Transgender-inclusive measures of sex/gender for population surveys: Mixed-methods evaluation and recommendations

Greta R Bauer, Jessica Braimoh, Ayden I Scheim, Christoffer Dharma, Greta R Bauer, Jessica Braimoh, Ayden I Scheim, Christoffer Dharma

Abstract

Given that an estimated 0.6% of the U.S. population is transgender (trans) and that large health disparities for this population have been documented, government and research organizations are increasingly expanding measures of sex/gender to be trans inclusive. Options suggested for trans community surveys, such as expansive check-all-that-apply gender identity lists and write-in options that offer maximum flexibility, are generally not appropriate for broad population surveys. These require limited questions and a small number of categories for analysis. Limited evaluation has been undertaken of trans-inclusive population survey measures for sex/gender, including those currently in use. Using an internet survey and follow-up of 311 participants, and cognitive interviews from a maximum-diversity sub-sample (n = 79), we conducted a mixed-methods evaluation of two existing measures: a two-step question developed in the United States and a multidimensional measure developed in Canada. We found very low levels of item missingness, and no indicators of confusion on the part of cisgender (non-trans) participants for both measures. However, a majority of interview participants indicated problems with each question item set. Agreement between the two measures in assessment of gender identity was very high (K = 0.9081), but gender identity was a poor proxy for other dimensions of sex or gender among trans participants. Issues to inform measure development or adaptation that emerged from analysis included dimensions of sex/gender measured, whether non-binary identities were trans, Indigenous and cultural identities, proxy reporting, temporality concerns, and the inability of a single item to provide a valid measure of sex/gender. Based on this evaluation, we recommend that population surveys meant for multi-purpose analysis consider a new Multidimensional Sex/Gender Measure for testing that includes three simple items (one asked only of a small sub-group) to assess gender identity and lived gender, with optional additions. We provide considerations for adaptation of this measure to different contexts.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1. Multidimensional test measure [4].
Fig 1. Multidimensional test measure [4].
Fig 2. Two-step gender identity test measure…
Fig 2. Two-step gender identity test measure [24].
Fig 3. Gender identity as a proxy…
Fig 3. Gender identity as a proxy for other dimension of sex/gender in trans persons.
Fig 4. Multidimensional Sex/Gender Measure (MSGM).
Fig 4. Multidimensional Sex/Gender Measure (MSGM).

