Validation of the “Gender Affirmation in Healthcare Settings” Scale Among Transgender Women Living with HIV in India: Findings from Exploratory and Confirmatory Factor Analyses

Purpose: Gender affirmation (GA) has been associated with improved healthcare engagement and health outcomes. Given the lack of a valid tool to measure GA in healthcare settings (GAHS) among transgender women living with HIV (TWLH) in India, we tested the validity and reliability of a 4-item GAHS scale. Methods: We used baseline, 3-month, and 6-month data from a longitudinal observational cohort study among 140 TWLH. We conducted exploratory factor analysis (EFA) using baseline data to determine the underlying factor structure measuring GA, and confirmatory factor analysis (CFA) using 3-month data. We assessed group ('transgender woman' vs indigenous transfeminine identities) and longitudinal measurement invariance across three time points. Convergent validity was assessed by correlating GA scores with medical GA and social factors, discriminant validity by their correlation with baseline HIV-related stigma, and predictive validity by their correlation with mental health and antiretroviral treatment (ART) outcomes. Results: =7.66 (2), p=0.02), high reliability (α=0.83), and measurement invariance. Convergent validity was supported by significant correlations between GA and social support, resilience resources, and physician trust. Discriminant validity was supported as GA scores were not correlated with internalized HIV-stigma. Higher baseline GA scores significantly predicted better 3-month ART adherence and lower anxiety, demonstrating predictive validity. Conclusion: The GAHS scale demonstrated strong psychometric properties, exhibiting good validity and reliability, making it suitable for screening or monitoring GA in healthcare settings and for research purposes. Future studies should evaluate this scale among diverse populations of transgender people.