Transgender Health Care Humanization Scale

1. Abstract

The Transgender Health Care Humanization Scale (THcH scale) is a specialized psychometric assessment instrument designed to measure and evaluate the attitudes, cognitive beliefs, and clinical engagement practices of healthcare professionals and medical trainees toward gender-diverse and transgender patients. Developed in response to pervasive systemic discrimination, pathologization, and institutional bias documented within medical environments, the THcH scale operationalizes the multi-faceted construct of healthcare humanization—defined as the holistic integration of empathy, interpersonal respect, recognition of human dignity, and the conscientious reduction of discriminatory practices. The scale comprises 12 items administered via a 5-point Likert scale ranging from 1 (‘Strongly Disagree’) to 5 (‘Strongly Agree’), yielding composite summative scores between 12 and 60.

Psychometric evaluation through robust split-sample methodologies has validated a structurally stable two-dimensional model: Factor 1 captures proactive clinical engagement, active communication, and clinical guidance in primary and baseline healthcare, while Factor 2 captures interpersonal affective attitudes, practitioner comfort, awareness of structural prejudice, and freedom from stigmatizing stereotypes. In validation cohorts comprising Brazilian physicians, nurses, dentists, and clinical students, the instrument displayed exceptional internal consistency, demonstrated by an overall Cronbach’s alpha of 0.915 (with subscale coefficients of 0.908 and 0.893). Confirmatory factor analysis (CFA) affirmed an outstanding structural fit (Comparative Fit Index [CFI] = 0.972, Tucker-Lewis Index [TLI] = 0.964, Root Mean Square Error of Approximation [RMSEA] = 0.069, and Standardized Root Mean Square Residual [SRMR] = 0.043). Furthermore, evaluation of divergent validity demonstrated that the scale measures professional humanistic competence independently from general personal religiosity. The THcH scale serves as a standardized, reliable tool for diagnostic cultural competency benchmarking, clinical workplace evaluations, and empirical validation of medical educational interventions.

2. Keywords

transgender healthcare, healthcare humanization, psychometrics, medical stigma, cultural competence, confirmatory factor analysis, minority stress, provider attitudes, health disparities, scale validation

3. Authors

The Transgender Health Care Humanization Scale was developed and psychometrically validated by a research team affiliated with the Postgraduate Program in Medicine and Health at the Federal University of Bahia (Universidade Federal da Bahia – UFBA), Salvador, Bahia, Brazil:

• Liliane Lins-Kusterer, MD, PhD — Postgraduate Program in Medicine and Health, Faculty of Medicine, Federal University of Bahia. Primary corresponding author. Email: [email protected].
• Nicolle Melo Vieira, MSc — Postgraduate Program in Medicine and Health, Faculty of Medicine, Federal University of Bahia, Salvador, Brazil.
• Carlos Brites, MD, PhD — Postgraduate Program in Medicine and Health, Faculty of Medicine, Federal University of Bahia, Salvador, Brazil.

4. Purpose

The primary purpose of the Transgender Health Care Humanization Scale is to address a historical, systemic failure in health sciences education and clinical delivery: the pervasive marginalization, pathologization, and dehumanization of transgender and gender-diverse (TGD) patients within institutional medical contexts. Despite growing international recognition of the human rights of sexual and gender minorities, medical, nursing, and dental curricula globally have historically maintained an acute deficit in formal training regarding gender-affirming care, structural determinants of health, and cultural humility. Consequently, practitioners frequently enter clinical practice harboring explicit or implicit biases, personal discomfort, or paternalistic assumptions that manifest as hostile, neglectful, or invalidating clinical interactions.

Extensive clinical and public health research demonstrates that transgender individuals encounter severe health disparities, characterized by disproportionate rates of mental health distress, human immunodeficiency virus (HIV) transmission, barriers to routine cancer screenings, and elevated suicide risk. These disparities are acutely exacerbated by healthcare avoidance; transgender individuals routinely postpone or completely avoid seeking critical medical treatment due to legitimate fears of mistreatment, misgendering, invasive curiosity, or outright denial of service by healthcare personnel. By providing an empirically grounded, psychometrically sound metric, the THcH scale allows clinical administrators, educators, and health systems researchers to shift the investigative lens away from patient pathology and focus squarely upon provider cultural competence and structural readiness.

