Culture, Health & Sexuality2021. 18 19. Hoy-Ellis CP. Minority Stress and Mental Health: A Review of the Literature. J Homosex. 2021:1-25. 20. Sumerau JE, Mathers LAB, Moon D. Foreclosing Fluidity at the Intersection of Gender and Sexual Normativities. Symbolic Interaction. 2020;43(2):205-234. 21. Zeglin RJ. The MSM (Non)Identity: Toward Understanding Sexual Behavior and Identity in Health Research and Practice with Straight Men Under the Umbrella. Sexuality Research and Social Policy. 2020;17(2):343-352. 22. Pollock L, Eyre SL. Growth into manhood: identity development among female-to-male transgender youth. Culture, Health & Sexuality. 2012;14(2):209-222. 23. Kuper LE, Wright L, Mustanski B. Gender identity development among transgender and gender nonconforming emerging adults: An intersectional approach. Vol 19. International Journal of Transgenderism2018. 24. Castleberry J. Addressing the Gender Continuum: A Concept Analysis. Journal of Transcultural Nursing. 2019;30(4):403-409. 25. Harsis C. Gender is not what you think it is. Medium 2018. 26. Beltz AM, Loviska AM, Weigard A. Daily gender expression is associated with psychological adjustment for some people, but mainly men. Scientific Reports. 2021;11(1). 27. Levitt HM, Puckett JA, Ippolito MR, Horne SG. Sexual minority women's gender identity and expression: challenges and supports. J Lesbian Stud. 2012;16(2):153-176. 28. Twist J, De Graaf NM. Gender diversity and non-binary presentations in young people attending the United Kingdom’s National Gender Identity Development Service. Clinical Child Psychology and Psychiatry. 2019;24(2):277-290. 29. Lindley LM, Nagoshi JL, Nagoshi CT, Hess III R, Boscia A. An eco-framework on the intersectionality of gender and sexual identities in transgender individuals. Vol 16. Psychology & Sexuality2021. 30. Callahan CJ, McGuire JK. Sexual orientation labelling: relational processes of trans identity development. Cult Health Sex. 2021:1-16. 31. Bry LJ, Mustanski B, Garofalo R, Burns MN. Management of a Concealable Stigmatized Identity: A Qualitative Study of Concealment, Disclosure, and Role Flexing Among Young, Resilient Sexual and Gender Minority Individuals. Journal of Homosexuality. 2017;64(6):745-769. 32. Tan KKH, Treharne GJ, Ellis SJ, Schmidt JM, Veale JF. Gender Minority Stress: A Critical Review. Journal of Homosexuality. 2020;67(10):1471-1489. 33. Lefevor GT, Boyd-Rogers CC, Sprague BM, Janis RA. Health Disparities Between Genderqueer, Transgender, and Cisgender Individuals: An Extension of Minority Stress Theory. Journal of Counseling Psychology. 2019;66(4):385-395. 34. Arayasirikul S, E.C. W. Spilling the T on transmisogyny and microaggressions: An intersectional oppression and social process among trans women. Vol 66. Journal of Homosexuality2019. 35. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674- 697. 36. Frost DM, Meyer IH. Minority stress theory: Application, critique, and continued relevance. Curr Opin Psychol. 2023;51:101579. 37. Jones BA, Pierre Bouman W, Haycraft E, Arcelus J. Mental health and quality of life in non-binary transgender adults: a case control study. International Journal of Transgenderism. 2019;20(2-3):251-262. 38. Rimes KA, Goodship N, Ussher G, Baker D, West E. Non-binary and binary transgender youth: Comparison of mental health, self-harm, suicidality, substance use and 19 victimization experiences. International Journal of Transgenderism. 2019;20(2-3):230- 240. 39. Weinhardt LS, Stevens P, Xie H, et al. Transgender and Gender Nonconforming Youths' Public Facilities Use and Psychological Well-Being: A Mixed-Method Study. Transgender Health. 2017;2(1):140-150. 40. Cerezo A, Cummings M, Holmes M, Williams C. Identity as Resistance: Identity Formation at the Intersection of Race, Gender Identity, and Sexual Orientation. Psychol Women Q. 2020;44(1):67-83. 41. Penrod J, Hupcey JE. Enhancing methodological clarity: principle-based concept analysis. J Adv Nurs. 2005;50(4):403-409. 20 Chapter Two Understanding Gender Expression: A Principle-Based Concept Analysis 21 Abstract Purpose: To better understand the experiences of transgender and gender expansive (TNB) individuals navigating the world, more than sexuality and gender data is necessary. The purpose of this concept analysis is to provide a theoretical definition of gender expression for future operationalization in research with TGE communities. Aims: (1) To identify gaps in current use of gender expression in the health science literature. (2) To articulate a theoretical definition of gender expression in the context of TNB communities. Description of Concept: For many TNB communities, gender expression is how an individual chooses to convey their gender to the outside world and is influenced by one’s concept of self, one’s gender, societal norms and pressures, complex situational interactions, and previous experiences. Methods: This is a principle-based concept analysis adapted from Penrod and Hupcey’s methodology. The use of gender expression is examined in the western scientific, social, and historical literature based on the following four principles: epistemological, pragmatic, linguistic, and logical. Lesbian, gay, and TNB voices past and present are included in the analysis. Findings: Within the TNB context, gender expression is clearly defined and consistently used in social and popular media as well as in historical lesbian and gay writings. The distinction between the adjacent concepts of gender and sexually remain clear despite the areas of overlap and interaction. In western, health science literature, gender expression is often used as a surrogate or synonym for gender, or left unidentified altogether, creating ambiguity and difficulty with generalization of findings. The analysis resulted in substantial evidence in support of utilizing gender expression to more accurately understand the nuances of the TNB experience. From Penrod and Hupcey’s methodology, a theoretical definition emerged, suitable for operationalization and validation in different TNB communities. Link to Research: While TNB communities have defined the concepts of sexuality, gender, and gender expression as separate, yet interrelated aspects of individual lived experiences, gender expression is a rarely acknowledged concept in health science literature. It is well established 22 that individuals who do not express their gender in socially expected ways face policing, bullying, harassment, and victimization in both public and private spaces. These experiences are associated with higher levels of adverse mental health outcomes such as anxiety, depression and suicide. However, only gender and sexuality are usually measured, overlooking an integral aspect of the experience. For meaningful research with TGE communities, gender expression must be explored and defined as an independent concept interacting with gender and sexuality. Conclusion: Intentionally bringing gender expression into research discourse as a concept distinct from gender and sexuality allows for participants to better describe their experiences, allows for describing correlating concepts accurately, and improves the quality and relevance of the work all while disrupting the perpetration of harmful stereotypes and simplifications of causal pathways. This concept analysis sets the foundation for future research examining the interactions between sexuality, gender, and gender expression and the resulting impact on identity management strategies and mental health. 23 Introduction Choosing clothes, hair style, how you carry yourself and all other aspects of how you present yourself to the world is a daily experience for most humans. However, for some, the consequences of those choices can be devastating and even deadly. In many primarily Christian colonized and colonizing societies, people who express their gender outside of expected societal norms experience violence and harm at disproportionate rates due to pervasive transphobia and transmisogyny.1-3 In the existing English language health science literature, gender expression is often conflated with distinctly different concepts such as gender or sexuality, which negates the impact of gender expression as a key influencing factor on health outcomes. To begin closing the gap on disproportionately poor health outcomes experienced by transgender and non-binary (TNB) individuals,2,4 the social constructs impacting their navigation of the normative cisgender and heterosexual (cisheteronormative) world must be defined and utilized consistently. It is well established that individuals who do not express their gender in socially expected ways face policing, bullying, harassment, and victimization in both public and private spaces.5-8 These experiences are associated with higher levels of adverse mental health outcomes such as anxiety, depression, and suicide.2,7,9 However, when only gender and sexuality are usually measured, an integral aspect of the experience is overlooked. For meaningful research with TNB communities, gender expression must be explored and defined as an independent concept interacting with gender and sexuality. Background Research focused solely on gender and sexuality along with the frequent incorrect use of gender expression in the health science literature does not allow for the complexities of TNB experiences to be captured. Clarification of gender expression as a concept is necessary to understand how TNB individuals process navigating their gender expression and the impacts of this process and relationship to mental health. While members of TNB communities in their own 24 words differentiate the concepts of sexuality, gender, and gender expression,10-13 gender expression is a concept regularly and inappropriately interchanged with sexuality and gender in the health science literature. Ample research highlights the health disparities and discrimination faced by TNB communities,4,14 including disparities and discrimination even within transgender communities perpetrated through transnormativity and transmisogyny (see Table 1 for definitions).10,11,15,16 Additionally, trans women and other trans feminine individuals face far elevated levels of mental and physical trauma and violence compared to their transmisogyny- exempt (TME) peers, directly related to their gender and gender expression through pervasive transmisogyny.1,3,17-19 Table 1. Terminology Term Definition Gender “one’s internal, deeply held sense of gender. Some people identify completely with the gender they were assigned at birth (usually male or female), while others may identify with only a part of that gender, or not at all.” (It Gets Better Project, 2021) Sexuality Sexuality is fluid and “multifaceted, including elements of attraction, sexual behavior, erotic-affectional behavior and fantasies, emotional attachments, self-dentification, and current relationship status” (Callahan & McGuire, 2021, p. 2). Transgender “Someone whose gender identity differs from the one that was assigned to them at birth.” (It Gets Better Project, 2021) Cisgender “A person whose gender identity matches the gender they were assigned at birth.” (It Gets Better Project, 2021) Gender expansive “Someone whose gender identity and/or gender expression expands beyond, actively resists, and/or does not conform to the current cultural or social expectations of gender, particularly in relation to male or female.” (It Gets Better Project, 2021) Transmisogyny Discrimination based not on the failure to “conform to gender norms per se, but because of the specific direction of their gender transgression – that is because of their feminine gender expression and/or their female gender identities.” (Serano, 2021) Transmisogyny- affected (TMA) Trans people “who would be recognized as men by their genitals at birth [and] reject manhood from an informed position.” “The violence against TMA people is the system rejecting their femininity.” (Harsis, 2021). Examples include trans women and other trans feminine people, including non-binary trans feminine people. Transmisogyny- exempt (TME) Trans people who “share the oppression and effects of general transantagonism but are exempt from the specific oppression of transmisogyny.” “The violence directed at TME people lies in the system categorizing them as feminine.” (Harsis, 2021) 25 Transnormativity “A hegemonic ideology that structures transgender experience, identification, and narratives into a hierarchy of legitimacy that is dependent upon a binary medical model and its accompanying standards, regardless of individual transgender people’s interest in or intention to undertake medical pathways to transition.” Johnson, 2016, p. 466 Transmedicalism “transmedicalism [is] an ideology stipulating that both gender dysphoria and (a strong desire for) medical transition are required in order to be considered ‘genuinely’ transgender. Often referred to in short, by themselves and others, as simply transmedicalists (and sometimes as truscum or transfundamentalists), those who subscribe to this view ratify medical authority in regulating transgender experience, insisting that deviating from the established medical model undermines public acceptance of trans communities and trivializes ‘authentic’ trans experiences.” (Konnelly, 2021, p. 3) In a 2018 systematic review of transgender and queer violence, gender expression and gender (used erroneously in the paper as “gender identity” when referring to transgender people and simply as “gender” when referring to cisgender people) are consistently used as synonyms in the literature.20 Even though sexuality, gender, and gender expression related violence often occur simultaneously and cannot be separated,11 understanding the separate concepts is crucial for research in TNB communities. The fluidity and relationship among sexuality, gender and gender expression create the complex and dynamic identities and experiences within TNB communities. A shared definition and operationalization of gender expression allows for an accurate description of personal experiences and acknowledges the impact of the perceptions of others on an individual’s health. This principle-based concept analysis clarifies the concept of gender expression and provides a theoretical definition for use in health science research with the aim of appropriate and accurate use when working with TNB communities. Data Sources Scientific Data Sources Scientific data were gathered from three journal databases: PubMed, CINAHL, and PsycINFO. With the assistance of a health sciences librarian, an exploration of search terms was used to determine which terms would yield the results of interest. Combinations of gender, expression, identity, transgender, presentation, feminine, and masculine were entered into each 26 search engine and a preliminary survey of results was conducted. The MeSH/Subject headings of “gender identity”, “sexual and gender minorities,” and “transgender persons” were used in PubMed and CINAHL which yielded results predominantly conflating “transgender” with “transsexual” and “gender expression” with “gender.” In general, the terms “gender expression” and “gender presentation” yielded the most relevant results. Within PsycINFO, using the subject headings of ‘gender identity’ and ‘transgender’ further refined the search. Table 2. Data Sources Database Search Terms Results Reviewed PubMed “gender presentation” “gender expression” 76 results 229 results All abstracts reviewed All abstracts reviewed CINAHL “gender presentation” “gender expression” “gender” AND “expression” “gender” AND “expression” AND “masculine” “gender” AND “expression” AND “feminine” 28 results 3656 results 2653 results 55 results 356 results All abstracts reviewed Yielded predominately gender with no differentiation between concepts Yielded predominately gene expression All abstracts reviewed All abstracts reviewed with high incidence of medical transition related results PsychINFO “gender” AND “expression” with heading of gender identity with heading of transgender 7552 results 441 results 84 results Yielded predominately gene expression Yielded predominately gender with no differentiation between concepts All abstracts reviewed Inclusion criteria for review were as follows: (1) full text available online, (2) research conducted and written in English, and (3) contained an explicit definition of gender expression AND/OR measured gender expression. The aim was to see how gender expression is being utilized in the literature, noting but not focusing on improper uses. Articles were excluded if gender and gender expression were used interchangeably or if gender expression was used to mean gender or vice versa. Articles focusing on transmedicalism and sexualization of trans bodies were excluded as they resoundingly ignored the perspective of the participants and used gender and gender expression as synonyms. The search yield 472 abstracts for review, with 28 articles meeting inclusion criteria. 27 Historical Literature Data Sources A small sampling of historical literature was sought to provide context, support, and perspective to the concept analysis. Looking from a historical perspective, a few of the ‘classic’ pulp fiction books were consulted including the memoir, Women’s Barracks by Tereska Torres,21 which is touted as the first lesbian pulp fiction book. Song of the Loon by Richard Amore,22 hailed as the first gay romance without a negative ending, provided additional insight into gender expression. Leslie Feinberg, a gender expert active in the 1980s to present, served as the source of information for the end of the twentieth century. To bridge the gap between the pulp literature of the 1960s to the 1980s, gender expression was reviewed in Maupin’s Tales of the City23 series which began in 1978, introducing some of the first queer characters to mainstream media. Whipping Girl by Julia Serano3 provided insight into trans women’s experiences in the early 2000s. Social Media Data Sources Social media sources included writers exploring the nuances of gender on Twitter and Medium.com. Focus was placed on the writings and perspectives of TMA people, especially TNB women and feminine individuals, as the majority of scientific articles and popular books reviewed highlighted TME people, especially those with the masculine-of-center experience. TMA sources on Twitter (handles) included jurist and bioethicist Florence Ashley (@ButNotTheCity), abolitionist health ethicist and nurse Em Rabelais (@Dr_Whomever), physician Elle Lett (@ElleLettMDPhD), law professor T. Anansi Wilson (@blaqueerflow), and several others, including Cat Harsis (@PurrCatharsis) and Bae Eli (@beaelix). Due to the expansive and difficult-to-locate nature of TNB communities’ documented experiences, these accounts served as examples and by no means constitute the complete experience of gender expression within different TNB communities. 28 Overview of the Concept For many TNB communities, gender expression is influenced by one’s concept of self, one’s gender, societal norms and pressures, complex situational interactions, and previous experiences. Using principle-based concept analysis methodology adapted from Penrod and Hupcey, the use of gender expression was examined in the western scientific literature, historical literature, and social media based on the following four principles: epistemological, pragmatic, linguistic, and logical.24 In western health science literature, gender expression is often used as a surrogate or synonym for gender, or left unidentified all together, creating ambiguity and difficulty with generalization of findings. Because the principle framework for concept analysis explicitly excludes community-derived literature and other representations of lived experience,24 we adapted the methodology to include Queer and TNB voices past and present through social and historical data sources in the analysis. Exploring the concept as used by community members ensure the gap in the scientific literature is adequately addressed. Within the TNB context, gender expression is clearly defined and consistently used in social media as well as in historical lesbian and gay writings. The analysis resulted in substantial evidence in support of utilizing gender expression as a situationally and contextually relevant concept, independent of gender and sexuality, to more accurately understand the nuances of the TNB experience. From the adaptation of Penrod and Hupcey’s methodology, a theoretical definition emerged, suitable for operationalization and validation in different TNB communities. Design The principle-based concept analysis, developed by Penrod and Hupcey,24 creates a clearly defined and operationalizable concept for use in scientific research. A common definition is required to maintain consistent use across different research settings. Concepts are refined through rigorous examination across four domains resulting in a delineation of concept boundaries.24 While Penrod and Hupcey argue that looking at the casual or social meaning of a 29 concept is not pertinent to the principle-based concept analysis,24 their methodology must be adapted when the concept is not well developed or defined in the scientific literature. In the case of gender expression, the health science literature is significantly lacking and lagging behind how TNB communities are currently using the concept. Without addressing the power, exclusion, and privilege inherent in academic research, there is no way to avoid epistemic injustice,25 hence the concept analysis methods required adaptation to center sources of knowledge within the community. Therefore, we explored uses of gender expression in the scientific as well as in historical literature and social media sources, allowing for the voices and experiences of those living the concept to be centered. Methods When scientific research is inherently biased, such as from cisheteronormative expectations of colonizing Christian societies and their current and former colonized territories and nations, social and popular media created by those with lived experience as TNB persons provide insights essential for a rigorous analysis. We conducted the analysis first with health science literature and then supplemented with historical and social media sources created by TNB people, as described above. The stories told through historical fiction and modern social media hold the truths of life experiences and were given epistemological consideration on par with the health science literature. Fiction, memoirs, and social media sources provided depth and elucidated the complexity of the concept of gender expression. The use of gender expression in the health science literature, historical literature, and social media was critiqued using the following four principles: epistemological, pragmatic, linguistic, and logical. See Table 3 for application of these principles in the context of gender expression. 