Conceptual Framework: A Biopsychosocial Model of Gender Affirmation and Hierarchy of Needs

This study applies a biopsychosocial model wherein biological, psychological, and social factors are expected to shape health outcomes [43,44]. Within this model, we draw on 2 conceptual frameworks (Figure 1). First, the Model of Gender Affirmation by Sevelius [45] conceptualizes that being affirmed in one’s gender influences psychological functioning and health behaviors (eg, HIV risk behaviors) for TGD people. A high need for gender affirmation and low access to gender affirmation are theorized to fuel poor HIV-related outcomes. Within a biopsychosocial model, it is also possible that hormonal and other system changes accompanying medical gender affirmation exert biological or clinical influences on psychosocial functioning. Second, the hierarchy of needs theory by Maslow [46,47] describes the pattern of motivations that humans generally move through to meet their needs. The theory suggests that at any given time, a certain need dominates. The most basic needs (ie, security, safety, and health) must be met before the individual will strongly desire (or focus motivation on) the higher-level needs (ie, belongingness and love, esteem, and self-actualization). Integrating the gender affirmation and hierarchy of needs frameworks, gender affirmation—social, psychological, medical, and legal [48]—takes precedence in the hierarchy of needs for TGD people, given that it pertains to security, safety, and health. Medical gender affirmation, for those TGD people who seek it, is a dominating health need that, once met, facilitates TGD patients’ abilities to address other health issues, such as HIV prevention and treatment. In this study, medical gender affirmation (exposure) is the hypothesized driving factor in improving TGD patients’ psychological functioning and HRQL (mediators), thereby increasing TGD individuals’ capacity to become engaged in HIV prevention and care (outcomes).

LEGACY cohort: the biopsychosocial model of gender affirmation and the hierarchy of needs in HIV prevention and treatment outcomes among transgender and gender diverse patients. PrEP: pre-exposure prophylaxis; STI: sexually transmitted infection.