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Perspectives from Transgender and Gender Diverse People on How to Ask About Gender

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Purpose: When inquiring about the gender of research participants, most studies use self-generated questions about gender or questions prepared by researchers that have been evaluated for comprehension by transgender and gender diverse (TGD) and cisgender individuals. However, many gaps still exist in this area, including identifying how TGD people would like to see their gender represented in questions about gender identity. To address this issue, we explored the perspectives of TGD people regarding the construction of questions about gender. Methods: In this online study of 695 TGD people (Mage = 25.52), participants provided written suggestions for how to ask about gender and these responses were analyzed thematically. Data were collected between fall 2015 and summer 2017. Results: Three broad categories of responses emerged: (1) specific identities to include in response options; (2) specific questions to ask about gender; and (3) qualifiers/nuanced considerations. Conclusion: Participants provided a variety of suggestions for how to ask about gender and future research is needed to explore the implementation of these suggestions. Recommendations are provided for options that researchers can explore for how to ask about gender. These findings highlight the ways that TGD people would like their gender to be asked about, which is necessary information to ensure that questions about gender reflect TGD people's identities accurately.
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Perspectives from Transgender and Gender Diverse
People on How to Ask About Gender
Jae A. Puckett, PhD,
1
Nina C. Brown, BA,
2
Terra Dunn,
1
Brian Mustanski, PhD,
3,4
and Michael E. Newcomb, PhD
3,4
Abstract
Purpose: When inquiring about the gender of research participants, most studies use self-generated questions
about gender or questions prepared by researchers that have been evaluated for comprehension by transgender
and gender diverse (TGD) and cisgender individuals. However, many gaps still exist in this area, including
identifying how TGD people would like to see their gender represented in questions about gender identity.
To address this issue, we explored the perspectives of TGD people regarding the construction of questions
about gender.
Methods: In this online study of 695 TGD people (M
age
=25.52), participants provided written suggestions for
how to ask about gender and these responses were analyzed thematically. Data were collected between fall 2015
and summer 2017.
Results: Three broad categories of responses emerged: (1) specific identities to include in response options; (2)
specific questions to ask about gender; and (3) qualifiers/nuanced considerations.
Conclusion: Participants provided a variety of suggestions for how to ask about gender and future research is
needed to explore the implementation of these suggestions. Recommendations are provided for options that re-
searchers can explore for how to ask about gender. These findings highlight the ways that TGD people would like
their gender to be asked about, which is necessary information to ensure that questions about gender reflect TGD
people’s identities accurately.
Keywords: gender identity, gender minorities, survey design, transgender
Introduction
Research has increasingly focused on the inclusive
measurement of transgender and gender diverse (TGD)
people’s gender identities. Measuring gender has important
implications for accurate representation of TGD people,
access to resources, and quality of data collection.
1–5
Most research has presented TGD people with questions
about gender and asked for their feedback on existing
items.
6–12
From this, a two-step method has been fre-
quently suggested,
2,4,6,11,13–18
entailing asking about
both the sex that someone was assigned at birth and their
current gender. The wording of these questions and response
options has varied across sources. Overall, the two-step method
provides a more comprehensive way of asking about gender
compared with single question formats that often conflate
sex and gender,
15,18
is easily understood by both TGD and cis-
gender individuals, and produces more reliable data on gender
than other methods.
2,6,7,18,19
There is some consensus that a two-step method for ask-
ing about gender is preferable to other methods, yet many
studies do not include these questions
10,17,20
and some col-
lect information about gender in problematic ways, such
as by a person’s voice
21
or through other practices, such
as relying on a person’s sex assigned at birth. Other specific
recommendations for improved measurement of gender in-
clude: providing write-in options,
10,14
recognizing that not
all TGD people identify with the label of transgender,
13
en-
abling multiple response options to be chosen instead of
forced choice formats,
22
including options for genderqueer
and non-binary people,
15,16
and recognizing that regrouping
participants or combining participants across response
1
Department of Psychology, Michigan State University, East Lansing, Michigan, USA.
2
College of Education, Wayne State University, Detroit, Michigan, USA.
3
Department of Medical Social Sciences, Northwestern University, Chicago, Illinois, USA.
4
Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, Illinois, USA.
LGBT Health
Volume 00, Number 00, 2020
ªMary Ann Liebert, Inc.
DOI: 10.1089/lgbt.2019.0295
1
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options can be invalidating.
10,19
In addition, there can be le-
gitimate concerns about safety for TGD people who share
their identity and individuals should have the option to
skip gender questions.
9,11
Some authors have recommended that questions and re-
sponse options be revised as social shifts in language and un-
derstandings of gender continue to happen.
20
One change
that relates to the frequently suggested two-step method is
the increased recognition of individuals who are intersex, in-
cluding on birth certificates.
23
Many of the existing sugges-
tions were made when states did not issue birth certificates
that recognized intersex individuals and as such, their recom-
mendations for asking about sex assigned at birth do not in-
clude options for people who are intersex. In addition, there
have been other social shifts in language to describe gender
and greater recognition of a variety of gender labels that
should be considered in response options, such as gender-
fluid.
24
Finally, some areas now allow non-binary options
on birth certificates as well and this may influence response
options in research questions (e.g., New York City).
25
Most of the existing research on the measurement of gen-
der has started with preformed questions and asked TGD
people to provide their perspectives on these items, rather
than starting by asking TGD people what questions they
would like to be asked in the first place. As such, there has
been minimal exploration of how TGD people would like
to see their gender represented in research studies—an im-
portant point to consider to improve accuracy and represen-
tation. To add to this literature, we sought to understand how
a TGD sample desired their gender to be asked about and
represented in research studies.