30 Table 3. Guiding Principles24, Application to Concept, and Scientific Exemplars of Gender Expression Principle Definition Application Exemplar Epistemological “Is the concept clearly defined and well differentiated form other concepts?” Is the concept defined within the scientific literature as defined by the community and media? “How a person presents their gender to the external world” (Sevelius et al., 2021) Pragmatic “Is the concept applicable and useful within the scientific realm of inquiry? Has it been operationalized?” How has gender expression been operationalized and for what purposes? “Do you see yourself as more masculine or more feminine than most other men/women?” (2) “Do you think people see you as more masculine or more feminine than most other men/women?” (Sandfort et al., 2018) Linguistic “Is the concept used consistently and appropriately within context?" Where are the consistencies and inconsistencies in use? Inconsistent: Used self- reported masculinity/femininity on a scale under the category of “gender” (Everett et al., 2019) Logical “Does the concept hold its boundaries through theoretical integration with other concepts?” Is gender expression distinct from related concepts such as sexuality and gender identity? “Not necessarily an identity but is rather the ways in which one’s gendered understanding of self is embodied and communicated to others” (Anderson, 2020) Epistemological Principle Penrod and Hupcey define the epistemological principle as the concept’s clear definition within the discipline.24 Sevelius and colleagues defined gender expression simply as “how a person presents their gender to the external world,”26 and, while succinct, it does not capture the potential fluidity of both gender and gender expression. Gender expression includes self- identified gender concepts of masculinity and femininity, societal gender roles and norms, gender itself,9,12,27 and any resistance to these concepts, roles, norms, and understandings. Gender expression is manifested through one’s outward presentation of gender including appearance, clothing, hairstyle, voice, make-up, posturing, and gesturing.9,28 The focus of gender expression is how one is perceived by the outside world. Table 4 contains the myriads of 31 similar definitions of gender expression found in the scientific literature providing clear evidence that the concept definition is well developed. When evaluated using Penrod and Hupcey’s epistemological principle criterion,24 gender expression as a concept is clearly defined and easily differentiated from similar concepts within the health science literature (more below under Logical Principle). Due to the rigorous analysis available within the scientific literature, the historical literature and social media sources are not discussed for this principle; however, epistemologically the definition in these sources mirrored the scientific literature findings.3,23,29 Table 4. Gender Expression Definitions Definition Source “One’s outward expression of gender along two spectra related to expressing masculine or feminine characteristics.” Hamilton et al., 2019, p. 150 “How a person presents their gender to the external world.” Sevelius et al., 2021, p. 1 “Ways in which an individual enacts their thoughts, beliefs about their gender or their gender self-concepts, such as femininity and masculinity of their appearance and behavior. It is a combination of an individual’s own view of their gender identity and their knowledge of, and prescription to, sociocultural gender norms, expectations, and attitudes.” Beltz et al., 2021, p.?? How “individuals express their unique gender identities through behavior and outward appearance.” Pardo, 2019, p. 121 “The ways in which an individual expresses their gender.” Twist & De Graaf, 2019 “The manifestations of an individual’s sense of being masculine and/or feminine through the use of names, clothing, hair style, accouterments, and body movements.” Anderson, 2020, p. 324 Pragmatic Principle The pragmatic principle determines the concept’s usefulness within the discipline.24 Additionally, how the concept has been operationalized in research is assessed, and specifically, how gender expression was measured and for what purpose was it measured within the health science literature.24 In the majority of the reviewed literature, gender expression was confined to the binary realm of masculine and feminine. Gender expression has been measured on a scale with some variation of the question: Do you see yourself as masculine/feminine? (scale: 0=not at all masculine/feminine to 5-extremely masculine/ feminine).6,10,27,30-34 A few studies allowed for participants to respond on separate scales of masculinity and femininity 32 rather than requiring them to be either masculine or feminine exclusively.27,28,31 Within the sexuality label of lesbian, gender expression was measured on scales of butch/stone butch and femme instead of, or in addition to, feminine and masculine.12,29,35 Even though assessing gender expression through a binary lens is problematic as it negates the existence of the spectrum of experience, it still upholds unique boundaries of gender expression. A few studies broke down the measurement of gender expression further into core components. Beltz and colleagues asked participants what the concepts of masculine and feminine meant to them in the context of their responses rather than relying on social roles.27 Levitt and colleagues asked how a participant was most comfortable expressing their gender rather than assuming that one always expresses in a consistent manner.35 Breaking down gender expression into “gendered behavior” based on social norms and “dress style and appearance” allowed for more flexibility and range of description of expression.28 Twist and De Graaf offered the most comprehensive and inclusive measurement of gender expression.34 Participants were asked to rank the top five factors that influence expression and define gender expression as “the ways in which an individual expresses their gender” allowing for the consideration of external appearance, name and pronouns, the physical body, and intrinsic factors such as personality, confidence and self-understanding,34 providing opportunity for more nuanced measurement of gender expression. Thus, despite some major flaws in the measurement of gender expression, it is a concept with high usefulness within the research arena and upholds the pragmatic principle.24 Linguistic Principle The linguistic principle focuses on the consistency and appropriateness with which the concept is used in the scientific literature.24 The linguistic principle also requires consideration of context and the level of context dependency. While maintaining consistency with the concept’s epistemological and pragmatic principles, a few additional terms are seen to describe gender expression. These are congruent with the concept, representing merely alternative terms for 33 gender expression. The term “perceived gender presentation” captures the aspect of gender expression by which the person themself perceives that the outside world will understand their own gender expression,34 maintaining consistent use as it is measured on a masculine to feminine scale. Gender presentation and gender expression are used synonymously without concept confusion.9-12,31,34,36 However, as more research is done in this area, there may be significant differences between these terms resulting in two separate concepts. It is reasonable to expect that there are aspects or concepts yet to be defined or identified within gender expression that may need to be further refined as understanding of the various aspects emerge as distinct from one another. When examining gender expression as distinctly different than other previously encompassing concepts such as gender and sexuality, inconsistencies and incorrect uses of the concept are found frequently in the health science literature. Everett and colleagues used a self- report of masculinity and femininity under the heading of ‘gender’.30 This is potentially consistent with the concept of gender expression; however, with a category of ‘gender’ it is impossible to ascertain, by reading the paper alone, what the authors intended to measure and therefore epitomizes the conflation of gender and gender expression. Grossman and D’Augelli as well as Blondeel and colleagues used gender expression and gender as synonyms.20,37 Gender expression intersects with context, especially in the consideration of safety,3,17,24,29,34,38-41 yet it is not entirely dependent, as it changes and fluctuates across situations and context. As the concept of gender expression is linguistically underdeveloped in the health science literature, we proceeded with a contextual analysis and examined gender expression in the grey literature. The lesbian pulp fiction stories of Beebo Brinker and Pat Conway from the 1950’s and 60’s are exemplary, as they consistently have the characters altering their gender expression based on the situations they find themselves, personal preferences, and most often for safety, yet their gender—all characters are women—is never in question.21,38-40,42 When the scientific and historical literature are analyzed together, gender 34 expression meets criteria for the linguistic principle, maintaining consistency of use across multiple contexts. Logical Principle The logical principle asks, “does the concept hold its boundaries through theoretical integration with other concepts?”24 To explore the boundaries of gender expression, the following application was used: Is gender expression distinct from related concepts such as sexuality and gender? Almost all the scientific literature that discussed gender expression also discussed gender and/or sexuality, creating an excellent opportunity to clearly see the boundaries between two highly related and often incorrectly conflated concepts. Gender expression remained related to but independent of gender consistently in historical literature, social media and sometimes in the scientific literature. Due to the inconsistency in use in the scientific literature, analysis relied heavily on the grey literature, Gender expression is “not necessarily an identity but is rather the ways in which one’s gendered understanding of self is embodied and communicated to others”.9 In the pulp novel The Third Street, Pat’s gender identity does not change when she goes “the whole works…aquamarine eye shadow, a brushing of pale lipstick” versus the “open-throated man’s shirt” she preferred.40 Clear examples highlighting the difference between gender expression and gender include that surgery for chest masculinization is sought by transgender men as well as non-binary individuals and cisgender men,41 and breast augmentation is undertaken by transgender women, non-binary individuals, and cisgender women.3 Even when the terms used to describe gender and gender expression are the same, an example being butch/femme, the distinction between concepts is maintained as separate categories with separate meanings.29,35 Hamilton and colleagues acknowledge that gender expression is along a spectrum of butch/femme or masculine/feminine characteristics with many combinations.12 Hetzel and Mann pushed the distinction between the two concepts farther by asking participants if there was a connection 35 between their gender and their gender presentation, making no assumptions about the relationship.36 In the both the scientific and historical literature, there are definite boundaries between gender expression and sexuality. Bannon clearly notes the distinction between concepts through her character Beebo, when she asks, “But can’t you just tell by looking at them that they’re – Lesbian?” and is promptly corrected that you cannot tell a person’s sexuality by their gender expression.39 Maupin provides the same explanation to Mary Ann in Tales of the City.23 Different sexualities may have prescribed gender presentations as seen with lesbian butch/femme expectations; however, the concepts do not blend.35 Dimberg and colleagues found there was increased difficulty in social interactions when gender presentation was incongruent with expected sexuality, but again the concepts remained separate.5 Based on the logical principle, the concept of gender expression “holds its boundaries” in discussion with related and similar concepts.24 Discussion Exploring a concept through its interactions with related concepts brings it out of the theoretical and into the practical realm. Separating gender expression from sexuality and gender allows for more accurate descriptions of the experiences of TNB communities. As highlighted in the literature, both scientific and community generated, the concept of gender expression is not new and is an integral component of TNB communities’ experiences navigating an often hostile world.1-3,10,17 Utilization of a theoretical definition and understanding of gender expression will improve researchers’ the ability to capture the nuanced experiences of those pushing gendered societal expectations. In turn, a definition will also help capture the experiences of those conforming to gendered societal expectations. How much of the well-documented discrimination2,11,15,16 is from sociopolitical responses to gender expression versus gender? How much of the mental health distress2,4 stems from experiences around gender expression rather than with gender or 36 sexuality? What is the interaction and impact of these concepts? How does transmisogyny change a person’s response to gender expression? What is the impact of other marginalized identities on gender expression and the subsequent life experiences? Feminine gender expression is highly policed and weaponized, resulting in harm to women and TNB feminine individuals.1-3,10 It is urgently critical to operationalize gender expression when considering the experiences of TNB women and feminine individuals, and even more so with those who are transmisogyny-affected, because policing and weaponizing of feminine gender expression is done with higher intensity for TMA than TME people.43,44 In order to understand the impact of gender expression on the mental and physical well-being of TNB women and feminine individuals, gender expression must be better conceptualized within the health science community. Only through clear conceptual definition can these differences be studied and the lived experiences of TNB communities be understood. Theoretical Definition Using the analysis from the principle-based concept analysis, the following theoretical definition of gender expression was developed. Gender expression is how an individual chooses to convey aspects of their identities to the outside world. It is multifaceted and fluid. Gender expression is influenced by one’s concept of self, one’s gender, and responses to social influences, complex situational interactions, and previous experiences. Gender expression manifests in the ways an individual dresses, wears their hair, behaves, speaks, postures, gestures, and adopts various gendered roles. This definition can be operationalized when conducting relevant research and will provide a shared understanding of meaning for discussion. The theoretical definition is also congruent to the experience of western TNB communities, increasing the value of the research generated, humbly noting much more work needs to go into understanding relationships of gender expression and other concepts, such as racism and ableism. When the concept is utilized, 37 gender expression can be operationalized in research without any need to reference a person’s sexuality or gender unless it is directly relevant to the study aims. As understandings of TNB communities by clinicians and researchers has increased, gender expression has emerged from its related concepts in the scientific literature. Grounding the definition in the historical and community understanding of the concept through rigorous analysis provides a basis for research going forward. More terms are being employed by different TNB communities to describe their experience in the world, and the health science research community has an opportunity to catch up. Consciously bringing gender expression into research allows for participants to better describe their experiences, allows for researchers to measure the adjacent concepts accurately, and improves the overall quality and relevancy of the work. Limitations The inclusion criteria limited the studies reviewed to English. This regrettably created a study participant pool comprised mainly of white individuals residing in high-income countries. Much of the literature analyzed assumed binary and white social expectations for gender expression, and in doing so is generating science that adheres to a white cisheteronormative lens, though this is not unexpected given that residents in most English-speaking countries are descendants of colonizing nations. The understandings of the concept of gender expression may be vastly different in Black, Indigenous, and other communities of color, communities residing in middle- and low-income countries, communities in countries where English is not (commonly) spoken, and communities in other cultural contexts. Additionally, many of the articles reviewed consisted of participants described as “assigned female at birth”. This resulted in a lack of generalizability to populations beyond these parameters and most likely without consideration for transmisogyny. The principle-based framework for concept analysis explicitly excludes community- derived literature and other representations of lived experience;24 as such, these documents 38 were included as a methodology adaptation out of necessity for this analysis. While some historical literature and social media may be included in the humanities, this analysis did not take on a comprehensive review of humanities literature, and it is important to note that this analysis was unable to account for the wealth and variety of popular and social media contributions from outside of the health science literature. Conclusion As health science researchers continue to strive to reduce health disparities and move towards health equity, understanding the experiences of TNB communities is essential. A shared definition of the concept of gender expression is just one step towards improving the integrity of research with TNB communities. For an example of the impact and significance of gender expression for those in TNB communities, consider Jess’ experience in Stone Butch Blues: “They took me to get my first sports coat and a tie at the secondhand stores...Jackie smoothed my lapels and nodded in approval…I had died and gone to butch heaven.”29 In order to research and discuss TNB communities, the concept of gender expression must be acknowledged and utilized accurately by researchers. Capturing the complexity of an individual’s experience allows for validation and a deeper exploration of the interactions and intersections impacting overall health outcomes. Gender expression is the external construct that interacts with the world (as opposed to the often-internal constructs of sexuality and gender) and therefore must be understood to advocate for more suitable environmental adaptations for the wide and varied expressions of TNB individuals. 39 References 1. Harsis C. Gender is not what you think it is. Medium 2018. 2. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 U.S.Transgender Survey.: Washington, DC: National Center for Transgender Equality; 2016. 3. Serano J. Whipping girl : a transsexual woman on sexism and the scapegoating of femininity. Second edition. ed. Berkeley, CA: Seal Press; 2016. 4. Hobster K, McLuskey J. Transgender patients’ experiences of health care. British Journal of Nursing. 2020;29(22):1348-1353. 5. Dimberg SK, Clark DA, SpaniermanL.B., VanDaalen RA. "School shouldn’t be something you have to survive”: Queer women’s experiences with microaggressions at a Canadian university. Vol 68. Journal of Homosexuality2021. 