Project Summary Transgender health research has historically focused on transgender women, yet where data are available, transgender men and transmasculine persons (TM) demonstrate similar or higher mental health burden. In low and middle-income countries, however, mental health among TM remains almost entirely unresearched. A 2019 systematic review revealed no scientific publications on TM mental health in India, a country that accounts for 15% of the global burden of mental disorders and where the transgender community is experiencing major socio-legal changes that may impact mental health. To fill this critical gap, a mixed- methods study of TM mental health is proposed, including the first quantitative survey of TM in South Asia. This study introduces a novel Transmasculine Gendered Situated Vulnerabilities framework which integrates gender-based analysis with a minority stress perspective to understand the mental health effects of vulnerabilities and resiliencies related to gender identity as well as assigned sex, situated within the Indian socio-cultural context. Applying a community-based participatory research approach and a sequential (QUAL QUANT) mixed-methods design, 30 TM will be qualitatively interviewed (15 in Delhi and 15 in Mumbai, India's largest cities) and 300 TM (150 per city) will be recruited to a quantitative survey using online and in- person approaches. The specific aims are to: 1. Using qualitative methods, identify gendered situated vulnerabilities and resiliencies experienced by Indian TM and explore perceived mental health impacts and recommendations for interventions. 2. Develop, adapt, and psychometrically assess measures of vulnerabilities (e.g., family rejection and violence) and resiliencies (e.g., community connectedness, family acceptance), for Indian TM. 3. Quantify mental health challenges (depression, anxiety, self-injury, suicidality) among Indian TM and evaluate associations with gendered situated vulnerabilities and multi-level resiliencies. To inform future research and interventions with this population, survey data will also be used to compare the effectiveness of online versus in-person recruitment strategies. The significance of this timely study lies in the identification of multi-level factors associated with mental health among Indian TM, with the potential to impact rapidly evolving transgender health and social policies in India and beyond. The proposed research applies an innovative theoretical framework to “put the gender back into transgender health”. Expected outcomes include the development of new measures reflecting family experiences of TM, with applications for global and U.S. transgender health research. Study results will inform the development and evaluation of an intervention to promote mental health for TM in India (R34/R01).