Methods
Participants and procedures
This online study, conducted between fall 2015 and sum-
mer 2017 entailed two sections: (1) a daily diary study for
participants who met the following inclusion criteria: identi-
fied as trans men, trans women, genderqueer, or non-binary,
ages 16–40, had sex in the past 30 days, and either binge
drank or used substances in the past 30 days; and (2) a
one-time survey for any TGD individuals who were at
least 16 years old but did not qualify for the daily diary
study (these participants were only required to be at least
age 16 or older and could have any TGD identity). The
data for the current analyses were drawn from this latter
one-time survey. All participants were from the United
States. The full procedures for this study are described else-
where, including information about ensuring the quality of
the online data collection.
26
The study was approved by
the primary investigator’s institutions (Northwestern Univer-
sity and the University of South Dakota) with a waiver of pa-
rental permission for participants ages 16–17. Participants
provided their consent/assent through the online survey.
There were 695 participants in the one-time survey.
Measures and open-ended item
Demographics. Participants reported their age, gender,
sex assigned at birth, differences of sex development, race/
ethnicity, sexual orientation, income, and education (re-
sponse options are presented in Table 1).
Table 1. Sample Demographics
Characteristic n(%)
Race/Ethnicity
White 526 (75.7)
Black/African American 13 (1.9)
American Indian or Alaska Native 1 (0.1)
Native Hawaiian or other Pacific Islander 0
Asian 21 (3)
Latino/a 25 (3.6)
Option not listed 8 (1.2)
Multiracial/Multiethnic 98 (14.1)
Gender Identity
Trans man/Transman 180 (25.9)
Trans woman/Transwoman 105 (15.1)
Woman 10 (1.4)
Man 31 (4.5)
Genderqueer 87 (12.5)
Non-binary 132 (19)
Agender 66 (9.5)
Androgyne 7 (1)
Bigender 22 (3.2)
Option not listed 55 (7.9)
Sex assigned at birth
Female 534 (76.8)
Male 156 (22.4)
Difference of sex development
Unsure 124 (17.8)
Yes 20 (2.9)
No 551 (79.3)
Sexual orientation
Queer 174 (25)
Pansexual 130 (18.7)
Bisexual 106 (15.3)
Gay 62 (8.9)
Asexual 100 (14.4)
Heterosexual/Straight 38 (5.5)
Lesbian 35 (5)
Option not listed 50 (7.2)
Education
Less than high school diploma 91 (13.1)
High school graduate or equivalent 88 (12.7)
Some college education, but have
not graduated
228 (32.8)
Associate’s degree or technical school
degree
52 (7.5)
Bachelor’s degree 160 (23)
Master’s degree 63 (9.1)
Doctorate or professional degree 13 (1.9)
Income
<$10,000 357 (51.4)
$10–19,999 112 (16.1)
$20–29,999 59 (8.5)
$30–39,999 49 (7.1)
$40–49,999 39 (5.6)
$50–69,999 36 (5.2)
$70–99,999 29 (4.2)
$100,000 11 (1.6)
There were five participants with missing data on the question
asking about sex assigned at birth, and three participants with miss-
ing data about their race/ethnicity and income. There were no cis-
gender individuals in the sample, thus the classification of ‘‘man’
and ‘‘woman’’ refers to trans men and trans women respectively.
2 PUCKETT ET AL.
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Open-ended item. Participants provided suggestions for
how gender should be asked about through an open-ended
question: ‘‘In studies that are for anyone, regardless of gen-
der identity, how would you like to see your gender repre-
sented in a question? Keep in mind that without some way
of indicating that someone does not identify with their sex
assigned at birth, the experiences of trans and gender non-
conforming individuals may be overlooked.’’
Analyses
Frequencies for demographics and demographic differences
in response rates were conducted in SPSS (IBM Corp.,
Armonk, NY). Qualitative coding was conducted in Dedoose
(Los Angeles, CA: SocioCultural Research Consultants). To
begin, the first and secondauthors reviewed all data and devel-
oped notes about prominent themes. The second author then
developed an initial code list that defined each theme. The
codes each represented unique suggestions for how partici-
pants believed gender should be asked about. The first author
reviewed the list and met with the second author to refine the
list and definitions for clarity. The second author then applied
the codes and then conducted a review of all the data within
each code. After this, the first author reviewed all coding, cor-
recting small changes to align coding with the codebook.
Afterward, the third author conducted reliability coding with
a random subset of 20% of the data, yielding a Kappa of
0.802 indicating substantial agreement between coders.
27
Results
The full sample of 695 participants ranged in age from 16 to
73 years (mean [M]=25.52; standard deviation [SD] =9.68)
and were primarily White (75.7%). Table 1 includes a full de-
scription of the sample. There were 314 participants who
responded to the open-ended item and reported suggestions
for how to ask about gender. Participants who did not provide
a response to the open-ended item were older (M=26.78,
SD =11.08) than participants who provided recommendations
(M=24.26, SD =7.81), t(627.67) =3.48. Participants who
identified as either transgender men (participants who indi-
cated a gender of man or trans man/transman) or transgender
women (participants who indicated a gender of woman or
trans woman/transwoman) were less likely to provide recom-
mendations (44.2%) than all other gender groups combined
(54.5%); v
2
(1) =7.35, p<0.01. There were no significant dif-
ferences in whether participants responded to the open-ended
question based on income [participants earning below
$20,000 per year compared with those earning more; v
2
(1) =0.001, p=0.98] and race/ethnicity [Participants of Color
compared with White participants; v
2
(1) =0.95, p=0.33]. Par-
ticipants’ suggestions fell into three categories: (1) specific
identities participants wished were included in gender ques-
tions to either capture how they or other TGD people identi-
fied; (2) specific questions to ask about gender; (3) qualifiers
or nuanced considerations for gender questions. Descriptions
of each category and examples are provided. The percentages
reported for each category align to the percentage of the subset
of participants who provided suggestions.
