Executive Summary
Why ask survey questions to identify transgender and other gender minorities in surveys?
Transgender and other gender minority individuals come from a wide range of geographic and demographic backgrounds. Transgender and other gender minority people are diverse in such factors as age, race, ethnicity, income, sexual orientation, socioeconomic status, and immigration status. Despite their differences, gender minority people from all backgrounds face common experiences of discrimination in a wide array of settings across the United States today. The consequences of discrimination can be severe. According to the 2011 National Healthcare Disparities Report, transgender people, particularly those who are visibly gender non-conforming, are more likely to experience violence in the home, on the street, and in health care settings. Transgender and other gender minority people also report an elevated prevalence of HIV and suicide attempts.
While the existing body of research has helped policymakers, researchers, providers, and advocates begin to investigate and address these concerns, many aspects of the needs and experiences of transgender people and other gender minorities remain unexplored. Collecting population-based data on the social, economic, and health concerns of these communities is essential if federal, state, local, and nonprofit agencies are to adequately serve gender minority people and develop effective strategies for improving the circumstances of transgender and other gender minority people’s lives. In particular, if transgender and other gender minority people could be identified in key federal surveys, the resulting data could provide transgender and other gender minority people with a critical tool to guide local and national discussions about policy, resource allocation, and other issues that affect them.
Key federal surveys targeted for the addition of sex and gender-related measures to identify transgender and other gender minority respondents are as follows:
The American Community Survey (ACS), the Current Population Survey (CPS), the Survey of Income and Program Participation (SIPP), the National Crime Victimization Survey (NCVS), the National Health Interview Survey (NHIS), and the National Survey of Veterans (NSV). A few surveys (the Behavioral Risk Factor Surveillance System (BRFSS), the Youth Risk Behavior Surveillance System (YRBS), and the National Inmate Survey (NIS)) do have measures to identify transgender and/or other gender minority respondents, but either more consistent addition of these measures is needed across surveys administered in the states or these surveys should consider revised measures.
What are the recommended approaches for identifying transgender and other gender minority respondents in surveys?
In this report, we describe recent research by GenIUSS scholars and other researchers to design and test measures that will identify transgender and other gender minority respondents in surveys of the general population (i.e., large-scale population-based surveys). Questions that enable survey respondents to be classified as transgender or cisgender, often used in combination, include measurement of sex, gender identity, and transgender status. In population-based surveys, it is as important to accurately identify gender minority respondents through these questions as it is to minimize “false positives,” which are members of the general population who might accidentally identify themselves as transgender or another gender minority. The measures listed as “recommended” in this report have tested well with both transgender and cisgender respondents. Measures listed as “promising” need further testing. Although further research is needed, particularly with more diverse, representative samples, there is sufficient evidence to include measures that classify transgender and other gender minority respondents and cisgender respondents in population-based surveys now.
The following are approaches the GENIUSS Group recommends
Transgender/cisgender status via the “two-step” approach
When two demographic items can be added to an adult survey (or, in most instances, a standing measure of sex replaced and a measure of current gender identity added), we recommend including measures of self-reported assigned sex at birth and current gender identity. Testing shows that the “two-step” approach appears the most likely to have high sensitivity, as well as high specificity, with adults. It is unclear whether assigned sex at birth should precede or follow current gender identity on population-based surveys; future studies should investigate ordering effects.
Transgender/cisgender status via the MA BRFSS 2013 single-item approach
When valid, self-report measures of assigned sex at birth and current gender identity are not on a survey and cannot be added (or replace existing measures), then the following stand-alone demographic item is recommended:
LGBT identity
When valid, self-report measures of assigned sex at birth and current gender identity are not on a survey and cannot be added (or replace existing measures) and a valid and separate measure of sexual orientation identity is not already on a survey and cannot be added, then the following stand-alone demographic item is recommended (without a write-in response option):
How and where should these measures be added to surveys?
After selecting survey items appropriate for the research question and study purpose, it is next necessary to consider how to conduct the survey, including mode of data collection, placement of questions, and skip patterns. Careful placement, survey mode adaptations, and skip patterns may improve the quality of data about transgender and other gender minority people.
Chapter 3 provides a detailed review of these considerations and describes the following best practices:
- We recommend asking assigned sex at birth and current gender identity questions to implement the two-step approach on population-based surveys.
- When possible, we recommend placing sex and gender-related questions on self-administered portions of a survey. This method could involve the inclusion of a subset of questions on a paper-and-pencil self-administered questionnaire or inclusion on a self-administered computer-assisted interview.
- We recommend including sex and gender-related survey questions at the end of the standard “demographics” section. for paper-and-pencil surveys, we recommend these questions be placed early in a survey, but not on the cover page to help ensure privacy or anonymity of respondents.