6. Gordon AR, Austin SB, Schultz J, Guss CE, Calzo JP, Wang ML. Gender expression, peer victimization, and disordered weight-control behaviors among U.S. high school students. Vol 68. Journal of Adolescent Health2021. 7. Gower AL, Rider GN, Coleman E, Brown C, Mcmorris BJ, Eisenberg ME. Perceived Gender Presentation Among Transgender and Gender Diverse Youth: Approaches to Analysis and Associations with Bullying Victimization and Emotional Distress. LGBT Health. 2018;5(5):312-319. 8. Mathers LAB. Bathrooms, Boundaries, and Emotional Burdens: Cisgendering Interactions Through the Interpretation of Transgender Experience. Symbolic Interaction. 2017;40(3):295-316. 9. Anderson SM. Gender matters: The perceived role of gender expression in discrimination against cisgender and transgender LGBQ individuals. Vol 44. Psychology of Women Quarterly2020. 10. Arayasirikul S, E.C. W. Spilling the T on transmisogyny and microaggressions: An intersectional oppression and social process among trans women. Vol 66. Journal of Homosexuality2019. 11. Bradford NJ, Rider GN, Catalpa JM, et al. Creating gender: A thematic analysis of genderqueer narratives. International Journal of Transgenderism. 2019;20(2-3):155-168. 12. Hamilton KM, Park LS, Carsey TA, Martinez LR. “Lez be honest”: Gender expression impacts workplace disclosure decisions. Vol 23. Journal of Lesbian Studies 2019. 13. Marquez AC. Displaying gender: Transgender people’s strategies in everyday life. Vol 42. Symbolic Interaction 2019. 14. Ding JM, Ehrenfeld JM, Edmiston EK, Eckstrand K, Beach LB. A Model for Improving Health Care Quality for Transgender and Gender Nonconforming Patients. The Joint Commission Journal on Quality and Patient Safety. 2020;46(1):37-43. 15. Darwin H. Doing Gender Beyond the Binary: A Virtual Ethnography. Symbolic Interaction. 2017;40(3):317-334. 16. Richards C, Bouman WP, Seal L, Barker MJ, Nieder TO, T’Sjoen G. Non-binary or genderqueer genders. International Review of Psychiatry. 2016;28(1):95-102. 17. Hudson KD. (Un)doing Transmisogynist Stigma in Health Care Settings: Experiences of Ten Transgender Women of Color. Journal of Progressive Human Services. 2019;30(1):69-87. 18. Noack-Lundberg K, Liamputtong P, Marjadi B, et al. Sexual violence and safety: the narratives of transwomen in online forums. Cult Health Sex. 2020;22(6):646-659. 19. Wirtz AL, Poteat TC, Malik M, Glass N. Gender-Based Violence Against Transgender People in the United States: A Call for Research and Programming. Trauma Violence Abuse. 2020;21(2):227-241. 40 20. Blondeel K, De Vasconcelos S, García-Moreno C, Stephenson R, Temmerman M, Toskin I. Violence motivated by perception of sexual orientation and gender identity: a systematic review. Bulletin of the World Health Organization. 2018;96(1):29-41L. 21. Torres T. Women's Barracks: Fawcett Publications, Inc.; 1950. 22. Amore R. Song of the Loon: Greenleaf Classics; 1966. 23. Maupin A. 28 Barbury Lane: Tales of the City Books 1-3: Harper Perennial; 2016. 24. Penrod J, Hupcey JE. Enhancing methodological clarity: principle-based concept analysis. J Adv Nurs. 2005;50(4):403-409. 25. Paradis-Gagné E, Pariseau-Legault P. Critical Research and Qualitative Methodologies: Theoretical Foundations and Contribution to Nursing Research. Research and Theory for Nursing Practice. 2022;36(2):119-138. 26. Sevelius JM, Chakravarty D, Dilworth SE, Rebchook G, Neilands TB. Measuring Satisfaction and Comfort with Gender Identity and Gender Expression among Transgender Women: Development and Validation of the Psychological Gender Affirmation Scale. International Journal of Environmental Research and Public Health. 2021;18(6):3298. 27. Beltz AM, Loviska AM, Weigard A. Daily gender expression is associated with psychological adjustment for some people, but mainly men. Scientific Reports. 2021;11(1). 28. Pardo ST. Toward a new theory of gender transcendence: Insights from a qualitative study of gendered self-concept and self-expression in a sample of individuals assigned female at birth. International Journal of Transpersonal Studies. 2019;38(1):118 – 139. 29. Feinberg L. The Stone Butch Blues: Firebrand Books; 1993. 30. Everett BG, Steele SM, Matthews AK, Hughes TL. Gender, Race, and Minority Stress Among Sexual Minority Women: An Intersectional Approach. Archives of Sexual Behavior. 2019;48(5):1505-1517. 31. Matheson L, Oritz DL, Hoskin RA, Holmberg D, Blair KL. The feminine target: Gender expression in same-sex relationships as a predictor of experiences with public displays of affection. The Canadian Journal of Human Sexuality.30(2):205 - 218. 32. Rider GN, Mcmorris BJ, Gower AL, Coleman E, Eisenberg ME. Health and Care Utilization of Transgender and Gender Nonconforming Youth: A Population-Based Study. Pediatrics. 2018;141(3):e20171683. 33. Sandfort TGM, Bos H, Reddy V. Gender Expression and Mental Health in Black South African Men Who Have Sex with Men: Further Explorations of Unexpected Findings. Archives of Sexual Behavior. 2018;47(8):2481-2490. 34. Twist J, De Graaf NM. Gender diversity and non-binary presentations in young people attending the United Kingdom’s National Gender Identity Development Service. Clinical Child Psychology and Psychiatry. 2019;24(2):277-290. 35. Levitt HM, Puckett JA, Ippolito MR, Horne SG. Sexual minority women's gender identity and expression: challenges and supports. J Lesbian Stud. 2012;16(2):153-176. 36. Hetzel CJ, Mann K. The social psychological dynamics of transgender and gender nonconforming identity formation, negotiation, and affirmation. Journal of Social and Personal Relationships. 2021;38(9):2566-2586. 37. Grossman AH, D'Augelli AR. Transgender Youth. Journal of Homosexuality. 2006;51(1):111-128. 38. Bannon A. Women in the Shadows: Clies Press, Inc.; 1959. 39. Bannon A. Beebo Brinker: Clies Press, Inc.; 1962. 40. Ellis J. The Third Street: Tower Publications; 1964. 41. Stein A. Unbound : transgender men and the remaking of identity. First edition. ed. New York: Pantheon Books; 2018. 42. Hastings M. Her Private Hell: Tower Publications; 1963. 41 43. Harsis C. We need to talk about transmisogyny. Medium2020. 44. Harsis C. On transmisogyny exempt privilege dynamics. Medium2021. 42 Chapter Three The Gender Expression Process: Operationalization and Implications for Data Collection 43 Abstract Aims/Purpose: Transgender and Non-Binary (TNB) individuals make up approximately 2% of the US population with ample research highlighting the mental health consequences such as depression, anxiety, and suicide from the daily discrimination faced by this community. The internal process and external manifestation of gender is often what triggers violence and discrimination. Research reports have repeatedly found that discrimination, violence, and rejection are related to both gender and gender expression as separate concepts, however it has not successfully operationalized gender expression as a measurable construct. The aim of this study was to describe the experience of navigating gender expression for TNB individuals, including identifying factors influencing gender expression in various contexts and social situations for operationalization in health science research. Methods: Participants were recruited during Seattle’s Pride Festival 2023. Interviews were conducted via videoconferencing, and participants received a $50 gift card for their time. Interviews were transcribed verbatim and analyzed using Atlas.ti. Dimensional analysis, based within constructivist grounded theory methodology, was employed to determine the context and boundaries of gender expression. Results: The process of gender expression is a balancing act of four distinct but intertwined dimensions: (1) conservative/alternative expression, (2) authenticity, (3) euphoria/dysphoria, and (4) level of energy/effort. This balance is constantly being weighed and altered based on additional influences (politics, safety, context, expectations, etc.) resulting in how someone ultimately shows up in the world at any given point in time. Understanding where someone is situated within these dimensions gives insight into their mental/emotional workload as well as how they are being perceived by the outside world, both of which impact mental and physical health. This process was reported across genders and gender expressions of participants. Conclusion/Impact: In order to understand the aspects of identity that impact experiences in the world, such as discrimination and violence, we need to measure these aspects accurately. 44 The current practices of measuring gender are inadequate to understand the experiences of transgender and nonbinary people. Operationalizing gender expression gives a clearer picture of how that person interacts with their environment and social situation and may prove to be more predictive of negative and discriminatory experiences than gender alone. 45 Introduction Transgender and Non-Binary (TNB) individuals make up approximately 2% of the US population with ample research highlighting the mental health consequences, such as depression, anxiety, and suicide from the daily discrimination, faced by this community.1,2 It is often gender expression, defined as the external situational and contextual construct within which one interacts with the world (as opposed to the often internal constructs of gender), that triggers violence and discrimination.1,3 Pervasive discrimination, violence, and poor mental health outcomes emerge as constants for all under the trans umbrella, despite inaccurate and insufficient data collection.1 Transgender women and other trans feminine individuals face even more discrimination and violence than their trans masculine counterparts due to pervasive transmisogyny.4-6 Additionally, very little research has been focused explicitly on non-binary (NB) populations.7 The cisgender, heteronormative, white supremist lens of western research has limited the exploration of the vastness of human gender and sexuality experiences in health science literature8 resulting in the conflation of gender and gender expression;9 the persistence of cisgender, heteronormative, binary assumptions;10,11 and the continuation of transmisogynistic research.6,12,13 What research does exist has repeatedly found that discrimination, violence, and rejection is related to both gender and gender expression as separate concepts;14 however, it has failed to explore the process and complexity of gender expression. The purpose of this study is to describe the experience of navigating gender expression for TNB individuals, including identifying factors influencing gender expression in various contexts and social situations. This description is a critical first step and informs the operationalization of gender expression in health science research. 46 Approach Methodological orientation Within the grounded theory tradition, a constructivist approach15 allows for the conceptualization of multiple realities and accounts for the contextual influence inseparable from the experience and process of gender expression. Constructivist grounded theory (CGT) moves beyond traditional grounded theory to incorporate the perspective and positionality of the researcher and the context and conditions in which phenomena occur.15 Utilizing CGT methodology, analysis of contradicting data is pursued rather than dismissing outliers.16 When considering gender expression, social and situational contexts, and identity intersections will likely result in a multitude of unique processes and experiences that will need to be addressed and incorporated into the larger analysis. Charmaz, as well as Clarke and colleagues, highlight the flexibility in CGT to pursue emerging themes and dive deeper into concepts as they arise from in-depth interviews, while focusing on the construction of information from specific contexts and conditions rather than discovery.15,16 Due to the unknown nature of gender expression, it is critical to have the ability to alter the interview direction in order to pursue concepts and themes as they are revealed through constant comparison and to theoretically sample for completeness of concept.15 Dimensional Analysis. Dimensional analysis came out of the grounded theory tradition as a mechanism to describe the process used to understand and make meaning from complicated experiences or phenomena.17,18 The focus on the dynamic interactions of components or dimensions allows for the exploration of complex social phemonena.18 Like other grounded theory methods, the description of the process is done linearly; however, the actual method is iterative and simultaneous.17,18 The analysis process begins with the identification of the data and its subsequent contribution to the various components of the phenomena under study.18 The key question under scrutiny with dimensional analysis is; “What all is involved here?”18 The 47 researcher is active in this process, considering all of the possibilities and interactions at play.18 As the process continues and dimensions emerge, designation labels are applied to these dimensions.18 Theoretical memos are written throughout the process to track lines of inquiry and formulations of theory.18 Each dimension is explored for explanatory power for the phenomena under study.18 Once the dimensions have been determined and exhausted, they are organized within the explanatory matrix which grounds the analytical process.18 The explanatory matrix frames the dimensions in the following categories: perspective, context, conditions, processes, consequences.18 Perspective denotes the dimension that provides significant depiction of the phenomenon under study.18 Context refers to the situations in which the dimension resides with attention to defining the boundaries.18 Conditions include the facets with potential to facilitate, mitigate, or mediate interactions within the preceding context.18 Process is induced by the conditions producing both expected and unexpected actions and interactions.18 Finally, the consequences encompass the results of the context, conditions, and process and echo the key perspective.18 As the different dimensions are assessed in each of the aspects of the explanatory matrix, the dimension with the most explanatory power is centered as the “key perspective” within to contextualize the data and the lesser explanatory dimensions move into the other positions depending on the relationship with the key dimension.17,18 Once the key perspective is identified, analysis is aimed at specificizing and testing the links of the theory until theoretical saturation is achieved.17 Recruitment Participants were recruited during Pride weekend in a large, West Coast urban setting. Study information was disseminated via posters on telephone poles placed in PRIDE festival high traffic areas and flyers distributed during the main PRIDE parade. Both the posters and the flyers contained a QR code linking to the participant interest survey. The survey included the inclusion criteria: (1) 18 years old or older, (2) reside in the Unites States, and (3) are transgender and/or non-binary and asked interested participants to leave their name and email 48 contact information, recognizing that cellular or internet access was required to enroll. All interested participants were contacted by the PI via email. Once eligibility was determined, an interview date and time was set at a convenient time for the participant and to be performed via videoconferencing. An informational consent documents was sent via email at the time of scheduling and verbal consent obtained at the start of each interview. The study determined to be exempt by University of Washington Human Subjects Division. Data Collection Twenty-eight interviews were completed over two months. All interviews were conducted and recorded via HIPAA-compliant videoconferencing software. Intensive interviewing was employed to ascertain participants’ experiences and how they contextualize those experiences.15 A semi-structured interview guide allowed for deeper probes into emerging factors that influenced a participant’s gender expression, including asking participants to “describe and reflect” on their experiences.15 Topics explored included: (1) describing gender, (2) describing gender expression, (3) feelings associated with gender expression, (4) gender expression process, (5) contextual and situational influences on gender expression, and (6) identity management. Terms, language, and emerging concepts from the analysis informed future iterations of the interview guide and the direction of subsequent interviews. Interviews ranged from 40 to 90 minutes depending on participant experiences. Participants were allowed to explore and follow lines of thought that they understood as relevant to their experience of gender expression without interference from the interviewer. Audio files from the interview were sent for professional transcription, resulting in verbatim, written transcripts of each interview. Field notes were taken during the interviews capturing nonverbal data and interviewer perceptions. Reflexive journaling19 was completed upon the conclusion of each interview to address personal connections, experiences, and bias that may have arisen during the interview process, with the intent of ensuring that influence from the PI’s own positionality was limited. 49 Additionally, all reflexive journaling included attention to interrogating methodology,15 potential transmisogyny, and white supremist ideology. Data Analysis Data analysis was primarily conducted with the aid of Atlas.ti software. As transcripts were obtained, they were uploaded into Atlas.ti, along with the field notes from the interview. Analysis occurred simultaneously with the addition of new interviews. Three types of memos were utilized throughout the process. Interview memos were created upon the completion of each interview to capture the initial concepts brought forward by each participant. Analysis memos provided the step by step thought process during analysis sessions, including coding choices, theme development, and dimensions to interrogate in future interviews. Theoretical memos tracked the process and rationale as concepts came forward with explanatory power. Analysis followed the three stages set forth by dimensional analysis, with each stage being processed and reprocessed as new data were brought in: (1) dimensionalizing/designation, (2) differentiation, and (3) integration/reintegration.17 Initially open coding was employed using gerunds as the codes whenever possible, congruent with process description.20 Dimensionalizing and designation began at the conclusion of the third interview. Codes were grouped into potential dimensions through their common properties creating new labels or designations. With each designation, a theoretical memo was generated describing the process and rationale for the designation including exemplar quotes. Codes contributed to multiple and changing designations as more data were brought into the analysis. The key explanatory concepts emerged through this iterative process. Once the key concepts were established, they were expanded to determine all of the properties attributed within each concept. This allowed for the broadest conceptualization of each explanatory dimension and the boundaries clearly articulated resulting in an emerging theory. The differential stage consisted of testing the identified dimensions in terms of their explanatory power. Several dimensions emerged as potential central perspectives and were assessed through examining the context, 50 conditions, process, and consequences of each potential perspective. One clear dimension, Equilibrium, came forward as providing the explanation within which to frame the other dimensions. Once the central perspective was determined, the process of integration and reintegration occurred. The various dimensions identified in the dimensionalizing/designation stage were utilized in the explanatory matrix in relation to the central perspective to formulate the final theoretical process. Rigor Rigor was attained through two main modalities: reflexive journaling and member checking. The PI engaged in structured reflexive journaling per the specifications set forth by Alvesson and Skoldberg.19 As the PI is also a transmisogyny-exempt community member5 with lived-experience of the topics explored, specific attention was paid to addressing transmisogynistic biases and keeping the participants’ experiences centered in the analysis. Member checking was completed during the integration/reintegration phase of analysis though consultation with three TNB community members with diverse identities and who were not participants in the study. Feedback was sought on the central premise and subsequent dimensions emerged. Discussion and review of each step in the process occurred between the PI and the primary mentor who has extensive experience in qualitative methodology. Results Sample Twenty-eight TNB individuals participated in the study (Table 1). The majority of the sample was young (under 30 years old) and white (75%), as anticipated by the recruitment methods and data from other studies (Table 2). Participants were allowed to describe their demographic characteristics through open ended questions allowing for use of whatever terms felt most authentic. This led to participants describing themselves with multiple terms resulting in counts higher than the study sample size. To preserve anonymity, cell sizes less than 2 were added to the additional categories provided by the participant. There was diverse representation 51 across genders and sexualities as well as a substantial percent of the sample