A total of 226 participants (71.97%) provided suggestions
for identities that should be included in gender questions (see
Table 2 for a list of responses). Of note, the raw counts of
these suggestions must be interpreted in light of the identities
of participants in our sample as these likely influenced sug-
gestions. Some labels suggested are infrequently included
in gender questions, such as agender, bigender, polygender,
and neutrois. Participants also offered nuanced ways of
recognizing a TGD experience, such as ‘‘man of transgender
experience.’
In terms of specific questions to ask about gender (n=44;
14.01%), there were two types of suggestions: (1) separate ques-
tionsforsexassignedatbirthandgender(n=16; 5.10%); and
(2) separate questions for gender and whether participants iden-
tified as TGD (n=28; 8.92%). The first suggestion allows par-
ticipants to indicate their current gender identity in inclusive
ways while also allowing researchers to crossreference this
with their sex assigned at birth to determine whether participants
who do not report a specific trans identity should be considered
TGD (e.g., a participant whose gender identity is woman and
Table 2. Gender Identity Suggestions
Agender (29)
Androgyne (2)
Bigender (3)
Cassgender (1)
Cis man/Cisgender man (4)
Cis woman/Cisgender woman (3)
Cisgender (1)
Demiboy (2)
Demigirl (1)
Femme nonbinary (1)
Fluid (1)
FtM (5)
Gender nonconforming (10)
Gender neutral (1)
Genderfluid (23)
Genderflux (2)
Genderless (1)
Genderqueer (39)
Man (8)
Man assigned female at birth (1)
Man of transgender experience (3)
Man who has transitioned (1)
Masculine nonbinary (1)
MtF (2)
Multigender (2)
Neither (1)
Neutrois (3)
No gender (1)
Non-binary (94)
Polygender (2)
Trans (8)
Trans feminine (6)
Trans boy (1)
Trans girl (1)
Trans guy (1)
Trans man/Transman /Transgender man (39)
Trans masculine (15)
Trans woman/Transwoman/Transgender woman (20)
Trans* (5)
Transgender (14)
Transsexual Man (1)
Two-spirit (3)
Without-gender (1)
Woman (8)
Values in parentheses represent the number of participants who
mentioned this gender identity; participants often made suggestions
for multiple identity labels.
TRANS PERSPECTIVES ON GENDER QUESTIONS 3
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who was male assigned at birth). This participant’s response
exemplifies this suggestion:
Make two separate questions, one just about gender identity,
and a separate question about what gender a person was
assigned at birth. If you have the question ‘‘what is your
gender’’ and two of the options are cis man and trans man,
[you’re] implying [that] these two groups are different
genders, which is transphobic, as they are both men.
Basically please don’t ask ‘‘what is your gender’’ when
you mean ‘‘what is you[r] gender and sex.’
Having separate questions for gender and sex assigned at
birth ensures that sex and gender are not conflated and that
TGD participants are acknowledged appropriately. When re-
searchers do not provide these types of options TGD people
may be erased, as this participant noted: ‘‘If a study asks me
if my gender is ‘male, female, or transgender,’ then I will
check the ‘male’ option, since transgender isn’t my gender.’’
The second option, having a question about gender and
about whether participants identify as TGD, allows partici-
pants to report their identity without it being compared
with their assigned sex. Some participants noted that being
asked about their sex assigned at birth was troubling (e.g.,
‘‘It should ask [if] we are trans, rather than our birth assign-
ment, because having to identify in any way with our sex
assigned at birth can be very painful.’’). Asking in this way
still allows researchers to identify TGD and cisgender partic-
ipants. Participants suggested a few different ways that the
question to indicate being TGD could be worded: (1) using
the language of transgender or cisgender experience (‘‘A
follow-up question, should someone choose man or woman,
is to state, ‘I am a man/woman of.’ transgender experience,
cisgender experience, or a preference not to say.’’); (2) a
yes/no question about identifying as transgender (‘‘I think
‘Are you transgender?’ could be a good follow-up ques-
tion’’); (3) asking if participants are cisgender; (4) asking par-
ticipants to self-select into being cisgender or transgender
(‘‘Fill in the blanks would be lovely, with the possibility for
marking trans, cis, or prefer not to answer.’’).
Other suggestions related to qualifiers or nuanced consider-
ations. Some participants (n=50; 15.92%) emphasized the im-
portance of being able to check multiple answers (e.g., ‘‘The
terms are not mutually exclusive and being asked to pick a sin-
gle term doesnot necessarily give the bestdescription of a per-
son’s gender identity and presentation; particularly terms like
non-binary and genderqueer, which encompass a wide spec-
trum of identities. I personally identify both with trans mascu-
linity and a non-binary identity.’’). Having participants only
choose one answer for their gender can result in less accuracy
in describing the lived experiences of participants or can be
marginalizing to those who identify as genderfluid or other
identities that may shift over time (‘‘I identify differently on
different days but don’t like the term genderfluid for myself,
soIprefertobeabletoselectmultipleoptions).
Other participants wanted gender to be asked as a fill in the
blank question (‘‘In a question about gender identity, I be-
lieve the best way to ask would be to just provide a fill in
bar so everyone can write individually their own identity
without feeling erased.’’) or to provide a list of gender op-
tions and the ability to write in a response if the others do
not fit for participants (n=56; 17.83%). Some participants
noted that just clicking an ‘‘other’’ category felt marginaliz-
ing and did not provide them with an opportunity to describe
their gender. Alternatives could be to have a ‘‘Not Listed’’
option with a space for participants to write in how they iden-
tify if they choose this option, which some participants stated
can feel less stigmatizing than the ‘‘other’’ option.