Are there any special considerations in using these measures related to age, race/ethnicity, socioeconomic status, and intersex status?
Chapter 4 describes considerations related to age, race/ethnicity, socioeconomic status, and intersex status when designing and analyzing sex and gender-related measures. Briefly, below are descriptions of some of these considerations:
Age
We outline three additional issues to consider when collecting data from adolescents:
- Transgender and other gender minority youth may not adopt alternative gender identity labels until mid- to late- adolescence but may exhibit behavior that is gender non-conforming in childhood. Cisgender youth, particularly cisgender lesbian, gay, and bisexual youth, may also exhibit gender non-conforming behavior that places them at elevated risk of violence and harassment. When sample sizes are small and/or the goal is to identify a minority group that is at risk of negative social attention (i.e., gender non-conforming youth), then a measure of gender expression, when accompanied by a valid measure of assigned sex at birth (or current gender identity–please refer to note on page 15 of Chapter 2), may be appropriate.
- Adolescents may have particular difficulties with complex vocabulary and sentences. There fore, questions designed for adolescents should take extra care to use plain language and simple sentences. Terms used in measures of sex and gender should be defined since adolescents, and cisgender (non-transgender) adolescents, in particular, conflate the terms sex and gender and have varying understanding of the term transgender, masculine, and feminine.
- Adolescents often lack privacy when completing surveys in schools. For this reason, we recommend that measures that make transgender or other gender minority youth identifiable not be placed at the beginning of surveys when peers are likely to be responding
to the same survey items at the same time.
Given these considerations, Chapter 4 provides recommended and promising approaches for measuring gender expression, transgender status, and sex assigned at birth among adolescents.
Race/Ethnicity
While some research has examined whether there are differences in response to measurement items on LGBT identity items associated with race or ethnicity, there has been limited analysis of whether known community-level differences in nomenclature and terminology related to self-identity influences the accuracy and sensitivity of measures that can be used to identify transgender and other gender minority people of color. In Chapter 4, we describe how minority stress affects transgender and other gender minority people of color in disparate ways, but gaining a fuller understanding of this disparate impact will only be advanced through large, ongoing surveys where data may be aggregated over time and across place. Further, we discuss issues regard-ing data analysis, measures for Spanish-language surveys based on research in Puerto Rico, and future research needs.
Socioeconomic Status (SES)
Social and economic marginalization is an unfortunate reality for many transgender and other gender minority people. Socioeconomic disparities are an important consideration due to the methodological implications for the science of understanding the health, epidemiology, and demography of gender minority populations. First, ensuring that low SES, vulnerable gender minority communities are “counted” is key to addressing the social determinants of health and to getting a fuller picture of the population health of transgender and other gender minority people. Second, if transgender and other gender minority people are disproportionately not living in traditional housing units typically considered for inclusion in population-based surveys (i.e., if they are homeless or unstably housed), then they are less likely to be included in those surveys. This situation creates selection bias whereby the sampling strategy disproportionately captures gender minority respondents who have higher SES, thus under-representing lower SES individuals in that population. Multiple sampling strategies and multiple survey modes, described in Chapter 4, may improve data collection efforts and accuracy.
Intersex Status
Three major issues in identifying intersex people/people with DSDs on surveys are as follows: First, some intersex people/people with DSDs do not identify with the term “intersex” as an identity or gender identity. Therefore, including the term “intersex” in questions that utilize a list of gender identity terms may not capture all intersex people/people with DSDs. second, “Intersex” is sometimes used as an identity among people who do not have intersex traits/DSDs. Therefore, researchers must utilize measures that will clearly identify respondents from the population of interest. finally, “intersex” is not included as an option for sex entered on birth certificate forms. Therefore, items asking assigned sex at birth should not include intersex as an answer option. In Chapter 4, we discuss some potential measures that could be tested to identify intersex people/people with DSDs on surveys.
Are there any considerations regarding analysis of these measures?
The relatively small samples usually associated with transgender and other gender minority populations coupled with distinctive issues associated with the measurement of sex and gender on surveys create a variety of analytical challenges for researchers. Chapter 5 summarizes some of these challenges and, where possible, identifies analytical strategies to improve the accuracy and validity of analyses. These strategies include the creation of a larger sample by routine administration of the same survey that allows aggregation of data over time and across survey locations. This type of aggregation can yield relatively large samples of transgender and other gender minority respondents that allow for nuanced analyses. The recommended “two-step” approach, described in Chapter 2, is particularly important since this approach is designed to capture the nuance of various subcategories of the gender minority population, which may otherwise be lost. A sample analysis of a “two-step” approach to identifying transgender and other gender minority respondents is provided in Chapter 5. Overall, we recommend using the most specific and detailed measures of sex and gender as are possible given the design and analysis plans of any particular survey.
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