References

    1. Bradburn N, Sudman S, Wansink B. Asking questions. San Francisco (CA): Jossey-Bass; 2004.
    1. Flores AR, Herman JL, Gates GJ, Brown T. How many adults identify as transgender in the United States? Los Angeles (CA): The Williams Institute; 2016. June p. 1–13.
    1. Reisner SL, Poteat T, Keatley JA, Cabral M. Global health burden and needs of transgender populations: a review. Lancet. 2016;388(10042):412–36. doi:
    1. Bauer GR. Making sure everyone counts: considerations for inclusion, identification, and analysis of transgender and transsexual participants in health surveys In: Coen S, Banister E, editors. What a difference sex and gender make. Vancouver: Institute of Gender and Health, Canadian Institutes of Health Research; 2012. pp. 59–67.
    1. Meier SLC, Labuski CM. The demographics of the transgender population Bamule AK, editor. International handbook on the demography of sexuality. Dordrecht (NL): Springer Netherlands; 2013. pp. 289–327.
    1. Reisner SL, Conron KJ, Scout Nfn, Baker K, Herman JL, Lombardi EL, et al. “Counting” transgender and gender-nonconforming adults in health research: recommendations from the Gender Identity in US Surveillance Group. TSQ: Transgender Studies Quarterly. 2015;2(1):34–57.
    1. Australian Bureau of Statistics. Standard for sex and gender variables, 2016. Canberra (AU); 2016. Available from:
    1. Habarta N, Wang G, Mulatu MS, Larish N. HIV testing by transgender status at Centers for Disease Control and prevention-funded sites in the United States, Puerto Rico, and US Virgin Islands, 2009–2011. Am J Public Health. 2015;105(9):1917–25. doi:
    1. Jans M, Grant D, Park R, Kil J, Viana J, Lordi N, et al. Using verbal paradata monitoring and behavior coding to pilot test gender identity questions in the California Health Interview Survey: the role of qualitative and quantitative feedback. Proceedings of the American Association for Public Opinion Research Annual Conference; 2015 May 14; Hollywood (FL).
    1. Statistics New Zealand. Statistical standard for gender identity. 2015. p. 1–10.
    1. Snider JA, Beauvais JE. Pap smear utilization in Canada: estimates after adjusting the eligible population for hysterectomy status. Chron Dis Inj Can. 1998;19(1):19.
    1. Krieger N. Genders, sexes, and health: what are the connections–and why does it matter? Int J Epidemiol. 2003;32(4):652–7.
    1. Fowler FJ Jr. Survey research methods. 4th ed. Thousand Oaks (CA): SAGE Publications; 2009.
    1. Sausa LA, Sevelius J, Keatley J, Iñiguez JR, Reyes M. Recommendations for inclusive data collection of trans people in HIV prevention, care & services. San Francisco (CA): Center of Excellence for Transgender Health; 2009. p. 1–10.
    1. Dillman DA. Mail and internet surveys. John Wiley & Sons; 2011.
    1. Groves RM, Fowler FJ Jr, Couper MP, Lepkowski JM, Singer E, Tourangeau R. Survey methodology. 2nd ed. Hoboken (NJ): Wiley; 2009.
    1. Public Religion Research Institute. PRRI Religion and Politics Tracking Survey. Washington (DC); 2011. p. 1–5. Available from:
    1. Nfn Scout, Gates GJ. Identifying transgender and other gender minority respondents on population-based surveys: considerations for analysis Herman JL, editor. Best practices for asking questions to identify transgender and other gender minority respondents on population-based surveys. Los Angeles (CA): The Williams Institute; 2014. p. 44–9.
    1. Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: a report of the National Transgender Discrimination Survey. Washington (DC): National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011.
    1. Scheim AI, Bauer GR. Sex and gender diversity among transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. J Sex Res. 2015;52(1):1–14. doi:
    1. Tate CC, Ledbetter JN, Youssef CP. A two-question method for assessing gender categories in the social and medical sciences. J Sex Res. 2013;50(8):767–776. doi:
    1. Robinson M. Two-spirit and bisexual people: different umbrella, same rain. J Bisex. 2017;17(1):7–29.
    1. Reisner SL, Conron KJ, Tardiff LA, Jarvi S, Gordon AR, Austin SB. Monitoring the health of transgender and other gender minority populations: validity of natal sex and gender identity survey items in a U.S. national cohort of young adults. BMC Public Health. 2014;14(1):1224.
    1. The GenIUSS Group. Best practices for asking questions to identify transgender and other gender minority respondents on population-based surveys. Herman JL, editor. Los Angeles (CA): The Williams Institute; 2014. p. 1–68.
    1. Conron KJ, Lombardi EL, Reisner SL. Identifying transgender and other gender minority respondents on population-based surveys: approaches Herman JL, editor. Best practices for asking questions to identify transgender and other gender minority respondents on population-based surveys. Los Angeles (CA): The Williams Institute; 2014. p.9–18.
    1. Lombardi EL, Banik S. The utility of the two-step gender measure within trans and cis populations. Sex Res Social Policy. 2016;13(3)288–97.
    1. Reisner SL, Biello K, Rosenberger JG, Austin SB, Haneuse S, Perez-Brumer A, et al. Using a two-step method to measure transgender identity in Latin America/the Caribbean, Portugal, and Spain. Arch Sex Behav. 2014;43(8):1503–1514. doi:
    1. Canadian Partnership for Tomorrow Project, Questionnaire Team. Ontario Health Study–Baseline Questionnaire [online questionnaire]. 2010.
    1. Statistics Canada. Canadian Community Health Survey questionnaire [online questionnaire]. 2013. Available from:
    1. Drennan J. Cognitive interviewing: verbal data in the design and pretesting of questionnaires. J Adv Nurs. 2003;42(1):57–63.
    1. Mavhu W, Langhaug L, Manyonga B, Power R, Cowan F. What is 'sex' exactly? Using cognitive interviewing to improve the validity of sexual behaviour reporting among young people in rural Zimbabwe. Cult Health Sex. 2008;10(6):563–572. doi:
    1. Willis GB, Lessler JT. Question Appraisal System QAS-99. Rockville (MD): Research Triangle Institute; 1999. Available from:
    1. Cary, NC. SAS/STAT Software. Version 9.4 [software]. 2013. Available from:
    1. QSR International Pty Ltd. NVivo qualitative data analysis software. Version 11 [software]. 2013. Available from:
    1. Combahee River Collective. The Combahee River Collective Statement Eisenstein ZR, editor. Capitalist patriarchy and the case for socialist feminism. New York City (NY): Monthly Review Press; 1978.
    1. Crenshaw K. Mapping the margins: intersectionality, identity politics, and violence against women of color. Stanford Law Rev. 1991;43(6):1241–99.
    1. Collins PH. Moving beyond gender: intersectionality and scientific knowledge In: Ferree MM, Lorber J, Hess BB, editors. Revisioning gender. Walnut Creek (CA): AltaMira Press; 1999. pp. 261–84.
    1. Bowleg L. When black + lesbian + woman ≠ black lesbian woman: the methodological challenges of quantitative intersectionality research. Sex Roles. 2008;59(5):312–25.
    1. Creswell J, Plano Clark VL, Gutmann ML, Hanson WE. Advanced mixed methods research designs In: Tashakkori A, Teddle C, editors. Handbook of mixed methods in social & behavioral research. Thousand Oaks (CA): Sage Publications; 2003. p. 209–40.
    1. Glen F, Hurrell K. Technical note: measuring gender identity. Manchester (UK): Equality and Human Rights Commission; 2012. p. 1–21.
    1. Preves SE. Intersex and identity: the contested self. New Brunswick (NJ): Rutgers University Press; 2003. 86 p.
    1. Bradford JB. Virginia Transgender Health Initiative Study (THIS), 2005–2006. Ann Arbor (MI): Interuniversity Consortium for Political and Social Research; 2005.
    1. Jacobs SE, Thomas W, Lang S, editors. Introduction. Two-spirit people: Native American gender identity, sexuality, and spirituality. Champaign (IL): University of Illinois Press; 1997. pp. 1–18.
    1. James K. Systems map: gender identity documentation in the federal jurisdiction. Vancouver (BC): British Columbia Law Institute; 2016.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir