PROJECT SUMMARY Background: In the United States transgender and gender diverse (TGD) communities experience a higher burden of mental health disorders compared to their cis-gender counterparts. Stigma has been shown to be a key factor in mental health disparities in the TGD population, though comparatively little is known about how stigma on the structural level, including laws, policies, social attitudes, and norms, affect the mental health of TGD individuals, especially among those living in rural areas. Given the recent increase in laws and policies that restrict or ban access to gender-affirming care and the NIMH's Strategic Plan Goal 2 highlighting the need for greater understanding of social and environmental risk factors for poor mental health, it is a critical moment to further understand this topic. Study Goals and Aims: The proposed study explores the formation of structural stigma and its relationship with mental health of TGD individuals living in the rural Untied States. Study aims include: 1) Analyze the formative process of state-level policies and laws pertaining to transgender healthcare in a subset of US states; 2) Explore the experiences of structural stigma and its effects on mental health among TGD adults living in the rural US; and 3) Assess relationship between state-level structural stigma and individual-level depressive symptoms. Approach: An explanatory, sequential mixed-methods design will use a combination of publicly available data and survey data from the Rural Engagement and Approaches for LGBTQ+ Mental health (REALM) study, an ongoing NIMH-funded R01 cohort study of LGBTQ+ adults living in the rural US led by scholars at Johns Hopkins University and Emory University. Aim 1 will include a content analysis of legislation to understand the rhetoric and scientific evidence used to support recent state-level laws and policies focused on transgender health. Aim 2 will collect primary qualitative data through repeated in-depth interviews with 25-35 TGD individuals to understand experiences of structural stigma and its effects on mental health. Aim 3 will use structural equation modeling to explore the relationship between state-level structural stigma and individual-level depressive symptoms. Triangulating findings from Aims 1-3 will bring a holistic understanding of the research topic and can be used to inform future mental health policy specifically for TGD individuals. Fellowship Information: The proposed research will serve as doctoral dissertation of Kirsten F. Siebach, PhD student at Johns Hopkins Bloomberg School of Public Health. The training and research will be supported by a tailored mentorship team who, combined, offer expertise in mental health, policy, and relevant methodological techniques. The training plan will prepare Kirsten to become a leading independent researcher in the relationship between the structural environment and mental health of LGBTQ+ populations.