There also are nuances that should be considered in ques-
tions about gender (n=16; 5.10%). Researchers may need to
define terms: ‘‘And, of course, since many cis folks and some
trans folks don’t know this language, the terms would have to
be defined.’’ In addition, participants recommended that re-
searchers use ‘‘male’’ and ‘‘female’’ when asking about
sex assigned at birth and disentangling this construct from
gender, as well as specifying ‘‘cis’’ or ‘‘cisgender’’ when a
response option is going to be interpreted as representing
people who are cisgender (e.g., when researchers intend
‘‘man’’ to mean cisgender men, they should explicitly state
‘‘cisgender man’’). Researchers also might consider the
order in which response options are listed and not placing
cisgender options at the start of the list (‘‘I like having cis-
man and cis-woman listed at the end.’’).
Some participants (n=32; 10.19%) indicated that they
would like the choice to not indicate that they were TGD
and felt that specifying being TGD separated them from
the gender with which they identified (‘‘I prefer to just see
man for me. I hate the implication that ‘transgender’ is
some third gender which others me and bars me from
being seen as fully male.’’). Similarly, some participants
reported that they would like to be able to indicate that
they preferred not to answer (n=9; 2.87%; ‘‘I usually select
‘decline [to] answer’ if that is an option.’’). Lastly, some par-
ticipants indicated that their responses to questions about
gender depended on the setting and the type of survey
(n=17; 5.41%). For example, one participant responded that:
In studies where my being trans is significant or relevant, like
this one, I would prefer to be listed as something like ‘‘trans
woman’’ like above, but if that weren’t relevant to the study
I would probably rather be listed just as ‘‘woman’’ or
‘‘female’’ or [something] like that.
Discussion
Participants reported a range of identities that they would
like to see represented in research studies, such as the uncom-
monly included identities of non-binary, agender, and gender-
fluid. Including terms that are important to TGD people may
result in more accurate reflections of TGD people’s identities
and experiences and better descriptions of participants. Even
so, there is still the issue of cisgender people understanding
these terms and concerns about possibly inaccurately classify-
ing individuals as TGD.
16
This is an important consideration
because inaccurate classification of cisgender people would re-
sult in flawed research and misinformation about TGD people.
Future research should examine whether definitional under-
standings of these gender terms are necessary or if cisgender
people are able to correctly classify themselves even if they
do not know the specific definitions of these terms. It may be
that cisgender people are able to identify that a term does
not apply to them even if they cannot provide a specific defini-
tion. Otherwise, prioritizing cisgender people’s experiences
and often limited understandings of gender identities may re-
sult in the continued marginalization of TGD people in ques-
tions about gender.
4 PUCKETT ET AL.
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Consistent with other recommendations, participants also
suggested a two-step method for asking about gender. Typi-
cally, this has been presented as inquiring about sex assigned
at birth and gender separately,
2,6,14,15
which some participants
also suggested. Others indicated that there should be a question
about gender followed by a specific question about whether
participants were TGD. Many of the additional suggestions
reflected nuances that can be considered in future testing of
questions about gender, such as disentangling sex and gender,
phrasing suggestions, and the ordering of response options.
Other suggestions included allowing multiple responses
rather than a forced choice format, providing a fill in the
Table 3. Recommendations for Gender Questions
Section of gender-related
questions Recommendations
1. Instructions or disclaimers: Researchers should state why they are asking about gender in their specific study.
Provide definitions that may be needed for interpretation of the question/response options
Provide any disclaimers about choices in wording (e.g., if the survey is just for TGD
individuals and there is a response option of ‘‘man’’ researchers can explain that this
survey is only for TGD people so they did not include the prefix of cis- or cisgender)
Indicate to participants whether a check-all format or a forced choice format is used in the
items.
2. Question about gender Option 1: ‘‘Which of the following labels best describes your current gender identity?’’
Possible response options:
Exhaustive list of identities, including cisgender and transgender specific prefixes and
labels (see Tables 1 and 2 for some options that could be included), as well as the option
of ‘‘Not listed’’ (with a write-in option to specify)
Brief list of identities for studies that include cisgender and TGD individuals:
Transgender Woman, Transgender Man, Cisgender Woman, Cisgender Man,
Genderqueer, Non-binary, Agender, Not listed (with a write-in option to specify)
Brief list of identities for studies that only include TGD individuals: Transgender
Woman, Transgender Man, Woman, Man, Genderqueer, Non-binary, Agender, Not
listed (with a write-in option to specify)
Always include the option ‘‘Prefer not to answer’’
Future research should examine response options such as ‘‘woman of transgender
experience’’ and ‘‘man of transgender experience’’ and similar types of response options
Option 1 follow-up question:
If researchers provided an extensive list of options and a check-all format, this could be
followed by a second question that asks TGD participants to self-select into a fewer
number of categories to assist with subcategory designation. For instance, in addition to a
check-all question with extensive options, researchers could ask: ‘‘Recognizing that
these are limited options, which of the following categories best describes your current
gender identity (please choose one): Trans Woman, Trans Man, Non-binary, I do not feel
that my identity fits into one of these categories’
Option 2: ‘‘What is your gender identity?’’ with an open-ended response format.
Follow-up prompt: ‘‘Above you provided your gender identity. To assist us with properly
classifying participants, please choose the gender identity label that you feel most closely
fits for you.’’