In research applications, the scale functions as an indispensable outcome metric for experimental and longitudinal study designs. Academic researchers can utilize the tool to evaluate the direct pedagogical efficacy of clinical diversity curricula, sensitivity workshops, and immersive clinical simulation interventions. In workplace and administrative contexts, healthcare institutions, public hospitals, and academic medical centers can deploy the scale as a diagnostic organizational climate assessment tool. It allows health system leadership to pinpoint specific institutional vulnerabilities—differentiating between deficits in actionable clinical communication skills versus entrenched negative interpersonal attitudes or stereotyping—thereby facilitating data-driven institutional reform, accreditation auditing, and equitable policy development.

5. Psychological Construct

The core psychological construct measured by the instrument is healthcare humanization within the operational domain of transgender patient management. Grounded in humanistic clinical ethics and contemporary psychometric standards, healthcare humanization is conceptualized not merely as technical clinical proficiency or passive tolerance, but as an active, multidimensional constellation of clinical engagement, unconditional positive regard, communicative empathy, and freedom from pathologizing stigma. The THcH scale operationalizes this construct across two distinct yet correlated theoretical dimensions:

Factor 1: Proactive Clinical Engagement and Basic Health Guidance

This dimension encompasses 4 items dedicated to assessing the provider’s active, operationalized dedication to delivering comprehensive, respectful primary and routine care to transgender individuals. It measures behavioral intentions and clinical communicative practices, specifically focusing on:

• Active and Empathetic Listening: The practitioner’s willingness to listen attentively to the patient’s self-articulated identity, health concerns, and lived experiences without interrupting, moralizing, or minimizing their clinical narrative.
• Preventive and Primary Health Guidance: The perceived professional obligation and proactive commitment to providing routine, uncompromised preventative education (e.g., cardiovascular health, cancer screenings, metabolic health) regardless of the patient’s gender identity or transition history.
• Patient Agency and Shared Decision-Making: Validating the patient’s autonomy, recognizing their expertise regarding their own body, and tailoring medical recommendations to their unique physiological and psychological realities.

Factor 2: Interpersonal Attitudes, De-stigmatization, and Structural Awareness

Comprising 8 items, this dimension captures the practitioner’s socio-emotional, cognitive, and affective orientation toward transgender patients. Rather than examining generic social tolerance, it taps directly into the psychological comfort and ethical maturity required in professional interactions:

• Affective Comfort and Absence of Apprehension: Evaluating whether the clinician experiences internal tension, aversion, or anxiety when treating gender-diverse individuals, ensuring care is free from clinical avoidance.
• Rejection of Stereotyping and Pathologization: Assessing the degree to which the clinician rejects derogatory cultural tropes, reductive hyper-sexualization, or assumptions that gender nonconformity is intrinsically indicative of psychopathology.
• Recognition of Systemic Prejudice and Vulnerability: The provider’s acute cognitive awareness of the socioeconomic, legal, and institutional violence routinely faced by transgender populations, which informs a protective, affirming, and humanized clinical approach.

6. Theoretical Framework

The conceptual architecture of the Transgender Health Care Humanization Scale is anchored in the convergence of three foundational sociological and psychological frameworks: Minority Stress Theory, the Dehumanization and Humanization Paradigm in social psychology, and Carl Rogers’ Person-Centered Care Model.

Minority Stress Theory

Pioneered by Ilan H. Meyer and extensively expanded within transgender health psychology by White Hughto, Reisner, and Pachankis, Minority Stress Theory posits that sexual and gender minority populations experience chronic, additive stress resulting from stigmatizing social environments. This stress manifests across distal processes (e.g., external discrimination, microaggressions, structural marginalization, violence) and proximal processes (e.g., internalized transphobia, hypervigilance, concealment of identity). Within clinical environments, distal stressors frequently emerge as medical paternalism, hostility, or denial of basic dignities. The THcH scale draws directly from this framework by conceptualizing the healthcare professional not merely as a passive actor, but as a primary environmental factor capable of mitigating distal minority stress through intentional, affirmative humanization.