identifying as disabled and/or neurodivergent. In the analysis and results, participants are referred to by their assigned number (ex. P3 refers to participant 3). Table 1. Recruitment Total Recruitment Survey Responses = 133 Recruitment Step Count % of Preceding Step % of total Contacted Participants Contacted 68 ~ ~ Participants Responded 40 58.8 58.8 Interviews Scheduled 37 92.5 54.4 Interviews Conducted 28 75.7 41.2 Table 2. Sample Characteristics (N=28) *Categories with cell sizes <2 were merged to closest category Characteristic Count (%) Age 18 – 24 25 – 30 31 – 40 > 40 13 (46.4) 6 (21.4) 4 (14.3) 2 (7.1) Disability 7 (25.0) Gender Non-binary Gender Queer Trans Man/Masculine/Male Trans Woman/Feminine/Female Transsexual Agender Gender Fluid Trans 11 (39.3) 6 (21.4) 6 (21.4) 4 (14.3) 3 (10.7) 3 (10.7) 2 (7.1) 2 (7.1) Neurodivergent 9 (32.1) Mental Health Diagnoses 7 (25.0) Race/Ethnicity White Hispanic/Latino Asian 21(75.0) 3 (10.7) 2 (7.1) Sexuality Bisexual Pansexual Queer Asexual Demisexual Lesbian 9 (32.1) 8 (28.6) 8 (28.6) 5 (17.9) 3 (10.7) 2 (7.1) 52 Dimensionalizing/Designation After the initial open coding of three transcripts, several dimensions appeared across experiences. Perceived risk, relationships, religion, social context, authenticity, politics, expectations, invalidations, self, transition, and many more concepts started building out the experiences of gender expression. As more data were added to the analysis, four dimensions emerged which encompassed the majority of codes and began to explain the phenomena of gender expression within the context of TNB experiences. Authenticity/Inauthenticity captured the level to which someone was able to be vulnerable and share themselves through gender expression. Conservative/Alternative encompassed the extent to which one does or does not adhere to the sociocultural gender expression expectations. Euphoria/Dysphoria includes the emotional feeling around all aspects of gender, gender expression, and the experience in the world. Level of Energy was comprised of emotional, physical, psychological energy, and effort required at any point in the process of gender expression. Differentiation The following dimensions were each tested as the central perspective: Authenticity, Conservative/Alternative, Euphoria/Dysphoria, and Level of Energy. During this analysis, the tension between each of the dimensions was overwhelming. Each dimension existed in relation to the other dimensions exerting varying levels of influence on the gender expression process. Achieving equilibrium across these four dimensions emerged as the central perspective with the most comprehensive explanatory power. Integration/Reintegration Once achieving equilibrium emerged as the central organizing perspective,18 subsequent interviews probed the experience of balancing the four dominant dimensions in terms of the context, conditions, process, and consequences. The complex and interrelated dimensions came together through this perspective of achieving equilibrium. Relationships between the dimensions through the lens of equilibrium were explored and solidified. Data collection and 53 analysis ceased when no new aspects of the dimensions or nuances of the explanatory relationships was reached. At this point, member checking occurred with three community members not associated with the study. They provided insight and feedback on the analysis, the explanatory matrix, and the conclusions being drawn. Unanimous agreement on the matrix was reached with no additional aspects or dimensions being added or noted. Dimensions Equilibrium Balancing the four dimensions of gender expression to reach a tenable equilibrium emerged as the central process of gender expression (Figure 1). “There is just all of these factors that my brain has to take into account to decide what I wear and how I look. Which is why I think it takes an exponentially large amount of space in my head.” (P7). This ever- changing balance results in the manifestation of gender expression. Figure 1. The Gender Expression Process (GEP) The balance between authenticity and the other dimensions, along with a myriad of other factors, such as social expectations and relationships, play a large part in the conditions and consequences of gender expression: “So I think a huge piece of this is just an internal struggle I have with how I think I’m supposed to be or how I think society thinks I’m supposed to be, which isn’t necessarily true, you know what I mean? It’s just an internal thing within me.” (P15). The balance of conservative and alternative expression exerts pressure in the process: “I’m always either playing into a stereotype or pushing against a stereotype I feel like when I am interacting 54 with people who believe in that binary.” (P26). The minimization of dysphoria and seeking euphoric feelings requires a consideration of many factors. This dimension is multifaceted, playing a role in the process of expression but also as an outcome of that expression: “I feel like the pressure to do that too, just to be gendered a certain way, is like really interesting and I’m balancing my personal comfort with social dysphoria versus gender dysphoria. Those kind of things kind of come up a lot for me on a daily basis.” (P25). All of the components of effort/energy play into gender expression daily. This level of energy is compounded if individuals have additional factors competing for their energy such as neurodivergence, chronic conditions, or mental health concerns. Level of energy at baseline requires balancing the other dimensions: “Yeah, it’s a lot of mental work. It creates so many of these like dual sides inside of me. So much of this like disconnect between who I want to be and how I want to present versus the expectations of who I should be and how I should present.” (P15). The constant assessment and evaluation of the four dimensions reaches an equilibrium resulting in the manifestation of gender expression. Authenticity/Inauthenticity Much discussion took place around the idea of authentic expression, including the level of vulnerability required. Repeatedly, queer and trans spaces provided the most freedom and safety in terms of expression: “[The spaces] I’m most authentically able to present is among my queer, specifically my trans friends. I have noticed there’s a bit of a difference between just generally LGBTQ friends and specifically other people who’ve explored their gender” (P18). These spaces allowed for exploration of expression without requiring explanations and justifications of expression. Having spaces and experiences of authentic expression along with an understanding of the complexity of the process of self-discovery were key to gender expression: “It’s important to make sure to have places to be authentic and to have that authentic experience and not let everything else take me out so much” (P18). Opportunities to 55 express authentically without repercussion or explanation were identified as sources of pride, happiness, and validation. On the other end of this spectrum is the experience of not being able to authentically show up. This increases stress and overall negative feelings: “I notice [the discomfort] more when I have to present in a way that doesn’t align with my gender.[…] I notice more negative. I can overwhelmingly feel really uncomfortable, really bad and negative and stuff.” (P13). Situations in which inauthentic expression is chosen often reflect safety concerns: “So even though I could go feminine and be safe, I’d rather try and go masculine to be safe because that’s as close to me as possible, even though people got issues with that.” (P7). A person’s level of authenticity to themselves, impacts their gender expression. Many factors including emotional/psychological/physical safety, potential explanations required, degree of “outness”, for example influence how authentic someone may choose to be in a specific space or context. Authenticity influences and is balanced with the other dimensions of gender expression. Conservative/Alternative When it comes to gender expression, there was congruence among participants regarding a conservative style. This was used to refer to the socially constructed binary norms of dress from dominant western norms. Often safety was cited as influencing the level of conservative expression desired in a given situation: “I tend to dress pretty conservatively […] just for safety considerations.” (P4). As within the dimension of authenticity, while safety was brought up, it was not necessarily the main influence behind choosing to express conservatively. The impact of safety will be discussed at length in Chapter 4. Notably, conservative gender expression can be the most comfortable and authentic expression for people as well. “I feel like I kind of fall into the stereotype of masculinity of how I choose to express my gender because that’s how I feel the most comfortable.” (P20). 56 Blending/Passing. Within the dimension of conservative expression lives the concept of passing or blending as cisgender. Several participants cited passing as an explicit goal of their gender expression, though the majority did not: “Like online and in my social circles 90% of the time I’m just a dude and I pass.” (P11). While there is initially safety in passing, it also comes with additional mental effort and stress: “It’s not who you are so you have to keep up this mask that is very draining to keep up this façade. […] Because you have to do the mental gymnastics to make sure that your stories are staying straight, that you’re not saying something that might slip and get you outed or get you judged for who you are. So it’s very mentally exhausting.” (P27). It was also noted by more than one participant that they were assumed to be cisgender, but whether it was a cis man or a cis women varied: “I guess my experience and my thought is most people aren’t that attentive and will assume unless explicitly told otherwise that I am cis, whether they think I’m a cis guy or a cis woman.” (P17). Across (a)genders, there was not a prescriptive alternative expression that was always well suited to every situation: “I need something. I need something so I look more queer. I need to look different. And part of that is looking queer, part of that is looking alternative, which again does go hand in hand. But there’s a need to have a baseline.” (P9). Often there was difficulty in finding the right words to express alternative expression that incorporated both masculine and feminine aspects. Terms like “drag light,” “feminine masculinity,” and “queer” were used by participants to convey the complexity of their authentic expressions. However, the underlying aspects of alternative expression, namely not expressing in expected or cisnormative ways based on presumed sex assigned at birth, were consistent: “But if I’m in a place where I feel like it’s fine for me to look a little strange and nobody’s going to bug me about it and it’s what I feel like today, […] so how do those two mix together to find some happy medium?” (P17). A key aspect is the consideration for how others will respond and the level of explanation that will be required: “Like people can be ambiguous and that’s okay but a lot of cisgender people, it fucks with their heads when you look one way but insist on terminology typically used for someone 57 who looks a different way.” (P11). Repeatedly, concerns about having to explain themselves, and/or being misgendered, were part of an alternative expression. Strong community presence, as in authenticity, allowed for more freedom in alternative expression: “But most of the time when I do walk around and, I mean I look queer just baseline, like there’s no passing. Like I’m not trying to pass as like anything.” (P9). This also touches on what is possible in terms of desired expression and how that impacts the balance. Euphoria/Dysphoria Euphoria and dysphoria are key and complex components of gender expression. Both can influence expression choices while also being the outcome of gender expression. Like the aforementioned dimensions, this is fluid and fluctuates. It can be as simple as a specific item or as complicated as an entire process: “Sometimes the same shirt can make me euphoric one day and dysphoric another day about the exact same feature kind of thing.” (P18). As with dysphoric feelings, euphoria can facilitate gender expression or be the result of gender expression: “Definitely, when I am expressing myself in like the perfect way and I’m like, ‘Yes, I know people are perceiving me in this way and I’m really happy about that.’” (P14). Often the outcome of the perfect balance of authenticity and conservative and/or alternative expression results in unexpected level of euphoria along with lifted mental weight. The experience of expressing in ways that validate and capture one’s essence result in a peace and happiness sometimes unanticipated: “I had absolutely no idea, absolutely none, that there was a thing on the other side of [gender dysphoria]. That there was a gender euphoria. That there was a feeling good about yourself, right about yourself, something that was really amazing. So I had never, never, never, ever experienced that before.” (P23). Having the GEP result in feelings of euphoria was sometimes a surprise but always a wonderful outcome of achieving equilibrium. Level of Effort The level of effort and energy associated with gender expression was articulated by every participant. Initially, effort was encompassed within the other dimensions; however, upon further 58 analysis it held as a separate aspect of gender expression. Varying levels of effort spanned across all of the other dimensions and not necessarily proportional, for example, authentic expression could be high effort or low effort. Additionally, the amount of energy required could be the main driver of expression in certain contexts. This level of energy required in certain contexts impacts mental and emotional capacity: “It takes a lot. I’m really sad to say, but yeah, it takes a lot out of my mental space. A lot of it has to do with like how do I navigate how I want to be in this space right now?” (P28). The constant energy burden infiltrates other aspects of life. “I think that the thing that a lot of people don’t realize is that it is constant. Like when I’m out and about it never leaves. There’s always an undercurrent […] of like how I have to exist in a public space.” (P6). Energy is divided across three aspects of gender expression: (1) the process of expressing, (2) safety, and (3) explaining expression. The Process of Expressing. The concrete process of expression requires varying levels of energy depending on a multitude of factors including the process of dressing and styling as well as procurement of clothing and transition-related medical care: “Some of it is just like how much mental energy I have for dealing with what clothes I want to wear and stuff.” (P17). Just having to begin the process of gender expression can be overwhelming and can be influenced by feelings of dysphoria: “I still put a lot of effort in like showering, and basic hygiene takes a lot more time for me because, like I said, I do it without the lights on. I can’t look at my body.” (P13). The impact of expression on the energy require to navigate spaces is taken into considerations as well: “I don’t think people appreciate how much work trans people put into it because just to appease other people.” (P10). Explaining Expression. Level of energy and effort spent on gender expression and the implications from that expression, such as having to justify or explain your choices, was brought up by all participants. A general lack of understanding from the cisgender community creates additional emotional labor for alternative expression among TNB people: “It’s exhausting. Like cis people, especially if I’m looking like a gender fuck and shit, they have so many questions.” https://go.atlasti.com/15170db2-1853-425a-a039-37ff1fa7ffaf/documents/d73b6ad9-c9ea-49e0-a2c9-1b72b10983ab/quotations/855c59b3-3a4c-41c7-a792-453edc827276 59 (P2). The expectation of explanations and justifications is felt across genders and expressions. Every single participant discussed the requirement of explanations for those outside of the community: “Because sometimes the constant explaining, while exhausting, I’m like, ‘Oh I know you’re interested and you want to know more and you want to learn and be better and you want to be a good ally.’” (P10). However, in spaces that are safe and require no explanation, the level of energy and effort required to navigate them successfully can effectively disappear. “I only ever find that experience basically when I’m hanging out almost exclusively with other non-binary people. But when that happens it is like gender disappears in this way that is like I feel like who I am and the way in which I have always seen the world is suddenly validated and real and all of these fucking constructs that are forced upon me constantly and assumptions about me just disappear. And it’s like a sense of ease and peace that exists nowhere else.” (P26). For this person, safety is a place “almost exclusively with other non-binary people” and where they didn’t have to explain themselves. Safety showed up similarly for other participants in queer and trans spaces although not universally. For more on safety, see Chapter Four. Discussion This is the first study to explore the specific process of gender expression for TNB people. Describing the GEP brings to light the additional activities required to navigate the world. Reaching equilibrium between the complex facets of gender expression gives rise to gender expression. Each of the dimensions could be the primary driver of gender expression exerting more influence on the delicate balance in any given context. At times the dimensions may interact or influence each other. When taken collectively, the complexity of gender expression begins to emerge. Balancing of each of these dimensions to find an equilibrium results in the process of gender expression. Authentic/Inauthentic expression encompasses the extent to which someone is able to present their truest self to the world. There is a high level of risk and vulnerability to authentic 60 expression that is tempered by previous and anticipated experiences. The level of authenticity someone chooses to express may be fairly constant or may vary widely based on the balance of competing dimensions. Authentic expression can be a motivator for overall expression or the result of the balance of key dimensions. Often, authentic expression leads to more feelings of euphoria but not in all cases. Conservative/Alternative expression describes the physical manifestation of gender expression. As with the other dimensions, conservative or alternative expressions can drive the process, and tend to be context driven. The level, ability, and desire to conform to dominant binary cultural standards can also lead to blending or passing as cisgender, which can serve as a goal of this dimension. Euphoria/Dysphoria includes the level of positive or negative feelings associated with the process and/or outcome of expression. As with the other dimensions, feelings of euphoria/dysphoria can be present at the start of the gender expression process and function as the primary driver While euphoria/dysphoria is part the process and the outcome of gender expression, it was referred to as an overarching concept by participants. Level of Effort/Energy covers the level of effort and/or energy associated with the process and/or outcome of expression. Effort and energy are assessed and expended at multiple points during the process and with the outcome. As was seen with euphoria/dysphoria, despite effort and energy being complicated and intertwined in various aspects of gender expression, participants referred to the level in a comprehensive manner leading to the operationalization as one concept encompassing several facets. Implications for Health Research Currently, there are efforts to capture sexuality, gender, and gender expression constructs in research, in attempts to better understand the experiences of TNB individuals.11,26 However, these attempts are incomplete, inaccurate, and often continue to perpetrate binary assumptions,11 with gender and gender expression conflation still common practice.26 Rather 61 than continuing to use these inaccurate measures for gender and/or gender expression, the GEP provides a community-based model for not only understanding the process of gender expression but also a potential approach for quantifiable measurement. Each of the components of the GEP can be operationalized and quantified on a linear scale and a composite score compiled. This scoring, in conjunction with gender and sexuality data has the potential to yield more accurate correlates with social interactions (discrimination, mental health screening, etc.) as well has provide quantitative data support for interventions targeting health inequities. Relevancy to Health Minority stress, as explained in the Gender Minority Stress Model, attributes the mental health disparities experienced by TNB communities to the stigma of their minoritized positions within society.3 Within this conceptualization, intersections of gender and sexuality impact on experiences of bias and discrimination,11,21-23 and yet gender expression is in the periphery. With the increased prevalence of mental health complaints among TNB individuals associated with social stigma,24 it is critical to understand how people interact socially, beginning with how they present themselves to the world. This study not only supports the presence of stress navigating the social situations but elucidates the process by which the additional mental workload accrues. The focus moves from gender and gender related expreinces14,25 to how those experiences are processed and inform future experiences. Operationalization Each of the dimensions can be measured on a continuous linear scale and the composite or balance assessed for any given experience. This approach allows for the quantification of each aspect and determines which, if any, are more prominent in various situations. There were no instances reported where one dimension always took priority over another, rather for all participants, the balance of the dimensions was highly variable. Additionally, the influence or impact on discrimination, anxiety, and other outcomes of interest 62 can be determined, potentially with a higher correlation and predictive value than gender or sexuality alone. From the results of this study, these four scales taken in tandem with one another will theoretically yield insight into the experience of gender expression. (1) Authentic/Inauthentic: the level to which authentic self is expressed (2) Conservative/Alternative: the level of adherence to dominant social expectations (3) Euphoria/Dysphoria: the level of positive or negative feelings associated with the process and/or outcome of expression (4) Level of Effort/Energy: the level of emotional/mental effort/energy associated with the process and/or outcome of expression Limitations While the study had many strengths including diversity of gender representation, high participation rates, and a wide variety of experiences, there are some limitations to acknowledge. There was a lack of participation from older individuals as well as from Black and other communities of color. Additionally, there was lack of representation from diverse cultures which may have differing social expectations around gender expression across different situations. Response Bias. With recruitment materials reaching an unknown number of individuals eligible for the study, it is impossible to know if there is a significant difference between those that responded and those that did not respond. It is impossible to know how many of those that received recruitment information responded. Participation Access Inequity. Recruitment was limited to those who attended Seattle Pride 2023. Additionally, participants were limited to those with reliable internet or cellular service along with a videoconferencing accessible device. All efforts possible were made to provide interview access to all eligible participants. 63 Researcher Bias. As with any research undertaking, researcher bias played a role. Despite reflexive journaling and rigorous methodology, one of the tenets of constructivist grounded theory is the fact the researcher is part of the analysis and interpretation, leaving the potential for biases to be part of the results. Memos were utilized to bring transparency to thought processes and interpretative leaps made by the researcher to limit bias. Conclusion The Gender Expression Process provides a new perspective on the manifestation of gender expression. It accounts for the fluidity and variability of expression from day to day or situation to situation. The GEP acknowledges the factors exerting influence on gender expression and allows for the level of influence to fluctuate through finding an equilibrium. Understanding how a person is balancing these dimensions provides better insight into their experiences than knowing gender alone. Further study will be required to determine the strength of correlation between the new scales and the level of impact on depression, anxiety, and psychological distress. The GEP also will need to be explored across more identities than represented in this study. In the meantime, gender expression should be considered part of sexuality and gender data and collected together when relevant and respectful. Additionally, the external social influences on the GEP will need to be ascertained and understood to build the complete picture of the experiences of TNB people. 64 References 1. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 U.S.Transgender Survey.: Washington, DC: National Center for Transgender Equality; 2016. 2. Hobster K, McLuskey J. Transgender patients’ experiences of health care. British Journal of Nursing. 2020;29(22):1348-1353. 3. Pellicane MJ, Ciesla JA. Associations between minority stress, depression, and suicidal ideation and attempts in transgender and gender diverse (TGD) individuals: Systematic review and meta-analysis. Clin Psychol Rev. 2022;91:102113. 4. Harsis C. We need to talk about transmisogyny. Medium2020. 5. Harsis C. On transmisogyny exempt privilege dynamics. Medium2021. 6. Serano J. Whipping girl : a transsexual woman on sexism and the scapegoating of femininity. Second edition. ed. Berkeley, CA: Seal Press; 2016. 7. Koehler A, Eyssel J, Nieder TO. Genders and Individual Treatment Progress in (Non- )Binary Trans Individuals. The Journal of Sexual Medicine. 2018;15(1):102-113. 8. Cerezo A, Cummings M, Holmes M, Williams C. Identity as Resistance: Identity Formation at the Intersection of Race, Gender Identity, and Sexual Orientation. Psychol Women Q. 2020;44(1):67-83. 9. Blondeel K, De Vasconcelos S, García-Moreno C, Stephenson R, Temmerman M, Toskin I. Violence motivated by perception of sexual orientation and gender identity: a systematic review. Bulletin of the World Health Organization. 2018;96(1):29-41L. 10. Sumerau JE, Mathers LAB, Moon D. Foreclosing Fluidity at the Intersection of Gender and Sexual Normativities. Symbolic Interaction. 2020;43(2):205-234. 11. Garbarski D. The Survey Measurement of Sexual Orientation: Configurations of Sexual Identity and Attraction and Associations with Mental Health. LGBT Health. 2021;8(4):307-315. 12. Arayasirikul S, E.C. W. Spilling the T on transmisogyny and microaggressions: An intersectional oppression and social process among trans women. Vol 66. Journal of Homosexuality2019. 13. Serano JM. Transmisogyny. The SAGE Encyclopedia of Trans Studies: SAGE Publications; 2021. 14. Hendricks ML, Testa RJ. A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the Minority Stress Model. Professional Psychology: Research and Practice. 2012;43(5):460-467. 15. Charmaz K. Constructing Grounded Theory. 2nd ed: SAGE Publications, Inc.; 2014. 16. Clarke AE, Friese C, Washburn RS. Situational Analysis: Grounded Theory After the Interpretive Turn. 2nd ed: SAGE Publications, inc.; 2018. 17. Bowers BJ, Schatzman L. Dimensional Analysis. In: Morse JM, Bowers BJ, Chamaz K, et al. Developing Grounded Theory: The Second Generation Revisited. 2nd ed: Routledge; 2021. 18. Kools S, McCarthy M, Durham R, Robrecht L. Dimensional Analysis: Broadening the Conception of Grounded Theory. Vol 61996. 19. Alvesson M, Skoldberg K. Reflexive Methodology: New Vistas for Qualitative Research (3rd Ed.): Sage; 2018. 20. Bryant A. The Grounded Theory Method. 2nd ed2020. 21. Oswald F, Champion A, Khera D, Young M, Pedersen CL. Stereotype Application at the Intersection of Body Shape, Gender/Sex, and Sexual Orientation. J Sex Res. 2023;60(6):841-858. 65 22. Speer SR, Atteberry-Ash B, Kattari SK, Kattari L, Gupta R, Walls NE. An Intersectional Modeling of Risk for Nonsuicidal Self-Injury among LGBTQ Adolescents. Journal of Child and Family Studies. 2022;31(4):1158-1171. 23. Drabish K, Theeke LA. Health Impact of Stigma, Discrimination, Prejudice, and Bias Experienced by Transgender People: A Systematic Review of Quantitative Studies. Issues in Mental Health Nursing. 2022;43(2):111-118. 24. Pinna F, Paribello P, Somaini G, et al. Mental health in transgender individuals: a systematic review. International Review of Psychiatry. 2022;34(3-4):292-359. 25. Testa RJ, Habarth J, Peta J, Balsam K, Bockting W. Development of the Gender Minority Stress and Resilience Measure. Psychology of Sexual Orientation and Gender Diversity. 2015;2(1):65-77. 26. Hart CG, Saperstein A, Magliozzi D, Westbrook L. Gender and Health: Beyond Binary Categorical Measurement. J Health Soc Behav. 2019;60(1):101-118. 66 Chapter Four Revisiting the Gender Minority Stress Model: The Impact of the Sociocultural Milieu and Gender Expression 67 Abstract Aims/Purpose: High rates of anxiety, depression, and suicide along with low health seeking behaviors are more common in Transgender and Nonbinary (TNB) communities than in cisgender communities.1 Approximately 40% of TNB individuals experience depression and are 13 times as likely to commit suicide than their cisgender counterparts due to experiences of discrimination and violence.2 The current Gender Minority Stress Model (GMSM) begins to connect the external experiences and internal messaging that contribute to these negative mental health outcomes among TNB individuals such as depression and suicide, through identification of external (distal) factors and internal (proximal) factors. However, interventions based on this model have not shown a reduction in adverse health outcomes for TNB people, indicating an urgent need for further exploration of the complex interactions and their impacts on psychological wellbeing. The aim of this study was to describe the contextual and situational influences, and their impact, on the process of gender expression, the directionality of these relationships, and psychological wellbeing. Methods: Participants were recruited during Seattle’s Pride Festival 2023. Interviews were conducted via Zoom, and participants received a $50 gift card for their time. Situational analysis was employed to describe the process of gender expression and relevant interactions between influencing factors. The analysis was inductive and not informed by the GMSM, though results were contextualized through the model post-analysis. Results: The Gender Expression Process, determined through an earlier dimensional analysis, was a conduit through which the social and contextual influences on gender, sexuality, and gender expression are filtered resulting in a particular expression in a given situation which in turn impacts mental health. The fundamental principles of the GMSM held true through the lens of gender expression with several new factors emerging as influential distal and proximal factors. Additionally, these factors could leverage positive or negative influence on the experiences of TNB individuals. 68 Conclusion/Impact: The level of effort required for TNB individuals to navigate the sociocultural milieu may account for the disproportionate rates of psychological distress and resulting adverse mental health outcomes. Adapting the GMSM would allow for more targeted interventions aimed at reducing baseline stress such as environmental alteration to create inclusive spaces, positive and diverse representation in media, financial supports, and neurodiversity support. Additionally, correlational and intervention research needs to focus on the interactions of these influencing factors resulting in more efficacious efforts to improve the experiences of TNB communities as they resiliently step outside each day. 69 Introduction Due to the disproportionate levels of mental distress experienced by transgender and nonbinary (TNB) people1 as a result of discrimination and violence, a framework to understand the sources of these inequities was developed. The Minority Stress Theory (MST) sought to explain the higher prevalence of mental health disorders among the lesbian, gay, and bisexual communities when compared to their heterosexual counterparts.3 The MST examined the aspects of social navigation unique to lesbian, gay, and bisexual people in an attempt to understand the marked difference in mental health when compared to the heterosexual population.3 The MST theorizes that distal stressors, objective and external conditions, lead to proximal stressors or subjective internal processes.3 Meyer posits that this additional stress due to LGB minority sexuality status accounts for the mental health disparities compared to the heterosexual population.3 The Gender Minority Stress Model (GMSM)4 is an expansion of the MST (Figure 1).3 In 2012, Hendricks and Testa adapted the MST to reflect the experiences of the transgender community, adding non-affirmation as a proximal stressor and including resilience factors resulting in the GMSM. Figure 1. The Gender Minority Stress Model4 70 Multiple studies summarized by Testa and colleagues have found correlations between minority stress and adverse health outcomes such as psychiatric disorders, psychological distress, mood disorders, social anxiety, and substance use.4 The GMSM used suicide attempts as the surrogate for mental health outcomes when examining each construct.5 Using the Interpersonal Theory of Suicide,6 Hendricks and Testa linked the suicide predictors to common experiences in the lives of transgender individuals, such as thwarted belonging or social isolation linked to gender-related rejection and gender-related discrimination and self-hate linked to internalized transphobia.5 Gaps in Knowledge Several gaps in the GMSM have been noted thus far, highlighting a need to re-examine the relevance and use of this model. The GMSM does not account for multidirectional relationships between constructs in the model.5 At this time, there is conflicting evidence regarding the directionality and level of influence of the GMSM constructs and their correlation with mental health outcomes.7-9 The model also does not consider personal growth and experiences over the course of a lifetime.10,11 Due to the deficit-based approach of the model,11 factors that have potential to mediate psychological wellbeing are not the focus. Additionally, binary assumptions about gender are abundant in the model despite acknowledging in their original MST and GMSM conceptional frameworks that not everyone conforms to binary genders or gender expressions.5,9,11 Gender expression, like gender and sexuality, is fluid and dynamic, influenced by multiple factors such as context, social expectations, social gender roles, gender, sexuality, and previous experiences.12-15 The Gender Expression Process (GEP), described in depth in Chapter 3, describes the individual process of expression but does not provide the social and cultural context within which it operates. While gender expression contributes to TNB experiences, it is not accounted for in the GMSM. The purpose of this study was to begin to address the gaps left by the GMSM in understanding the complexity and nuance of TNB 71 experiences in the world, including the GEP and how those experiences impact psychological wellbeing. This study used a community-centered, strengths-based approach, prioritizing community knowledge and experience as the source of information. The aim of this study was to describe the impact of contextual and situational influences on the process of gender expression, the directionality of these relationships, and the impact of gender expression on psychological wellbeing. Methods Methodology Constructivist grounded theory (CGT) provides a methodological foundation to analyze complex social and contextual phenomena, such as gender expression, recognizing the intertwined nature of context and experience.16 Within CGT, the viewpoint and positionality of the researcher is acknowledged and incorporated into the analysis.16 CGT’s flexibility allows for pursuance of outliers, contradictory information, and paths requiring a deeper dive into the context and conditions used to construct meaning.16,17 While the GMSM provided the background and gaps for this study, the analysis was conducted inductively in alignment with CGT methodology, with a post-hoc analysis comparing findings from this study to the GMSM. Situational Analysis (SA) is an extension of the constructivist grounded theory methodology developed by Adele Clarke in 2003. It does not just acknowledge the situational context as in CGT but attends to all aspects involved contextually,17 which is required to understand the process of gender expression. SA allows for the exploration of the phenomena in terms of the situation, namely “human, nonhuman, discursive, historical, cultural, political and other elements.”17 Insight into the relationships between influential elements are ascertained through specific mapping processes.17 Gender expression processes and experiences stem from not only from personal factors, but are influenced by and not limited to political, social, cultural, and historical factors.4,10,18,19 SA provides the framework to analyze the influencing factors and differences (if any) between situations and under a variety of contexts. 72 Figure 2. The Analysis Process Recruitment Recruitment took place in an urban PRIDE festival, June 2023. QR codes for the study were handed out during the parade and placed on telephone poles around the areas hosting PRIDE specific events. The QR code linked potential participants to an interest survey, after which the PI reached out to all interested persons via email. Once eligibility was determined based on the following inclusion criteria: (1) 18 years old or older, (2) reside in the Unites States, and (3) are transgender and/or non-binary, an interview date and time was set at a convenient time for the participant. An informational consent document was sent via email at the time of scheduling and verbal consent obtained at the start of each interview. Data Collection Twenty-eight interviews were completed over two months. The interviews ranged from 40 to 90 minutes long and were conducted and recorded via HIPAA-compliant 73 videoconferencing software. Intensive interviewing was utilized to explore not just the participants’ experiences but how they contextualized the experience and its meaning.16 An interview guide was developed covering the “domains of inquiry” and allowed space to follow up new ideas as they occurred during the interview.16 Reflexive journaling during the interview guide creation process allowed the researcher to examine bias and assumptions as well as level of intrusiveness within the interview questions.16 Semi-structured interviews were employed to inquire about each participant’s gender expression, and the process, experience, and impact (if any) on their daily life. Due to the flexible nature of intensive interviewing,16 follow up questions were employed to explore emerging factors that influenced a participant’s gender expression. Interview questions asked the participants to describe and make meaning from their experiences.16 Additional questions probed into the relationship between gender expression and the experience of stress and anxiety across social contexts. The interviewer paid special attention to terms and uses of language by the participants to inform subsequent interviews. For additional details on data collection, see Chapter Three as the interview guide adaptations for Chapter Three and Chapter Four were done simultaneously. Data collection ceased upon reaching theoretical satuation.16 Data Analysis Analysis was conducted in the same manner for each interview. Upon concluding each interview, the PI generated interview field notes including impression and observations from the interview. Audio recordings were professionally transcribed verbatim. Transcribed interviews were de-identified and uploaded into data management software, Atlas.ti, to support analysis. Three types of memos were created during the analysis process and informed subsequent interviews and analytic paths. Interview memos were generated immediately after each interview and captured the immediate tone, message and topics of the interview. Analysis memos were created simultaneously during the analysis process including but not limited to coding decisions at each coding level, described below, and situational map creation and 74 exploration. Lastly, theoretical memos aided in the generation of a theoretical framework describing the relationships between influential factors and situational contexts. Analytical and theoretical memos informed the interview guide revisions to probe influential relationships found in the emerging maps. Coding was conducted in Atlas.ti following the two coding steps of CGT, (1) naming each individual line or phrase through open coding and (2) focused coding.16,20 Gerunds were utilized as codes whenever possible, congruent with process description.20 Transcripts were coded in their entirety regardless of apparent relevancy in the moment. After the initial coding pass, the codes were examined for redundancies and combined as appropriate. The second step of CGT coding, focused16 or selective coding20, involved a focused assessment and comparison of the initial codes in an emergent process.16 Focused codes were created and analysis memos were created to track the process and document focus code definitions.16 The focused codes were compared with initial codes to assure congruency with the original meaning while refining the analysis.16 Subsequent transcripts were coded using the focused codes. After coding, dimensional analysis commenced to describe the GEP [see Chapter Three]. From the dimensional analysis, the themes that impacted all aspects of the emerging GEP were examined using situational analysis [See Figure 2]. The GEP was centered in the situational analysis process. The situational mapping process began with attention to the directionality, relationships, and influence of the emerging themes. A ‘messy’ mapping process17 was employed with flexibility to move and adjust code groups as more data were added to the map. During the mapping process, analysis memos were created to record the analytical process of the PI. Maps were revisited and revised with each subsequent interview. As new concepts emerged, maps were split, adjusted, and revised as appropriate. With each interview, the new focused codes were added to the maps. If similar or redundant codes resulted from the interview, it was denoted on the map as carrying more weight. Unique or novel codes were added. Maps were adjusted to incorporate the new codes 75 and to reflect emerging perspectives. Once a tentative map was created, the original data was consulted for any areas of clarification. Attention to what was unstated or what was invisible was a focus of mapping.17 Memos were created to document the process of theory generation as maps were tested and compared to the data. Theoretical saturation was considered met when no new concepts emerged during the analysis that would warrant an additional map or alter the understanding of the existing maps.16 Analytic memos created during the coding process guided the category development used to determine completeness of a concept.16 Once the data set was complete, maps were adjusted as necessary to build a picture of the experience of gender expression. Memos were utilized to provide additional context and insight into the process of gender expression. Finalized maps were utilized to depict and augment the findings of the study. This was completed through a constructivist interpretation placing emphasis on how meaning was constructed in specific contexts and situations.16 The findings of the situational analysis were then examined in the context of the GMSM to determine relevancy and potential for adaptation. Rigor Rigor was attained through adherence to the CGT methodology, frequent reflexive journaling,21 and memo creation at each step for transparency. As a community member with lived experience, the PI focused on centering participant experiences. Member checking was conducted beginning with preliminary analysis as well as close mentorship from an experienced grounded theory researcher. For more on rigor see Chapter Three. Results Sample The same participants provided the data for both Chapter Three and Chapter Four. The twenty-eight TNB people who completed interviews were given the opportunity to describe themselves in terms that felt authentic to their experience. Many participants choose more than one label to describe themselves, hence the number of demographic descriptors exceeds the 76 total number of participants. [See Table 1.]