Response options: I am transgender; I am not transgender; Prefer not to answer
Option 2 follow-up questions:
For participants who indicate that they are not transgender: ‘‘Which of the following best
describes your gender?’’ with the following response options: Woman, Man, Prefer not to
answer
For participants who indicate they are transgender: ‘‘Which of the following best
describes your gender?’’ with the following response options: Trans Woman, Trans Man,
Woman, Man, Non-binary, Genderqueer, Agender, Not listed (with write-in option),
Prefer not to answer
These response options could be shortened to other possible combinations as outlined
above
3. Question about either sex
assigned at birth or
identification as TGD
Option 1: ‘‘What sex were you assigned at birth?’’
Response options: Male Assigned at Birth; Female Assigned at Birth; Intersex
Option 2: ‘‘I am’’:
Response options: Cisgender, Transgender, Prefer not to answer
Option 3: ‘‘Do you identify as transgender?’’
Response options: Yes, No, Unsure, Prefer not to answer
Additional question: ‘‘Do you identify as intersex or as having a difference of sex
development?’’
Response options: Yes, No, Unsure, Prefer not to answer
TGD, transgender and gender diverse.
TRANS PERSPECTIVES ON GENDER QUESTIONS 5
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blank, and including a ‘‘not listed’’ option with a text entry
field. These recommendations may complicate researchers’
use of the data because they may then be faced with uncer-
tainty about how to create subgroups, how to describe their
sample, or how to code written responses. Although these
suggestions create complexity, they should still be consid-
ered. Some recommendations can be more easily imple-
mented than others. For instance, providing a ‘‘not listed’’
option enables participants to write in their gender identity
and researchers can then categorize participants as being
TGD or into specific gender groups based on those re-
sponses. In comparison, check-all formats may be especially
challenging to navigate as there can be a variety of unique
combinations of identities. To summarize, we have provided
a list of potential questions and response options in Table 3
that incorporates the recommendations of our participants
along with the existing literature.
2–4,6,7,22
Although not ex-
haustive, this may provide some avenues for future research
to explore.
Limitations
Many participants did not respond to the open-ended ques-
tion and we cannot be sure if this was due to a misunderstand-
ing or other reasons, such as feeling satisfied with the current
study’s gender question (the open-ended question was directly
after our gender question and was optional). Other research in-
dicates that missingness on open-ended questions is not un-
usual, particularly for online studies.
28–30
In addition, some
suggestions conflicted, such as the options of asking about
sex assigned at birth and current gender identity, or asking
about gender identity only and having a follow-up question
about whether the person identifies as transgender, cisgender,
or prefers not to say. Future research is needed to test various
formats and to identify the method that would result in the
most accurate information while also being the most affirm-
ing. In addition, our sample was recruited online and findings
may differ if conducted in-person, which would also allow
follow-up questions to clarify responses. Future research
should consider the social shifts that have occurred,
20
such
as the recognition of intersex and non-binary identities on
birth certificates.
25
Our sample also was limited in that
*76% of the sample was White and had a fairly young age.
Given that this is common of online studies, future research
may increase their racial and ethnic diversity and may have
a wider age range by utilizing a varietyof recruitment methods
and in-person forms of participation.
Conclusion
Improving items about gender is an important step to in-
creasing accurate representation of TGD people in research.
Although more research is needed to continue evaluating
these suggestions, participants provided some options that
may benefit TGD people. With improved measurement of
gender, future research will be strengthened and TGD peo-
ple’s experiences will be better reflected.
Acknowledgments
The authors thank the members of the Trans Health Com-
munity Advisory Board who assisted with this project for
their time, feedback, and dedicated involvement. They also
would like to thank the participants who took part in this re-
search for their time and effort.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
The project described herein was supported by a grant from
the National Institute on Drug Abuse (1F32DA038557).
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Jae A. Puckett, PhD
Department of Psychology
Michigan State University
316 Physics Road, Room 262
East Lansing, MI 48824
USA
E-mail: pucket26@msu.edu
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... Additionally, it is essential in conversation and in the written report to use the same language that the client uses when they refer to their body (e.g. using "chest" instead of "breasts") and their gender. Puckett et al. (2020) emphasize the importance of making explicit why you are asking about gender and always providing a "prefer not to answer" option. To learn more about systematic methods of collecting these data in affirmative and effective ways, we recommend reading Puckett et al. (2020). ...
... Puckett et al. (2020) emphasize the importance of making explicit why you are asking about gender and always providing a "prefer not to answer" option. To learn more about systematic methods of collecting these data in affirmative and effective ways, we recommend reading Puckett et al. (2020). Briefly, they suggest two alternate methods: (1) ask separate questions about sex assigned at birth and current gender identity, or (2) ask about gender and whether the person is transgender or has a history of gender transition. ...
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Objective: To provide guidance and resources on how to practice culturally safe and humble neuropsychology with transgender and gender diverse (TGD) individuals and communities. Methods: We gathered a multidisciplinary team of clinicians with relevant professional and/or lived experience to review pertinent literature, discuss important concepts, and identify key resources. From this process, we outline practical steps to advance gender affirmative neuropsychological practice. Results: Professional awareness and knowledge regarding how to gather context-relevant, gender identity information is critical. TGD individuals form a heterogenous group; a one-size-fits-all approach is not adequate. It is incumbent upon neuropsychologists to engage in clinical and research practices in a manner that does not perpetuate gender minority stress and trauma. Creating an open, safe environment of care requires intentionality and careful thinking to determine what information is relevant for a particular referral question. We provide recommendations and resources for neuropsychologists. Conclusion: When neuropsychologists are proactive, responsible, and intentional, they can better provide individualized, person-centered, and trauma-informed care to TGD individuals.
... Previous research has shown that including SOGI questions in healthcare intake forms is acceptable, relevant, and important to patients and providers, especially since sexual and gender minorities experience significant health disparities and require care and services tailored to their unique needs (Cahill et al., 2014;Thompson, 2016;Dichter et al., 2018;Haider et al., 2018;Rullo et al., 2018;Pinto et al., 2019;Puckett et al., 2020;Lau et al., 2021). Importantly, these findings suggest that most individuals are not offended by SOGI questions. ...