The Dehumanization and Infrahumanization Framework

In social cognitive psychology, dehumanization describes the psychological process whereby members of outgroups are perceived as lacking fundamental human qualities, such as emotional depth, moral agency, or refined cognitive capacities. Haslam’s dual model differentiates between animalistic dehumanization (denying uniquely human attributes such as civility, refinement, and moral sensitivity) and mechanistic dehumanization (denying human nature, treating individuals as cold, interchangeable objects or clinical specimens). Transgender patients in medical contexts routinely endure mechanistic dehumanization, where their bodies are scrutinized merely as anatomic curiosities, and animalistic dehumanization, where their moral worth is questioned. The THcH scale operationalizes ‘humanization’ as the inverse of these processes: affirming full moral agency, emotional authenticity, and bodily autonomy.

Person-Centered Clinical Care

Formulated on the humanistic principles of Carl Rogers, person-centered healthcare mandates that therapeutic efficacy relies upon three core clinician conditions: congruence (genuineness), unconditional positive regard (warm acceptance devoid of moral judgment), and empathetic understanding. In the context of transgender health, the THcH scale posits that humanized medical delivery demands clinicians systematically dismantle implicit institutional prejudice to embody unconditional regard toward individuals whose gender experience diverges from cisnormative expectations.

7. Validity

The psychometric validation of the Transgender Health Care Humanization Scale was conducted using rigorous, contemporary methodological standards designed to verify the construct, convergent, and divergent validity of the 12-item instrument.

Construct and Structural Validity

Construct validity was established through an empirical split-sample exploratory and confirmatory factor analysis design. The emergent two-factor architecture demonstrated that the scale effectively operationalizes healthcare humanization without item cross-loadings or structural indeterminacy. The first factor systematically clustered behavioral and communication variables related to guidance and listening, while the second factor consolidated cognitive and affective attitudes concerning stigma and equity.

Divergent and Discriminant Validity

A critical psychometric consideration during the instrument’s validation was ensuring that the THcH scale measured distinct professional clinical competencies rather than merely reflecting general personal religiosity, social desirability, or broader ideological conservatism. To empirically establish discriminant validity, the authors evaluated scale performance against the Duke University Religion Index (DUREL), an internationally validated 5-item instrument measuring three dimensions of religiosity: Organizational Religious Activity (ORA), Non-Organizational Religious Activity (NORA), and Intrinsic Religiosity (IR).

Theoretical psychometric postulations suggested that while personal faith traditions significantly influence broader worldview constructs, professional humanized care toward marginalized patients should function as an autonomous clinical competency. The empirical findings robustly supported this divergence:

• Factor 1 (Proactive Engagement): Exhibited near-zero, statistically non-significant correlations with all three DUREL subscales (ORA, NORA, and IR), confirming that a provider’s proactive commitment to clinical guidance and active listening is completely independent of their personal religious commitments.
• Factor 2 (Interpersonal Attitudes): Displayed only weak to negligible correlations with religious activities. This isolated variance demonstrated that the scale does not conflate personal faith with professional interpersonal bias, thus verifying high divergent validity.

8. Reliability

The Transgender Health Care Humanization Scale demonstrates outstanding internal consistency and psychometric reliability across clinical and educational cohorts. Following established psychometric conventions (Nunnally & Bernstein, 1994), an assessment instrument intended for group-level benchmarking and educational evaluation should display reliability coefficients exceeding 0.70, while values surpassing 0.80 or 0.90 indicate superior measurement precision.

During the structural validation phase involving healthcare workers and clinical trainees across public university healthcare facilities:

• Total Scale Internal Consistency: The overarching 12-item composite scale achieved an overall Cronbach’s alpha of α = 0.915 during the confirmatory structural stage, indicating exceptionally high item homogeneity and minimal measurement error variance.
• Factor 1 Reliability (Clinical Engagement): Comprising 4 items, this subscale yielded a Cronbach’s alpha of α = 0.908, demonstrating that questions addressing active listening and guidance reliably capture a coherent behavioral dimension.
• Factor 2 Reliability (Interpersonal Attitudes): Comprising 8 items, this subscale demonstrated a Cronbach’s alpha of α = 0.893, verifying strong internal coherence across the attitudinal, non-stigmatizing items.

The narrow standard errors associated with these subscale scores confirm that the instrument provides dependable, reproducible measurements of provider attitudes across independent administrative testing cycles.

9. Factor Analysis

The dimensional architecture of the THcH scale was examined using a split-sample structural equation modeling approach on a total cohort of N = 450 healthcare professionals (including attending physicians, registered nurses, and dentists) and final-semester clinical undergraduate students from a major public university hospital in Brazil. The dataset was split into two independent subsamples using established random assignment protocols (Lorenzo-Seva, 2022) to prevent capitalizing on chance.

