TransModScrapWork.docx (PDF)

WHOQOL-BREF:
Transgender Youth Module (A)
General Population

ABOUT THIS QUESTIONNAIRE:
The Transgender Youth Module is designed to inform researchers about how transgender youth (ages
15-24) feel about their health and well-being. This questionnaire is based on the World Health
Organization’s BREF inventory, but has had major revisions to cover issues relevant to trans people.
Responses gathered will help healthcare professionals create better treatment plans and address the
unique healthcare needs of trans youth. In case you have any questions regarding the survey, please
email Calliope Wong (researcher) at calliope.wong@uconn.edu. Thank you in advance for your time and
suggestions.

ABOUT YOU: ​Before we begin, we’d like to ask you a few general questions. Please circle your answer or
fill in the lines provided.
What is your date of birth? ________ / ________ / ________ Day / Month / Year
What is your name? (please give the name you prefer/wish to be called) __________________________
In terms of gender, how do you identify? __________________________________
What are your preferred gender pronouns? (ex. she/her/hers, they/them/theirs)
__________________________________________________
What is the highest level of education you received? (please circle)
None at all

Grade school

Middle school

High school

College

Graduate School/beyond

Since you are filling in this questionnaire at a healthcare office, what is the reason you are seeing your
doctor today? (please circle the dot that applies)
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I’m well--just following up on my meds/hormones.

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I’m well--looking to start meds/hormones.

●

I’m not well--here for a problem related to my meds/hormones.

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I’m not well--here for a problem not related to my meds/hormones.

●

If none of these answers fit your situation, or if you wish to provide more information, please
explain on the line below:

_____________________________________________________________________________________

Generally speaking, are you well? Do you have any chronic health conditions such as: (please circle)
1.
2.
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4.
5.
6.
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8.
9.
10.
11.

Asthma
Diabetes
High blood pressure
Eating disorders
Mobility impairment
Chronic pain
Alcohol dependence
Tobacco dependence
Depression
Anxiety
Other:__________________________________________________

What is your race or ethnic background? _____________________________
Do you currently use/have a history of using recreational drugs? _______________________________
Have you ever suffered from domestic, familial, or other forms of abuse?
_____________________________________________________________________________________
At this point, we’ve finished with the general questions. Please read the instruction sheet attached, and
begin answer the questions that start on the next page.
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Below, please answer questions 1-8, which ask about you and your daily life.
1.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

2.
What are the things that add value to your life? (circle/write in all relevant answers)
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School activities:____________________________________________________
Religious activities:_______________________________________________
Sports/Physical activities:__________________________________________
Music:______________________________________________________
Hobbies:________________________________________________________
Spending time with friends:_______________________________________
Spending time with family:____________________________________________
Spending time with online communities:_______________________________
Other: ____________________________________________________

3.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

4.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

5.
What are the parts of your life that you feel best and worst about? (Please write what you are
comfortable sharing.)
Best:______________________________________________________________
Worst:_____________________________________________________________
Why:______________________________________________________________

6.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

7.
When you encounter major problems, your attitude/strategy is mostly to: (circle those you use most)
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do nothing: wait for the problem to go away
proceed with caution, and see what happens
address the issue immediately
seek the help of mentors
talk things out with friends
other strategies you use: __________________________________

8.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Questions 9-16 ask about your social life and your connections with other people.

9.
Do people know you are trans?
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No one except me knows I’m trans
My family knows
My friends know
Most people know I’m trans, but it wasn’t my choice for them to know
I’m out to most people
I’m very open about being trans
Other:________________________________________

10.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

11.
How does being transgender fit in with your cultural or ethnic background? (please check the
appropriate box and explain)
▢Not at all:________________________________________________________
▢A little:__________________________________________________________
▢Somewhat:_______________________________________________________
▢Mostly:__________________________________________________________
▢Completely:______________________________________________________

12.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

13.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

14.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

15.
How big a role does dysphoria (the painful disconnect between how others see you, and how you see
yourself) play in your life? (please circle and write on the lines):
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It is severe and out of control:____________________________________________

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It is bad, but manageable:________________________________________________

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I have good and bad days:________________________________________________

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I mostly have good days:_________________________________________________

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Dysphoria hardly affects me:_____________________________________________

Please share how you deal with dysphoria?
_____________________________________________________________________________________

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_____________________________________________________________________________________

16.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Questions 17-25 ask about your health and healthcare.
17.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

18.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

19.
When was the last time you saw a doctor?: ​(if you can’t remember, please approximate)
________________________________________________
For what purpose?: ​(circle answer(s) that apply)
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Physical exam or wellness visit

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To check up on a chronic condition (asthma, high blood pressure, etc)

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ER for a problem

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To start a medication

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To start hormones

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Other:​__________________________________________

20.
Do you feel respected by the health care professionals you meet? (This can include psychologists,
nurses, doctors, and other specialists)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

22.
Please describe what sources of information you used to help you transition? (ex. friends, family,
mentors, books, etc):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

23.
Please describe where you are currently in your transition (share only what you are comfortable
with):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________