... Additionally, qualitative opinions supported the inclusion of pronoun specification to represent oneself more accurately. This suggests that the collection of pronoun questions in social surveys is received with relatively positive attitudes, and is inline with previous research advocating the collection of SOGI information (Cahill et al., 2014;Westbrook and Saperstein, 2015;Thompson, 2016;Dichter et al., 2018;Haider et al., 2018;Rullo et al., 2018;Grasso et al., 2019;Pinto et al., 2019;Guss et al., 2020;Puckett et al., 2020;Suen et al., 2020;Lau et al., 2021). This experiment highlights the importance of pronoun clarity for genderqueer populations; additionally, for cisgender populations, no negative reaction is likely to be perceived by the inclusion of a pronoun question. ...
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... There are multiple perspectives on the measurement of gender/sex, including a two-step and multidimensional sex/gender measure approach [17,105], continuous multidimensional measurement for gender/sex [104,[106][107][108], and open-text responses [109]. Readers who are interested can see Shibley-Hyde et al. [110] and Fraser [9] for researcher perspectives, and Puckett et al. [111] for community perspectives on these different measurement options. Further, given that aspects of a persons' sexual and gender/sex identity can change over time [17,104,[112][113][114], longitudinal studies should also consider measurement of these variables across time points. ...
... For example, in a demographics table, 'women' should be reserved for all women (i.e., trans* women, cis women, trans feminine* participants). Additionally, to avoid implying that trans women and cis women are different genders, a separate line can be included to indicate what percentage of the women are of cisgender versus transgender experience [111]. In cases where only cis women are included, 'cis women' should be used, rather than 'women.' ...
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Purpose of Review The purpose of this review is to summarize the current knowledge on sexual communication among sexual and gender/sex diverse (SGD) groups. Complementing an existing review of the literature on safer-sex communication with SGD individuals (Parrillo & Brown, 2021), we focus on sexual communication related to promoting sexual satisfaction. Recent Findings The two-pathways model of sexual communication has yet to be generalized with SGD samples. Research comparing SGD with non-SGD individuals has varied in whether there are differences between groups. There is some evidence of differences between gender diverse and non-gender diverse groups in sexual communication. Emerging evidence of the unique strengths and challenges of sexual communication among gender/sex diverse groups highlights the importance of deepening gender/sex diverse-specific sexual communications research. Summary A lack of literature regarding sexual communication in SGD groups is reported. Results on whether there are differences between and/or within groups are mixed and confounded by inconsistent methodologies for measurement of demographic and sexual communication variables. Clearly, further research is needed to increase our understanding of sexual communication in SGD groups. As such, we provide recommendations for future research, specifically regarding inclusive demographic and analytical considerations.
... Literatur die Frage nach dem bei Geburt zugewiesenen Geschlecht als verletzend erfahren werden [37]. Bei Anpassungen muss aber auch die Allgemeinverständlichkeit und Akzeptanz des Erhebungsinstruments sichergestellt werden. ...
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... dysphoria), participatory studies to further develop the survey instrument are desirable. For example, the question about the sex assigned at birth can be experienced as hurtful [37]. When making adjustments, however, the general comprehensibility and acceptance of the survey instrument must also be ensured. ...
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Sex/gender diversity is increasingly recognised by society and should be taken into account more in population- representative studies, as they are important data sources for targeting health promotion, prevention and care. In 2019, the Robert Koch Institute started a population-representative health survey with the study Health in Germany Update (GEDA 2019/2020-EHIS) with a modified, two-stage measures of sex/gender. The survey covered sex registered at birth and gender identity with an open response option. This article describes the aims, the procedure and the experiences with the operationalisation of sex/gender and the results. Out of 23,001 respondents, 22,826 persons are classified as cisgender, 113 persons as transgender and 29 persons as gender-diverse. 33 respondents were counted as having missing values. A survey of interviewers showed that the two-stage measures of sex/gender had a high level of acceptance overall and that there were only a few interview drop-outs. On the basis of previous experience, the modified query can be used for further surveys, but should also be adapted in perspective. For this purpose, participatory studies are desirable that focus on how the acceptance of measures of sex/gender can be further improved and how hurtful experiences in the context of the questions asked can be avoided.
... 37 Moreover, greater heterogeneity in self-descriptors is reported by people who exist outside the gender binary. 36,38,39 This suggests that binary trans participants are fewer and less likely to use terms other than ''man'' or ''woman'' to define themselves. On this basis, it was agreed that the genders of participants reporting ''different identity'' are more likely to be congruent with definitions of ''nonbinary'' genders and these groups were combined to increase power of subsequent analyses. ...
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Purpose The purpose of this study was to compare five gender groups (cisgender women, cisgender men, transgender women, transgender men, people with non-binary/other identities) on measures of use of and dependence on seven substances. Methods A two-stage approach to assessing gender allowed 126,648 participants from the 2018 Global Drug Survey to be classified to one of these five gender groups. Participants were asked to disclose use of each substance in the preceding 12 months. The Alcohol Use Disorder Identification Test and the Severity of Dependence Scale were used to assess dependence. Multivariable logistic regression generated odds ratios to measure the association between gender and each substance use/dependence outcome, with cisgender women as the reference group. Results The sample comprised 43,331 cisgender women, 81,607 cisgender men, 215 transgender women, 254 transgender men, and 1,241 people with non-binary/other identities. Relative to cisgender women, non-binary/other participants reported greater odds of last 12-month use of all substances (adjusted odds ratio (AOR)=1.66-2.93), except alcohol (lower odds; AOR=0.42), and greater odds of dependence on cannabis (AOR=2.39), 3,4-methylenedioxymethamphetamine (MDMA; AOR=1.64) and alcohol (AOR=3.28), adjusting only for age (all p<0.05). Conclusion Transgender 2018 Global Drug Survey respondents, particularly those with non-binary/other identities, had greater odds of reporting most substance use outcomes than cisgender women. These findings suggest a nuanced approach to gender reporting in surveys and treatment centres is required to understand the needs of transgender people who use substances.
... While 'gender diverse' is an academic term that includes nonbinary people, 'nonbinary' is a more common self-identifier. 38 Finally, we have chosen to use identity-first rather than person-first language since many TGGD people, including both TGGD authors and some of our participants, prefer it. We respect others' right to their own preferences. ...
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Transgender and gender diverse people often experience voice-gender incongruence, which is inversely correlated with health and quality of life. Such incongruence could be reduced with voice and communication training, but expert-administered training is often inaccessible while self-guided training is difficult and potentially risky. Training could alternatively be provided through software (eg, smartphone apps), but such software is at an early stage. This qualitatively driven mixed-methods study thus includes surveys and interviews with 21 transfeminine, transmasculine and nonbinary people to identify general views of voice and communication training software as well as most desirable features of such software. Participants were positive about the general idea and described ways to effectively implement four critical features: feedback, accountability, automated goal setting, and training characteristics other than pitch. They also discussed optional or undesirable features. These findings may inform development of voice and communication training software, thus improving health and quality of life for gender minorities.
... Community participants in our interviews identified that markers of stigma and lack of support in the waiting room, paperwork, and initial encounters with a clinician or support staff often act as barriers to care or cause stress and anxiety. For example, a binary option for gender on intake paperwork conveys a stigmatizing message, whereas a blank space for specifying gender and the name you wish to be called allows maximum flexibility for a wide variety of gender identities and individual situations Puckett et al., 2020). Another option is to defer discussion of these identity markers until in the privacy of the therapy room. ...
Article
Objectives To evaluate the difference between female and male sports medicine physicians regarding disrespectful attitudes and sexual harassment perceived from athletes, coaches, physicians, athletic trainers (ATs) and organisations/administrations. Methods and study design anonymous survey was distributed to sports medicine physicians practicing in 51 countries. χ ² analysis was used to detect differences between female and male sports medicine physicians and logistic regression analysis was used to determine the independent variables that affect disrespectful attitudes and sexual harassment from sports participants. Results 1193 sports medicine physicians (31.9% female) participated from 51 countries. The survey revealed that female physicians, compared with male physicians, perceive significantly more disrespect or have their judgement questioned more by the following categories: male and female athletes, male and female coaches, female physicians with more years of experience, male physicians (regardless of years of experience), male and female ATs and organisation/administrations (all p<0.05). The only category where the frequency of disrespect was perceived equally by male and female physicians was during their interactions with female physicians who have the same or lesser years of experience. Female sports medicine physicians noted more sexual harassment than male physicians during interactions with male athletes, coaches, ATs and physicians (all p<0.001). In the logistic regression, gender was a related factor for perceiving disrespect, especially from male coaches (OR=2.01) and physicians with more years of experience (OR=2.18). Conclusions Female sports medicine physicians around the world experience disrespectful attitudes, questioning of their judgement and are sexually harassed significantly more often than male counterparts.
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Background: We conducted a scoping review to examine the literature regarding pregnancy-related morbidities among birthing individuals and infants experiencing housing instability (HI). Methods: Articles were identified through electronic database searches, using numerous search terms related to pregnancy and housing. US studies published in English between 1991 and 2019 were included. Peer-reviewed qualitative and quantitative articles were synthesized and critically appraised by 2 reviewers using quality appraisal tools from the Joanna Briggs Institute. Results: Inconsistent definitions for HI weakened the rigor of aggregate findings, and birthing individual outcomes were underreported compared with infant outcomes (n = 9 095 499 women, 11 articles). Many studies reported mental health-related outcomes among birthing individuals with HI. Discussion: Study sampling approaches and lack of a standard definition of HI limit review findings, but examining this relationship is critical to understanding the effect of social determinants on birthing individual health. Future research should address the nescience regarding birthing individual outcomes in this population. Policy-level advocacy addressing social determinants must also refine policy impacting community-based prenatal programs and services for the birthing individual with HI.
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Research has generally shown the benefits of social support, such as the buffering effects on life stressors, yet there has been little empirical investigation of different types of support resources for transgender individuals. We examined family support, support from friends, and connectedness to a transgender community and how these forms of support come together to influence mental health and resilience. The sample included 695 transgender participants (mean age = 25.52 years, SD = 9.68, range = 16-73; 75.7% White) who completed an online survey. Greater than half of participants reported moderate to severe levels of anxious and depressive symptoms. Family social support had the strongest correlations with symptoms of anxiety and depression (r = -.31 and -.37, respectively, p < .01) and was the only form of support associated with resilience when controlling for other forms of support. Latent profile analyses revealed 4 groups based on levels of social support from family and friends and community connectedness. Notably, Class 1 (n = 323; 47.1%) had high levels of support from family and friends and high levels of community connectedness. This class had lower levels of depression and anxiety symptoms and higher levels of resilience compared to other classes (Class 2, n = 276, 40.3%, high friend/community, low family; Class 3, n = 47, 6.9%, low support; Class 4, n = 39, 5.7%, high family, low friend/community). This study highlights the importance of examining support from a more holistic approach and provides insight into unique associations between familial social support and resilience. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Background: Sexual orientation and gender identity are key social determinants of health, but data on these characteristics are rarely routinely collected. We examined patients' reactions to being asked routinely about their sexual orientation and gender identity, and compared answers to the gender identity question against other data in the medical chart on gender identity. Methods: We analyzed data on any patient who answered at least 1 question on a routinely administered sociodemographic survey between Dec. 1, 2013, and Mar. 31, 2016. We also conducted semistructured interviews with 27 patients after survey completion. Results: The survey was offered to 15 221 patients and 14 247 (93.6%) responded to at least 1 of the sociodemographic survey questions. Most respondents answered the sexual orientation (90.6%) and gender identity (96.1%) questions. Many patients who had been classified as transgender or gender diverse in their medical chart did not self-identify as transgender, but rather selected female (22.9%) or male (15.4%). In the semistructured interviews, many patients expressed appreciation at the variety of options available, although some did not see their identities reflected in the options and some felt uncomfortable answering the questions. Interpretation: We found a high response rate to questions about sexual orientation and gender identity. Fitting with other research, we suggest using a 2-part question to explore gender identity. Future research should evaluate the acceptability and feasibility of administering these questions in a variety of care settings. These data can help organizations identify health inequities related to sexual orientation and gender identity.