Exploratory Factor Analysis (EFA)

The calibration subsample (n = 240) was subjected to exploratory factor analysis. Prior to extraction, sample adequacy and data factorability were verified. The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy comfortably exceeded the 0.80 threshold, and Bartlett’s Test of Sphericity reached statistical significance (p < 0.001), confirming substantial multivariate correlation suitable for matrix decomposition.

Using oblique rotation (Promax) to accommodate expected theoretical correlations between dimensions of humanization, the EFA yielded a clean, unforced two-factor solution based on Cattell’s scree plot criterion and eigenvalue extraction (> 1.0). The two latent factors accounted for a large proportion of total variance. Factor 1 accounted for proactive clinical engagement (items 1–4), and Factor 2 captured interpersonal attitudes and de-stigmatization (items 5–12). No substantive cross-loadings (> 0.32) were observed across discordant factors.

Confirmatory Factor Analysis (CFA)

To confirm the structural stability of the two-factor model, a Confirmatory Factor Analysis using Maximum Likelihood estimation was conducted on the independent validation subsample (n = 203). The hypothesized two-factor structure demonstrated exceptional goodness-of-fit across stringent psychometric indices:

• Comparative Fit Index (CFI): 0.972 (exceeding the strict > 0.95 cutoff for superior structural fit).
• Tucker-Lewis Index (TLI): 0.964 (well above the > 0.95 threshold).
• Root Mean Square Error of Approximation (RMSEA): 0.069 (90% Confidence Interval within acceptable bounds, fulfilling the < 0.08 criterion for good fit).
• Standardized Root Mean Square Residual (SRMR): 0.043 (substantially below the < 0.08 benchmark, indicating minimal residual error).

Standardized factor loadings across both latent constructs were uniformly high and statistically significant (all p < 0.001), confirming that each item functions as a robust indicator of its designated latent construct.

10. Instrument / Measurement Tool

The specifications, administration procedures, and scoring mechanics of the Transgender Health Care Humanization Scale are detailed below:

• Test Type: Psychometric self-report attitudinal and behavioral rating scale.
• Target Population: Practicing healthcare professionals (physicians, nurses, dentists, allied health clinicians) and undergraduate/postgraduate clinical trainees.
• Administration Method: Self-administered; available in paper-and-pencil or computerized/online survey formats.
• Total Number of Items: 12 items.
• Dimensional Structure: Multidimensional (2 correlated subscales):
  • Factor 1: Proactive Clinical Engagement and Guidance (Items 1, 2, 3, 4).
  • Factor 2: Interpersonal Attitudes and De-stigmatization (Items 5, 6, 7, 8, 9, 10, 11, 12).
• Response Format: 5-point Likert scale:
  • 1 = Strongly Disagree
  • 2 = Disagree
  • 3 = Neither Agree nor Disagree
  • 4 = Agree
  • 5 = Strongly Agree
• Scoring Instructions: Total scores are calculated by summing the ordinal response values across all 12 items. Total scale scores range from 12 to 60. Higher aggregate scores indicate higher degrees of clinical humanization, empathetic engagement, and affirmation toward transgender patients. Subscale scores may be examined separately to distinguish between active clinical engagement (score range: 4–20) and non-stigmatizing interpersonal attitudes (score range: 8–40).
• Administration Time: Approximately 3 to 5 minutes.
• Available Language Versions: Brazilian Portuguese (original validation language) and English.

11. Permissions & Fee and Test Year

The Transgender Health Care Humanization Scale was formally published and validated in 2023 (with full open-access theoretical dissemination in early 2024). The original psychometric development was conducted under academic and institutional ethical oversight in Brazil, with research approval granted by the relevant Institutional Review Boards.

Regarding permissions and academic access: the THcH scale is an academic assessment instrument designed to advance public health and equity in medicine. While published within peer-reviewed academic literature, the individual proprietary scale items remain under the intellectual property of the original authors and publishers. The instrument is generally made accessible free of charge for non-commercial academic research, medical education benchmarking, and clinical quality improvement programs upon request. Researchers, clinical directors, and educators wishing to administer the THcH scale or integrate its full inventory into institutional surveys should contact the primary corresponding author directly (Liliane Lins-Kusterer) to obtain the authorized item inventory and administrative scoring guidelines.

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13. Items of the Scale