. Cell sizes of less than 2 were combined into the category of the participants’ choosing in an attempt to preserve anonymity. The sample was comprised of diverse genders and agender people, with strong representation from those who are neurodivergent and/or disabled. However, the majority of participants are white and under age 30. Table 1. Sample Characteristics (n=28) Characteristic Count (%) Age 18 – 24 25 – 30 31 – 40 > 40 13 (46.4) 6 (21.4) 4 (14.3) 2 (7.1) Disability 7 (25.0) Gender Non-binary Gender Queer Trans Man/Masculine/Male Trans Woman/Feminine/Female Transsexual Agender Gender Fluid Trans 11 (39.3) 6 (21.4) 6 (21.4) 4 (14.3) 3 (10.7) 3 (10.7) 2 (7.1) 2 (7.1) Neurodivergent 9 (32.1) Mental Health Diagnoses 7 (25.0) Race/Ethnicity White Hispanic/Latino Asian 21(75.0) 3 (10.7) 2 (7.1) Sexuality Bisexual Pansexual Queer Asexual Demisexual Lesbian 9 (32.1) 8 (28.6) 8 (28.6) 5 (17.9) 3 (10.7) 2 (7.1) *Categories with cell sizes <2 were merged to closest category Gender Expression and the Sociocultural Milieu While there are four distinct dimensions that are balanced in the GEP, authenticity/inauthenticity, euphoria/dysphoria, conservative/alternative, and level of energy [see Chapter Three], there are additional factors that influence the dimensions and subsequent 77 equilibrium in any given context. The sociocultural milieu (SM), which encompasses structural aspects, the political landscape, individual level factors, and all facets of the society in which we live, plays an important and interactive role in not only the process of gender expression but the outcomes of the experience [See Figure 1.]. Not only do the SM factors influence the dimensions of the GEP but also the GEP equilibrium overall. The multitude of influencing factors identified in the SM do not exist independent of each other, rather they exist in interacting clusters. While all aspects of the SM bidirectionally influence each other, certain interactions are more dependent than others. This complex, bidirectional web of influence creates a dynamic narrative through which all experiences are contextualized with the potential to build resiliency and well as frame adverse experiences. Figure 3. The Sociocultural Milieu (SM) and The Gender Expression Process (GEP) The following results are not exhaustive, rather exemplary influences brought up by many of the participants. They are discussed in alphabetical order so as to not falsely elevate level of influence or importance. Those factors that are also present in the GMSM are denoted by an asterisk in Figure 3, and not all of them are expounded upon in this paper as they have been well documented in other work.3-5 Additionally, in order to shift to a strengths-based, common experience focus, and per participants’ requests, specific genders and gender expressions are removed from quotations when possible. This strategy allows the experiences 78 to come forward without othering or focusing on gender differences. The following factors were well described by participants: financial, multiple marginalizing identities, media representation, neurodivergence, political context, practicality, religion, safety, and societal expectations. Financial. Repeatedly, the financial cost of gender expression was brought up by participants. “I have to spend like an extra two hours and like spend thousands of fucking dollars on things cis people would never think of.” (P10). Throughout the interviews participants discussed the hidden costs of gender expression for TNB people and the impact on the overall GEP. Financial constraints, or lack thereof, impact the level of authenticity that was feasible to express. “I would say that my gender expression is kind of a mixed bag where sometimes I’m able to authentically present myself and other times less so. […] like clothes cost money and having the clothes to present how I would like to present costs money.” (P18). Euphoria/dysphoria was also impacted by one’s financial position. “It is important to me because there is a lot of stuff that still gives me dysphoria and would kind of cut down on the time it required me to get ready in the morning if I could just do it. […] Shit is expensive.” (P10). The dimensions exerting influence on the GEP equilibrium are impacted by the resources available to individuals. Clothes, hair style, and other adornments affected feelings of euphoria/dysphoria, the ability to present conservative/alternative, the level of authenticity/inauthenticity achievable, and the amount of effort required to find the equilibrium. Within the purview of financial burden comes the cost of gender affirming medical care. For those interested in surgical gender care, the financial burden required leaves it out of reach for many. “All of that is definitely like a big impediment to gender expression. Because if I thought, what would I do if I had two million dollars? I think I would be calling up doctors and be like scheduling things. So it’s definitely an impediment to gender expression is access to resources.” (P1). The access or lack of access to gender-affirming care and resources impacts all aspects of the GEP equilibrium depending on how large of a discrepancy exists between how one views themself, capturing the internalized understanding of what one’s body is or should be. 79 Even for those not interested in various aspects of surgical gender care, there is an acknowledgement that it is not financially feasible. “[…] Bottom surgery. And I’m like, that’s not something I want to do. Or like having a hysterectomy or something, which one, I can’t afford and two, the rate of success is like, the complication rate is really high. So it’s like that’s just not something I want to do.” (P20). Along with highlighting the financial burden, which is variable based on location and insurance, P20’s statement depicts how inaccurate, as hysterectomies are widely considered safe, and likely transphobic, medical information can be found in the community. Across interviews, GEP equilibrium was influenced by the financial resources available. For many this influence was a limitation to expressing gender in the most optimal way. Media Representation. Visibility of positive TNB experiences is sought by TNB people for validation and understanding of their experiences. “During our formative years, we were so desperate for transgender people and transgender-related content.” (P5). The manifestations of the GEP were seen through various social media outlets. “I don’t know, I feel like social media, and I feel like the internet plays a really big part of [gender expression] because you’re putting a certain portion of yourself out for people to see, […] how you dress yourself, how you act, how you interact with other people regardless of whether that’s how your gender presents.” (P9).The interaction and curation of self-image on social media influences authenticity, conservative/alternative, euphoria/dysphoria, and can consume a high level of energy. Self-exploration and community formation through social media positively impacted the GEP. Several participants discussed using labels, despite not always accurately capturing identity or expression, as a way to find community. “[Finding] specific labels, because especially with social media, if you’re able to get your identity down to a term that you can search in the search box and then be able to access community that way.” (P9). Community connection provided space to share stories, language, and experiences impacting ability to express authentically. “As I got further into the social media spheres of trans and non-binary folks and https://go.atlasti.com/15170db2-1853-425a-a039-37ff1fa7ffaf/documents/de72157e-4a53-47fc-a086-b5ec7cd3fc5d/quotations/bd11ddae-8a45-4a5b-91b1-2d22fd82b437 80 started to resonate more with the language they were using, the stories they were telling, the narratives of their transitions, I was like, ‘Huh, that’s interesting’.” (P21). Through these community spaces TNB people saw their experiences represented. “’This is what my community does and this is how I want to be a part of this community,’ I think that’s another big part of it, of like the expression, is having how I look every day be a part of that.” (P9). As people found community, the dimensions driving equilibrium tend towards positive. “I feel more comfortable expressing my gender in an expansive way when I’m with people I know and I’m really close to and they see me for who I am no matter how I’m presenting. That’s when I feel safest presenting in all kinds of ways.” (P2). Favorable representation in the media provided positive influence on the GEP often resulting in more authentic and euphoric expression. Representation through conventional news channels and in politics, plays a large role in the process of gender expression, impacting euphoria/dysphoria, conservative/alternative, and level of energy. In the current sociopolitical environment, much of the representation is aimed at perpetrating fear of and harm to TNB communities. This will be discussed further under Political Context. Multiple Marginalized Identities. While the sample was fairly homogeneous on racial/ethnic identities, those that carried additional marginalized identities discussed the impact on the process and experience of gender expression. “I am the only person of color in our family. I am the adopted child. I am the only child because all of my other cousins have siblings. Like I am the only queer person in our family. I am the only trans person. I am the only just about anything you could pick in my family.” (P7). The compounding of multiple marginalized identities added to feelings of isolation and othering, impacting levels of energy available and conservative/alternative expression. “My race, ethnicity, already made me “other” so I know what it’s like for people to see you and immediately assume you’re part of the out group and not similar enough to them to communicate, to connect with.” (P11). Part of the level of effort expenditure was due to additional questioning regarding gender expression on top of 81 explanations required for other identities. “Oh this is what gender is. This is what my gender is. This is what that means. ‘Oh, why do you do this then?’ ‘I do that because of this.’ ‘So how does this affect that?’ ‘It affects it this way.’ And it’s very repetitive and it reminds me a lot of being the only disabled person in a circle.” (P18). Depending on the additional marginalized identities held by a person, different dimensions of the GEP were impacted and the equilibrium and resulting expression changed. Neurodivergence. For those who are neurodivergent, the process of gender expression is complicated and influenced by this experience. Predominately, neurodivergence was discussed in terms of the impact on level of energy and effort available for gender expression. “There is just all of these factors that my brain has to take into account to decide what I wear and how I look. Which is why I think it takes an exponentially large amount of space in my head because of the neurodiversity in that at the same time.” (P7). The process of finding equilibrium could be more challenging or time consuming for neurodivergent people. It also influenced feelings of euphoria and dysphoria. “Or like maybe I’m really overstimulated that day. I’m more likely to feel dysphoric kind of thing. To experience that feeling or be able to not ignore it as easily kind of thing.” (P18). Neurodivergence and practicality were often intertwined due to sensory needs and the desire for function over other aspects of gender expression. “I’m very particular about my look and my style and my color. Yeah, and like material. I have sensory issues. Like it has to be, and there are things that make me particularly dysmorphic.” (P12). All aspects of the GEP are impacted by neurodivergence often adding other aspects, such as fabric considerations or sensation, to be balanced in pursuit of equilibrium. Political Context. The political context impacts all facets of life for TNB individuals. “I mean it’s definitely a point of anxiety. It’s definitely added a layer of stress onto my life that wasn’t there before just because the future is so uncertain with the political climate.” (P16). The GEP is heavily influenced by political context often bringing concerns of safety to the forefront. While safety cannot be considered separately from the political climate, it will be addressed https://go.atlasti.com/15170db2-1853-425a-a039-37ff1fa7ffaf/documents/00f05e45-9995-4ead-8d43-76c1476d5f19/quotations/96b44be6-579a-4895-9bca-a7ddda0aa896 82 more specifically later in this paper. “It really, really makes me just want to sort of hide back in the shadows. Be like, ‘I’m going to wait until everything is better,’ and then just keep this to myself until it feels like the world is a safer place or there’s less of a spotlight on me.” (P15). The GEP is impacted by and impacts the political context as a political statement. Authenticity can drive the GEP bypassing comfort and safety in pursuit of visibility, although not everyone or every situation allows for this expression. “So I am, thankfully, able to some degree in those more uncomfortable, unsafe situations, still somewhat present those ways. But I can’t like wear clothing that is political in a way that’s like, ‘Hey, I’m trans, fuck you if you don’t like it.’ I can’t. I would really love to be able to wear things like that and be able to continue to be that physical political statement, but that would be a little too obvious.” (P18). The GEP equilibrium was impacted when someone could not manifest their expression in the way they would like because of political and subsequent safety concerns. The political context can also impact the GEP in much more straightforward ways through laws restricting access to basic needs and medical care. “Hey, does this state have a bathroom law? You know? This country, will it allow me to get hormones? What’s going to happen?” (P14). As the political context shifts and changes each election cycle, the level impact on the GEP shifts. Practicality. One of the main components that influence the dimensions of gender expression is practicality. The need to be functional, comfortable, activity-based or in line with other pragmatic reasons was considered in all four process dimensions, authenticity/inauthenticity, euphoria/dysphoria, conservative/alternative, and level of energy. Practicality also interacts with safety, potentially augmenting or mitigating perceived risks. “’What’s the weather? Who’s out there? What day is it? Is there a [hockey] game? Are there going to be a bunch of bros in the street? Are there going to be a bunch of like cis straight white families gawking at literally everyone? Is it Pride? Who am I with? Where am I going? Am I taking the bus? What bus? Where?’ I’d say as a person I tend to think of things in a kind of utilitarian and efficiency-based mindset.” (P22). The process of gender expression relies on 83 finding equilibrium between the dimensions, but practicality was a lens through which the entire process takes place. For many participants, the practicality of expression was more influential than the dimensions involved in the process. “So mostly practical considerations and that’s a thing that actually the gender conversation has brought to light for me as well is that I am just way more practical and if something isn’t comfortable or isn’t useful, I’m like, ‘Why do I have to do that? I’m a whole adult, I can opt out of that.’” (P21). Practicality may have as much to do with gender expression as gender or sexuality. “Every assumption of how I present is because of my gender even though a lot of it actually isn’t. A lot of it is for comfort or a lot of it is for mobility or a lot of it's for practicality or for medical reasons.” (P6). However, practicality does not bypass the process, rather it exerts influence on each of the four dimensions and this equilibrium results in gender expression. “I choose like my physical comfort in my clothes first. Like just being able to move, yeah, move around.” (P12). Once physical comfort has been addressed, the dimensions of the GEP come into play. “So it’s this very weird mix of trying to figure out how do I find clothes that I am comfortable in physically and clothes that I am comfortable in expressing.” (P7). Several participants started with comfort and found their way to the manifestation of gender expression that suited them. “So the physical feeling of comfort was kind of what I addressed in my wardrobe first and that was kind of like the biggest change that I noticed over time. I also kind of felt a lot more comfortable -- it’s hard to separate this out I guess, between when my presentation started changing versus when my whole views on gender itself started changing around that same time.” (P4). Often the combination of equilibrium and comfort was the ideal expression. Energy and mental health also were encompassed in practicality. The starting mental state and energy level influence the balance within the GEP. If mental energy is low, level of effort may exert the most influence on the resulting expression. “Some of it is just like how much mental energy I have for dealing with what clothes I want to wear and stuff. There’s definitely 84 days where I’m too tired and too busy and it doesn’t matter and it’s just like a hoodie and sweats. And that’s like sub-par but also like not that deep, you know?” (P17). On the other side, if mental energy is higher, the equilibrium of the GEP was dominant in the manifestation of expression. “I guess depending on where I am mentally, that really plays a role in how much energy I spend and like how I go out to the world and express my gender expression. Because I know that when I’m mentally okay and feel a lot more stable, I feel a lot more like confident and solid if I were to like not think about my gender expression so much.” (P28). Like other aspects of practicality, in some instances, mental energy and mental health were the primary influences on the GEP. The GEP was also the starting point for some participants, with aspects of practicality brought in with the balancing of the dimensions. “It definitely starts internally where some days I just feel like wanting to [express in a certain way] more than other days. […] And whether I do or however I decide that I want to present that day comes down to where I’m going that day, what I’m doing, who I’m with.” (P15). Aspects of expression also worked in tandem with practicality to influence the GEP. “A lot of the times I still lean much more [gender expression] when it comes to the practicality of things, mainly because then I can actually move in things and I don’t have to worry about if I bend over or need to kneel down for something that something’s going to get exposed or anything like that. And pockets.” (P7). While practicality is not gender related, the influence on the GEP was significant for TNB people. Relationships. Relationships with family and friends played a role in the GEP. Levels of acceptance and relationship maintenance change the balance between the dimensions, sometimes to protect a relationship and sometimes to push a relationship recognizing the risk of irreparably severing it. “I do want to maintain this relationship but there’s a time and a place when bringing up my gender and so I’m shelving my own gender. I’m shelving my expectations.” (P6). As relationships evolve, there can be a point in which authenticity and equilibrium are more influential, resulting in the need to justify and explain gender expression. “I can be 85 presenting the way that I want to present even if it doesn’t meet their [family] expectations and I don’t have to explain to them why I want to look that way.” (P15). The level of explanation required to express after balancing the GEP dimensions feeds back into the dimension, level of effort. “’Are you sure? You still like wearing more feminine clothes. Are you sure you’re still a man? Are you sure you’re still a trans man? Are you sure you’re a boy?’ I got this from family, friends, society, doctors (which was infuriating) and just all of these people.” (P7). Some choose to forgo explanations and risk familial relationships by leading with the GEP in a way that is congruent with their desired expression. “I can be presenting the way that I want to present even if it doesn’t meet their [family] expectations and I don’t have to explain to them why I want to look that way.” (P15). Relationships and expectations are intertwined in their influence on the GEP. Regardless of the relationship, the effort involved in the GEP can take away from the ability to genuinely participate. “And it means that there’s a lot less room in my brain for other conversations or genuine relationship. It’s a lot more surface level in some areas I think. Like there is still the chance for deep intimate connection but it’s a lot harder to get there and to manage because so much space is being taken up. So much bandwidth is just ‘Don’t fuck up gender.’” (P18). When the relationship is marred by misgendering or lack of understanding of gender and gender expression, connection was difficult. “And I think in the beginning for me it was very hard when anybody misgendered me and it felt like, ‘Oh, they don’t accept me. They’re not trying hard enough.’” (P9). Overall, relationships impacted the GEP through the balance of authenticity/inauthenticity, level of effort, and conservative/alternative expression. Conversely, the manifestation of gender expression by way of the GEP impacted a myriad of relationships. Religion. For participants affiliated with religious organizations, past and/or present, religion played a large role in all aspects of gender expression. While the majority of the religious experiences were negative, some religious traditions provided support and 86 acceptance. The religious traditions grounded in Christianity tended to be harmful for TNB individuals, and for some that residual mental anguish remains and influences gender expression. “I grew up in a very Catholic Christian household and I later kind of had to remove myself from the church for, you know, my gender and sexuality reasons because it became a toxic place for my mental health.” (P5). The Conservative Christian religious groups dictated acceptable gender expressions, which influences all four dimensions of gender expression. “I have PTSD from religious trauma and having that be so closely tied with my family does make [gender expression] more stressful.” (P16). Depending on the extent of the religious trauma, it may take a prominent influencing role in gender expression. “After my second stint at conversion therapy [a practice, usually Christian, that forces cisgender heterosexuality as the only acceptable gender and sexuality; it has been outlawed in many states and countries], […] I didn’t want other people like my family or my teachers to suspect that I might be trans or like bi or something like that, so I would dress really […] to make up for that.” (P13). The balancing of authenticity tended towards inauthentic to hide and prevent more trauma. This became the driver of the GEP. Safety. The majority of participants spoke to the importance of safety in their daily gender expression. “I would say my expression would change if I thought I was in a situation or an area that wasn’t safe.” (P14). Safety encompassed physical safety and psychological safety as well as the perceived risk of danger. “I think it really depends on what my perceived sense of safety is in whatever space I’m entering. And then that will guide the choices that I make.” (P1). Concerns were raised over the inability to predict levels of safety regardless of expression. “It’s really hard to anticipate. I keep going back to the fact that like people will harass you for every little thing. I can’t prevent, I can’t even anticipate what the problem is going to be.” (P6). Safety was explored through each of the GEP constructs, influencing the balance within each construct. The interactions between safety and the GEP are multidirectional and fluid with experiences informing the process of equilibrium within GEP and vice versa. Concerns around 87 safety, passing/blending, or hiding identities consume high levels of energy and contribute to stress and anxiety. Safety concerns were spread across genders and sexualities without anyone expressing more concerns around safety than any other in this group of participants. Safety influenced the dimension of authenticity in a multitude of ways. And while it was an influence, it did not predict or push gender expression in a particular direction. Some participants chose to express more authentically for psychological safety and risk physical safety, and others chose to be less authentic and bear the psychological impact in favor of physical safety. “So even though I could go feminine and be safe, I’d rather try and go masculine to be safe because that’s as close to me as possible, even though people got issues with that.” (P7). The concerns around safety came from being perceived as transgender as well as from being perceived as cisgender. “Sometimes, it’s just dangerous when you contradict someone’s immediate perception of who you are.” (P11). The balance of conservative/alternative expression within the GEP both influences and is influenced by safety. “I think it’s one of those things where when I’m passing in public and people don’t know, it goes two ways where it doesn’t matter because like gender never comes up in conversation or whatever, or it does matter and it either turns into -- I’ve only really had the transphobic people somehow appear and they think I’m cisgender a couple of times.” (P5). This in and of itself is a complex situation, either way a person is perceived, there is risk creating additional influence on the dimension of effort. A notable aspect of safety stems from pervasive misogyny and transmisogyny. “My lived experience thus far is that I’m not sure if there is anything more dangerous to be than a woman in this world. Like I don’t know if there is anything more dangerous than appearing to be or to want to be or to appear as a woman.” (P22). The influence of transmisogyny on safety was voiced by participants of all genders. “I think that the thing that a lot of people don’t realize is that it is constant. Like when I’m out and about it never leaves. There’s always an undercurrent. And there’s the normal undercurrent of like, I present femininely and women always, not to be 88 like men are always predators because obviously women are also, but there’s this undercurrent of like how I have to exist in a public space.” (P6). The pervasive undercurrent of violence influences the level of effort and authenticity in the GEP as well as overall mental health. For some, alone in their home was the only place safe enough to express in ways that felt most true. “When I’m indoors in my house, I’ll wear something maybe more feminine and I’ll feel more comfortable because I just feel safe and I’ll experiment.” (P1). While most noted that due to living in a liberal urban area, they had less personal experience with overt violence, there was acknowledgement that this is a critical component of gender expression, particularly for trans feminine people. “So like when I’m in [liberal urban city] I don’t put as much effort in when I’m in [liberal urban city] or like when I lived in [liberal urban city]. I don’t put as much effort in because it’s much safer, right?” (P13). Political context terms of liberal urban areas influenced GEP through levels of safety. Participants who had lived in more politically conservative areas voiced the converse of this. “I actually used to live in [historically conservative city] where I felt like I had to be kind of like on guard. I had this like, this worry of somebody just like sucker punching me.” (P3). Being able to live in a more trans friendly location decreased the impact of safety on the GEP. Those that had the financial ability to do so, chose locations for this reason, highlighting the complex interactions between financial resources, safety and the GEP. “But I wouldn’t really want to put myself in a state that had a record or a country that had a record of being unsafe for trans people. Because that’s an amount of stress I don’t want in my life.” (P14). The GEP was tangibly impacted by the threat to safety experienced regularly by TNB people. Societal Expectations (family, professional, social). Societal expectations had a large overlap with political context, media representation, and relationships and impacted the GEP in similar ways, often in tandem with one another. For this study sample, colonial, Christian, cisheteronormative expectations were the standard by which gender expression was viewed. “What needs to look like a man or what constitutes what a man is or what women are supposed 89 to be. It’s just very binary and it’s so interesting. It’s so interesting because I feel like a lot of gaslighting happens, I feel like, with cis people. They’re like, ‘Oh, it’s not a big deal,’ but then it is a big deal.” (P28). Trying to gauge and anticipate the expectations of others is very impactful in the gender expression of many people. This is reflected in the level of energy and effort expended and the level of conservative or alternative expression chosen. “Performing femininely, […] you kind of have to, I feel like in this cishet world you have to talk a certain way, you need to be submissive, you need to be yielding and that’s the expectation.” (P2). Authenticity also often needed to be balanced with expectations. “So, it’s kind of my mix of what is societally appropriate to what am I willing to push the boundaries on.” (P7). Within expectations hangs many tenuous relationships, which are discussed earlier in this paper. There can also be a lack of expectations, leaving people with both freedom of expression and uncertainty. “You can’t really pass as non-binary. There is no expectation of what that looks like.” (P18). The individual dimensions of the GEP are influenced by societal expectations explicitly through what it means to present conservatively versus alternatively, as well as in finding an equilibrium of expression. Interactions between SM, GEP and the GMSM When completing a post hoc comparison of the situational analysis findings with the GMSM (Figure 1), the factors identified in the SM (Figure 3) imperfectly map onto the existing distal, proximal, and resiliency factors. This analysis supported the existing model, added new distal and proximal factors, acknowledged the bidirectional nature of the relationships, and added the GEP as an important matrix mediating the impact on mental health. Distal Factors. The distal factors in the GMSM consist of external influences on mental health.3,4 In the original model the distal factors include: gender-related discrimination, gender- related rejection, gender-related victimization, and non-affirmation of gender identity.4,5 The factors identified in the SM that align with the distal factors include media representation, political context, relationships, religion, safety, and societal expectations. The resiliency factors 90 of the GMSM, community connectedness and identity pride, are encompassed within the SM factors of relationships and media representation. There is overlap between the original GMSM factors and with the SM factors; however, the SM factors expand the understanding of the distal factors as well as describe the bidirectional web of interaction. These interactions not only exist among the distal factors but also between distal factors, proximal factors, the GEP and mental health. Table 2 provides exemplars of the complexity and interconnectedness of the distal factors with proximal factors and the GEP. Table 2. Distal Factor Interaction Exemplars Interaction(s) Exemplar Role Within the GMSM Safety, Societal Expectations & GEP really hard for I mean it definitely is me because even sometimes something very basic like wearing like boots. Like I have these boots, they’re not even necessarily like girlie or anything but it makes it hard. It’s hard to put them on and then feel confident enough to walk out because I’m always kind of thinking, beyond even just being ridiculed, what if someone attacks me or what if someone insults me. (P1) The distal factors of safety and societal expectations influenced the GEP and resulting expression. Safety concerns impacted the GEP as societal expectations influence the conservative/alternative dimension. These societal expectations created the bounds out of which came the safety concerns. These interactions then tilted the equilibrium of the GEP. Safety, Practicality & GEP When I’m wearing tight clothing at the gym the violence is just a constant undercurrent of low key, well if I outperform the men around me are they going to become aggressive or more respectful? And I never know. I never know. […] I still don’t know which side it’s going to be that day like if they’re going to come over and give me a fist bump or if they’re going to fucking attack me. (P22) The original proximal factor of negative expectations was part of the anticipated safety concerns which interacted with the practicality of expression. The GEP was conducted through both of these lenses simultaneously. Relationships, Societal Expectations, Acceptance & Religion ”Oh why didn’t you feel like you could tell us?” and then having to explain that at one point I thought there was the potential they would cut me off or they would say, “Love the sinner, hate the sin,” kind of thing. And I would have to explain that I am the sin. (P18) Religion informs societal expectations and impacts relationships and acceptance. To add to the complexity, within the context of relationships there was potential financial impact, either with additional support or loss of support. All of the factors impact the GEP as discussed in earlier sections. 91 Internalized Transphobia, Media Representation, Political Context, Societal Expectations I do see lots of rhetoric like in the media and in politics and I think a lot of it comes from hearing, especially right wing rhetoric about who they think trans people are and their ideas for how people should exist in society. I feel like that, I start to internalize that much more than I internalize all the people out there defending it. (P15) The matrix of media representation, political context and societal expectations directly impacts the proximal factor of internalized transphobia. These distal factors, while separate, are inextricably linked and exert influence on the GEP. Proximal Factors. The proximal factors of the GMSM include internalized transphobia, negative expectations, and concealment, representing the internal aspects contributing to the additional stress experienced by TNB people.4,5 As with the distal factors, the findings of this study encompassed the original constructs and expanded the personalized aspects of the model. These new factors include financial, multiple marginalized identities, neurodivergence, and practicality. Internalized transphobia and negative expectations, while residing as proximal factors, were influenced and partially described in the distal SM factors of safety, societal expectations, political context, and media representation. The proximal factors are part of the interactions between the distal factors and the GEP resulting in mental and physical health outcomes. Table 3. provides exemplars of the bidirectional influences and relationships among proximal factors, distal factors, and the GEP. Table 3. Proximal Factor Interaction Exemplars Interaction(s) Exemplar Role Within the GMSM Practicality, Relationships & GEP But then, because it also makes me happy, these other parts. But I’m trying to decide. Is it worth the energy and the time and the strain to like have them understand or should I just leave it alone? Is the relationship fine? Does it need this or does my life need this? I’m always sort of questioning. (P8) Time and energy, both aspects of the proximal factor practicality, had a bidirectional link with relationships. Carefully weighing practicality with relationships affected the equilibrium in the GEP in terms of authenticity and feelings of euphoria. Practicality, Safety & GEP Usually my strategy for public transit is to blend in as much as I can. So wearing a dress that I would love to wear might be all nice in other contexts but like on the subway there The distal factor of safety, the proximal factor of practicality and the conservative/alternative dimension of the GEP were 92 is kind of fears of like, “Oh,” you know. I’m kind of around a lot more people and specifically people that I don’t know and there’s just some inherent risk to dealing with people in public transits. I tend to dress pretty conservatively there just for safety considerations. (P4) taken into consideration together in the GEP overall, resulting in a less authentic, more conservative expression than would otherwise have been manifested. Internalized Transphobia, Safety, Political Context, Societal Expectations, & GEP I had a lot of internalized transphobia as I think a lot of trans people do. So that was always a factor. […] I was kind of convinced that I would never look the way I wanted to. So I didn’t want to try out of fear of looking silly. And also there is just like the reality of other very transphobic people […] the current trans panic that’s happening right now was just starting to ramp up so I was terrified of that and I wasn’t sure what it would mean for me. And I was living in a military town when I first started so there was a lot of right wing presence and even just like asshole military guys. Again, the inherent association between the distal factors of safety, political context, and societal expectations created the circumstances giving rise to internalized transphobia. The internalized transphobia influenced concerns around whether authentic and desired expression was possible. The GEP was conducted through this lens. Neurodivergence, Practicality & GEP For me it’s a lot of mental energy, but I think that also ties into my neurodiversity in that just some of these small things will take up exponentially larger amount of mental space than it would for somebody who is not neurodivergent. Because for me I’m always thinking about, for me I often think more about what is the fabric, how does it feel, what am I doing, how hot is it outside, am I going to be doing things where I’m going to get sweaty and active or am I just sitting at a desk?” (P7). Neurodivergence and practicality were interconnected in terms of sensory needs and activity- based needs. Neither factor dominated the influence, rather the juxtaposition of both decreased the available mental energy for the GEP. This impacts the dimension level of effort within the GEP. Financial, Relationships, Societal Expectations & GEP I would have to spend more money on feminine clothes so I couldn’t spend as much money on masculine clothes. So what I say it’s really conflicting as to should I present more femininely or masculinely even though I really should present however I want, it’s still that thought process of what does my partner want me to present as, because I have trouble figuring out whether someone is actually comfortable with me. (P13) The distal factors of relationships and societal expectations directly contributed to the financial burden of expression. The distal factors also influence the GEP dimensions of conservative/alternative and authenticity as expectations are attempted to be met. 93 Discussion This study contributes to the understanding of TNB experiences around gender expression separate from gender and sexuality. It is the only study to our knowledge that explored gender expression and its influencing factors independent of gender. Through this study, we found several sociocultural factors that influence the process of gender expression for TNB people. The GEP is situated within the SM, adding layers of complexity to the manifestation of gender expression. Not only do the SM factors impact the GEP, but several of them have the potential to promote resiliency for TNB individuals, shifting to a strengths-based or resiliency-based understanding of experiences. We propose expanding the GMSM to encompass these preliminary results and support further research into the pathways and interactions of the GEP, SM, and GMSM. The GMSM is the current framework from which we contextualize and understand the disproportionate rate of adverse experiences and mental health outcomes in TNB communities. When looking at the current results in the context of the GMSM, there was tangential overlap, but from the community perspective the focus has shifted to a conceptualization of the experiences of TNB individuals highlighting sources of resiliency as well as of stress. While the tenets of the GMSM are still present in the experiences elucidated in this study [denoted by an asterisk in Figure 1.], the focus and emphasis has moved significantly towards the interactions of the influencing factors and the GEP. Within this conceptualization is the acknowledgement that many of the influencing factors are contextually and situationally dependent but have the power to impact experiences positively or negatively and to varying degrees. Many of the SM factors do not function independently rather work in tandem to influence the GEP. The process and outcome of gender expression must take this sociocultural milieu in context when considering the experience of TNB individuals. 