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Background: Transgender inclusive and gender affirmative healthcare includes asking patients about gender identity and sex assigned at birth through what is known as the "2-step" methodology. In May 2016, the sexually transmitted disease (STD) clinic in Seattle, WA switched from using a 1-step to a 2-step gender identity question. We aimed to determine if the updated questions increased ascertainment of transgender and gender nonconforming (TGNC) patients and used the improved gender identity data to describe the human immunodeficiency virus/STD risk profile of TGNC patients. Methods: We conducted a pre-post analysis comparing the proportion of patients that identified as TGNC during the year before and after implementation of the 2-step questions. Gender identity and medical history questions were ascertained using a computer-assisted self-interview. The 2-step question included 2 new gender response options: non-binary/genderqueer and write-in. Results: Institution of the 2-step question resulted in a 4.8-fold increase in patients who were identified as TGNC: 36 (0.5%) of 6635 to 172 (2.4%) of 7025 patients (P < 0.001). After implementation, 89 patients identified as non-binary/genderqueer (51.7% of TGNC patients). The proportion of patients identified as transgender men and women increased from 0.2% to 0.5% (P = 0.002) and 0.4% to 0.6% (P = 0.096), respectively. Non-binary patients' human immunodeficiency virus/sexually transmitted infection risk profile was distinct from that of transgender and cisgender men who have sex with men, suggesting that distinguishing subpopulations within the TGNC population is important for risk stratification. Conclusions: Using a 2-step gender identity question and including non-binary/genderqueer options increased our clinic's ascertainment of TGNC patients and more accurately captured gender identity among STD clinic patients.
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This article presents the findings from the first qualitative study to consider the relationship between intersex experience and law; representing a significant contribution to a currently under-researched area of law. Since 2013 there has been a global move towards the legal recognition of intersex, with Australia, Germany and Malta all using different techniques to construct and regulate intersex embodiment. This article is the first to compare and problematise these differing legal approaches in the legal literature. In doing so it demonstrates that many of these approaches are grounded in ideas of formal equality that lead to the entrenchment of vulnerability and fail to build resilience for the intersex community. Through engagement with the intersex community a more contextual account of substantive equality is enabled encouraging new approaches to law and social justice. Our qualitative study revealed that prevention of non-therapeutic medical interventions on the bodies of children was understood to be the key method to achieving equality for intersex embodied people. Whilst this is the cornerstone of intersex-led legislative reform such an approach necessitates support through a mixture of formal and substantive equality methods such as anti-discrimination law, education and enforcement procedures. This article concludes by offering a series of recommendations to legislators capable of enabling substantive intersex equality.
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Youth and young adults (YYA) who are LGBTQ are overrepresented in the population of youth experiencing homelessness. Youth homelessness service providers need to be able to identify and refer YYA who are LGBTQ to appropriate and competent supportive services that will address their unique needs, ensure that transgender and gender expansive YYA are referred to using accurate names and pronouns, and collect data that can provide a better understanding of the prevalence of homelessness among YYA who are LGBTQ. Enabling YYA to identify sexual orientation, gender identity, and pronouns when seeking homelessness services is one recommended practice for working with YYA who are LGBTQ. Th study aimed to better understand the experience of being asked sexual orientation, gender identity (SOGI) and pronoun questions when accessing YYA housing supports and services, and to center the voices of YYA who are LGBTQ in the conversation regarding SOGI and pronoun questions. While the vast majority of respondents supported asking YYA about their pronouns, they had mixed views about whether or not sexual orientation and gender identity should be asked when YYA access homelessness services.
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Gender-minority health disparity research is limited by binary gender measurement practices. This study seeks to broaden current discourse on gender identity measurement in the USA, including measurement adoption challenges and mitigation strategies, thereby allowing for better data collection to understand and address health disparities for people of all genders. Three data sources were used to triangulate findings: expert interviews with gender and sexuality research leaders; key-informant interviews with gender minorities in New Orleans, LA; and document analysis of relevant surveys, guides and commentaries. Ten key dilemmas were identified: 1) moving beyond binary gender construction; 2) conflation of gender, sex and sexual orientation; 3) emerging nature of gender-related language; 4) concerns about item sensitivity; 5) research fatigue among gender minorities; 6) design and analytical limitations; 7) categorical and procedural consistency; 8) pre-populated vs. open-field survey items; 9) potential misclassification; and 10) competing data collection needs. Researchers must continue working toward consensus concerning better practices is gender measurement and be explicit about their methodological choices. The existence of these dilemmas must not impede research on important health issues affecting gender minorities.