94 Adapting the GMSM Addressing the critiques of the GMSM brought forth by the original author,11 this new conceptualization of the experiences of TNB individuals highlights the multidirectional nature of the overarching processes involved in their daily lives. The Sociocultural Milieu is comprised of a multitude of interacting factors, both distal and proximal, resulting in the context for gender expression. This model adaptation also allows the SM factors to interact and compound their influences on the GEP. All aspects of the SM and the GEP are interrelated, changing the experience and level of influence simultaneously (See Figure 4). Figure 4. The SM, GEP and GMSM (*Asterisk denotes factors in the original GMSM) Hypothetically, based on new experiences, history, and anticipated outcomes, different SM factors may exert more influence on the GEP and the driving dimensions of the GEP may change. Conversely, the level of psychological wellbeing in any given situation will impact the equilibrium priorities and the dominant SM factors. The adapted model supports current understanding of gender minority stress4 and the influential nature of social environments2,5,22 Discrimination Rejection Victimization Non-Affirmation Internalized Transphobia Negative Expectations Concealment Community Connectedness Pride Mental & Physical Health Distal Stress Factors* Proximal Stress Factors* Resilience Factors* Outcomes* Authenticity/Inauthenticity Euphoria/Dysphoria High Energy/Low Energy Conservative/Alternative Equilibrium The Gender Expression Process Influencing Factors Acceptance* (-/+) Discrimination* (-/+) Financial (-/+) Identity Pride* (+) Internalized Transphobia* (-) Intersecting Identities (-/+) Media Representation (-/+) Neurodivergence (-/+) Political Context (-/+) Practicality (-/+) Relationships (-/+) Religion (-/+) Safety* (-/+) Societal Expectations (-/+) The Sociocultural Milieu 95 and adds context through which those influences are processed and manifested during the navigation of social situations. All aspects of the original model remain; however, shifting the focus to allow for more avenues of resilience requires expanding the original constructs and acknowledging the complex web of interactions at play. Expanding the framework of the GMSM to encompass the SM factors promotes shifting to strength-based model, aligning with TNB communities’ priorities. Future Research The GMSM attempted to elucidate causal pathways for interventions to reduce adverse mental health outcomes in the TNB community. However, a main critique of the model is its lack of focus on the important influence of social safety on psychological wellbeing.11 This new conceptualization is in its preliminary stage and requires additional study to validate the findings. Further analysis is required to determine the specific interactions and levels of impact on the GEP and how this translates into mental health. The causal pathways by which the SM factors exert the most influence need to be determined and explored as avenues of intervention. Harmful influences need to be mitigated and positive influences harnessed and expanded. Resoundingly throughout the interviews, participants reiterated the positive SM influences on the GEP and the profound impact on psychological wellbeing. Shifting the focus of interventions to increasing positive influences rather than mitigating harm aligns with community priorities. The acknowledgement of resiliency factors has been noted;4,22 however, they have not been leveraged as an approach in attempts to improve overall mental health of TNB people. Within the SM, multiple influencing factors such as media representation, societal expectations, identity affirmation, and acceptance are prime foci for efforts to increase positive experiences. Future research into the impact and efficacy of positive influencing factors is needed. Limitations The study sample was drawn from a large urban center, was resoundingly white and young, and was limited to those that attended PRIDE festivities. The findings and influences, 96 therefore, need to be interrogated in diverse populations with specific attention to multiply marginalized identities. Additionally, the PI’s personal experiences, even as a community member, inevitably played a role in the interpretation of the data. Reflexive journaling and rigorous methodology sought to limit bias, but congruent with constructivist grounded theory, it is not possible to fully eliminate bias. Conclusion The influential work of Meyer3 and Hendricks and Testa5 brought the stress and mental health toll experienced by minoritized sexualities and genders to the attention of the academic research community. Although the associations between the distal factors and the outcomes are well established,1 the pathways by which the distal factors influence the proximal factors and how all the factors in the sociocultural milieu relate to each other and to health outcomes are less well known.8,11 Frost and Meyer acknowledge these limitations, including the unidirectionality of the GMSM and its focus on deficits.11 While deficit-based models have provided the framework for work within the TNB community for the past two decades, shifting to a strength-based model that includes resiliency factors, may provide the catalyst to meaningful progress in closing the gap in health disparities. As health inequalities increase between TNB and cisgender populations,11 it is imperative to shift our foundational frameworks to community- centered strengths-based models which illuminate the complex interactions and spaces for intervention. 97 References 1. 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Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin. 2003;129(5):674-697. 19. Serano J. Whipping girl : a transsexual woman on sexism and the scapegoating of femininity. Second edition. ed. Berkeley, CA: Seal Press; 2016. 20. Bryant A. The Grounded Theory Method. 2nd ed2020. 98 21. Alvesson M, Skoldberg K. Reflexive Methodology: New Vistas for Qualitative Research (3rd Ed.): Sage; 2018. 22. Tankersley AP, Grafsky EL, Dike J, Jones RT. Risk and Resilience Factors for Mental Health among Transgender and Gender Nonconforming (TGNC) Youth: A Systematic Review. Clinical Child and Family Psychology Review. 2021;24(2):183-206. 99 Chapter Five Conclusion and Implications 100 Conclusion The diversity of genders, sexualities, and expressions within the TNB community is evolving and growing constantly. As healthcare professionals strive to care for TNB folks, a better understanding of their experience in the world and the processes that make up those experiences is needed. Beginning with describing the boundaries of gender expression in relation to other adjacent concepts, through investigating the individual process of gender expression and finally understanding the situational context within which gender expression takes place, these dissertation studies inform a new framework that begins to take shape from which to explore how TNB individuals navigate the world. This new lens supports a necessary shift in how research with TNB communities is conducted and how healthcare interventions are designed. Gender Expression In Chapter Two, the concept of gender expression was examined through an adaptation of the principle-based concept analysis. The principle-based concept analysis methodology1 was utilized to center the voices of those with lived experience, TNB community members, as the concept boundaries were explored. Reviewing historical literature, social media discourse and the academic research proved illuminating on the concept of gender expression over time. Gender expression has been clearly delineated from gender and sexuality within Queer literature over the past several decades.2-7 Social media discourse authored by TNB community members upholds this distinction and brings to light the importance and nuances of gender expression.8,9 The academic research literature attempts discussion of gender expression,10-12 but of the three sources fails to uniformly recognize gender expression as a separate concept from gender.13,14 Despite the discrepancies in use in the academic research setting, the requirements of the four principles, epistemological, pragmatic, linguistic and logical, were all met. Utilizing findings from the academic literature, gender expression is clearly defined as how a person 101 manifests and shares their gender with the world, meeting criteria for the epistemological principle.12,15-19 The pragmatic principle was also met through the academic research literature. Multiple attempts have been made at quantifying and measuring gender expression17,18,20-23 and while they may not align with community understanding, making these attempts demonstrate the usefulness. The consistency and accuracy of use across contexts, the linguistic principle, is inadequately articulated in the academic literature.14,24 However, when the historical literature and social media discourse are considered, gender expression maintains its distinction across contexts.2-4,25 Finally, the logical principle was explored through both academic research and the historical literature. In both, gender expression was presented with the concepts of gender and sexuality, resulting in clear boundaries between related concepts.6,16,26,27 Through this concept analysis, a theoretical definition was created for gender expression which can be utilized in the context of research and healthcare to better articulate the experiences of TNB people. The Gender Expression Process (GEP) In Chapter Three, the internal process of gender expression for TNB individuals was elucidated. Using dimensional analysis,28 understanding the process by which one manifests gender expression was sought. Four dimensions emerged, which included authenticity/inauthenticity, conservative/alternative, euphoria/dysphoria, and level of effort. Authenticity/inauthenticity encompassed the degree to which someone expresses their gender in a way that feels true to who they are internally. Conservative/alternative referred to the level of adherence to the sociocultural expectations for a specific gender, regardless of what someone’s gender or lack of gender happens to be. Euphoria/dysphoria described the emotional influence and impact on every aspect of gender expression. And finally, the level of effort denoted the psychological and physical energy and effort expended during the process. The key explanatory dimension of the GEP is the balance of these four constructs. The process of gender expression was fluid and contextually dependent but always involved reaching an equilibrium among each of the constructs. The constructs exert influence on one another with 102 variability in the driving construct for any given situation. The manifestation of gender expression was less central to the experience of TNB people, rather the internal process to find balance emerged as the critical aspect of the process. The Sociocultural Milieu (SM) and the Gender Minority Stress Model (GMSM) In Chapter Four, the ways in which the sociocultural milieu (SM) influences and is influenced by the GEP for TNB people was described. After articulating the process of gender expression, we sought to understand how this process is impacted by situational and contextual factors through situational analysis. The analysis focused on the aspects of gender expression that were influencing factors across all four of the constructs identified in the GEP. Some of the major sociocultural factors influencing and being influenced by the GEP were safety, religion, media representation, societal expectations, political environment, practicality, and neurodivergence. This is by no means an exhaustive list but provides insight into the interactions between the SM and the GEP. Any or all of these factors will interact with the four GEP constructs for any given situation. At the conclusion of the analysis, the Gender Minority Stress Model29 was examined for congruence with the findings. Some facets were supported by the study findings, predominately through the imperfect overlap of the factors found in the SM. However, the multidirectional interactions between the GEP and the SM was not well represented. After careful interrogation, it became clear the GMSM was no longer an adequate lens through which to view the experiences of TNB individuals. This study supports a shift to a strengths-based interactional adaptation of the GMSM for working with TNB people. Implications for Future Research Gender expression is a critical component of people’s experiences and yet has failed to be adequately captured with sexuality and gender [sexual orientation and gender identity (SOGI)].10,30 As more research is conducted aimed at reducing health disparities in TNB communities, accurate data needs to be collected. Beginning the process with a community 103 driven understanding of the concept and process will increase the relevancy of the work. Based on these findings, these are some recommendations for those engaging in healthcare research with TNB populations: 1. Consistently and accurately use sexuality, gender, and gender expression in research: The first step is consistency in language. Over the past 20 years, more and more research has attempted to collect data on a variety of sexualities and genders. The bar needs to be raised another notch and focus on relevant and respectful data collection. Within this, terminology that people use to describe themselves must be acknowledged and used. 2. Inquire about gender expression any time SOGI data is collected: As research is conducted with TNB people, there needs to be an opportunity to describe their gender expression along with relevant sexuality and gender information. This will begin to build the data necessary to understand the relationship between sexuality, gender and gender expression and people’s experiences of discrimination, mental health, and overall wellbeing. Beyond capturing accurate SOGI and gender expression data, further research is needed to better understand the pathways and impacts of both the GEP and the sociocultural milieu. The sociocultural milieu within which we experience the world is more impactful than explicitly called out in the original GMSM, and this milieu needs to be examined in relation to health disparities.31 Both the original author of the MST31 and the participants of this study recognize that the deficits focus of the current research frameworks are not closing the gap in inequity and advocate for a shift to a strengths-based lens. Based on the new preliminary model developed in this study, we have the following calls for future research on this model: 1. The impact of reaching equilibrium on psychological wellbeing needs to be interrogated: While level of effort is a component of the GEP, it is unclear how this impacts overall psychological wellbeing. The mental load of navigating social situations 104 was well acknowledged within this study, however the impact outside of the GEP was not examined. The inclusion of the GEP in the GMSM warrants exploration of how this impacts the currently established GMSM pathways to mental health outcomes. 2. Explore the GEP and SM constructs in relation to one another as well as to mental health outcomes: The highly complex interactions between the SM factors and the SM factors and GEP were articulated through this study, however the strengths of the influences were not ascertained. The level of interconnectedness and impact needs to be examined to understand potential intervention targets. Additionally, the correlations between gender, gender expression, and experiences needs to be assessed. This will provide insight into gender expression as a predictor of experiences and its subsequent psychological impact. 3. Validation across other identities: Due to the homogeneous nature of this study sample, more research should be conducted to determine if the GEP and the SM encompass the experiences of TNB people with identities not represented in this study. The GEP and safety, as a sociocultural milieu factor, need to be explored explicitly in order to fully understand how TNB people of color, especially trans feminine and trans women, experience navigating the world. Additionally, further study into the experiences of older TNB adults needs to be conducted to determine if there are generational differences. Implications for Nursing Practice and Education In alignment with the emancipatory approach of nursing philosophy, this study elucidates structural sources of undue stress contributing to well documented health disparities32 experienced by TNB communities. From the information graciously shared by the study participants, there are several opportunities for nurses to positively impact the lives of TNB people. 105 1. Leverage SM factors, financial and representation, to increase accessibility to care. Nurses and other healthcare providers should shift their focus to the SM in efforts to increase healthcare accessibility for TNB people. While this study does not determine the level of impact the SM factors have or delineate specific interventions, it supports leveraging the financial factors and representation in favor of TNB people, specifically: (1) Nurses need to be familiar with low/no cost insurance options in their state that have trans affirming policies as well as how to apply for coverage. Nurses should advocate for sliding scale payment structures within their organizations. Along with advocating at an organizational level, nurses should utilize their political power to advocate for healthcare access, not just for gender affirming care, but for all care. (2) Positive TNB representation in healthcare settings can be championed by nurses. Starting with nursing faculty, we need to ensure that TNB stories are included in all courses and in all contexts, not just in gender related medicalized contexts. Nursing students should leave nursing school understanding the complexity of TNB people’s experiences as well as be capable working with a variety of people. Within the structure of academia, we need to create inclusive learning environments for TNB students to thrive and join the healthcare professions, creating representation in all healthcare personnel. Once in the organizational setting, nurse need to advocate for genderless bathrooms, inclusive signage, and educational materials. These measures are low to no risk of harm with potential to create not only access to care but foster positive relationship within the healthcare system. 2. Leverage the SM factor, political context, to increase accessibility to care. Nurses need to advocate for supportive TNB legislation locally and nationally. Nurses have the power to speak out against anti-transgender legislation, to actively campaign against politicians perpetrating hateful anti-transgender rhetoric. The visibility of nursing 106 politically standing together in support of TNB communities may be the starting point of changing the political context in which TNB people are living. As more research is conducted exploring the expansion of the GMSM and our understanding of the mental and physical impacts of this additional chronic stress for TNB people, there will be multiple avenues for nurses to pursue as advocates for positive intervention. Focusing on increasing the positive aspects of the SM factors should be the focus of nursing aimed at decreasing the health equity gap. Conclusion The results of this Constructivist Grounded Theory study elucidated many new factors associated with the Gender Expression Process as well as how gender expression is situated in the sociocultural milieu. Reframing how gender expression is defined and utilized within health science research provides a starting point through which gender expression is explore. By listening to the experiences of TNB community members, an understanding of the complexity of the GEP emerged. Expanding the current frameworks created to depict the higher level of stress and adverse mental health outcomes in TNB populations provide more insight and potential intervention points. 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