|
Roughly six per 1000 people in the United States identify as transgender.
Williams Institute, 2016 |
It is estimated that approximately 1.4 million people in the United States identify as transgender, including approximately 140,000 veterans and service members (Gates & Herman, 2014; Herman et al., 2017). However, transgender and gender diverse (TGD) individuals are often not reflected in research studies, either as a function of researchers not gathering expansive gender identity demographic information or not reporting this information in their published reports. For example, the PTSD Trials Standardized Data Repository includes information on randomized clinical trials (RCTs) for posttraumatic stress disorder (PTSD), including study information, outcomes, and sample characteristics. As of 2022, of 390 RCTs targeting PTSD, zero studies reported participants’ gender identities other than “male” or “female” and only one reported sexual orientation. Similarly, a systematic review found that of 232 RCTs for depression and anxiety, none reported on TGD identity or mentioned TGD as an exclusion criterion in their study (Heck et al., 2017). TGD data is also absent from most substance use treatment literature, with no more than 2% of studies reviewed including expansive gender information for the sample (Flentje et al., 2015).
It is well-documented that TGD individuals are at increased risk for trauma exposure and related outcomes, such as PTSD, substance use disorder, depression, and anxiety (Livingston et al. 2022; Hendricks & Testa, 2012), and that minority stress is a significant contributor (Hendricks & Testa, 2012). There has been a substantial increase in TGD-focused research in the last decade to better understand drivers and solutions to these disparities. However, relying on TGD-focused research alone to understand and improve health among TGD individuals represents a missed opportunity compared to a situation in which inclusive information about gender is routinely and accurately captured in trauma and related intervention research. For example, expanding demographic forms could hasten efforts to examine whether current research and trial findings generalize to TGD individuals, whether adaptations that are responsive to minority stress and other concerns are needed, and better position research to identify emerging or perhaps unknown disparities in their data.
Increasing the visibility of TGD individuals in research has been an ongoing conversation in the scientific community for quite some time. Many scholars are committed to diversity, equity, and inclusion, and are producing exceptionally high-quality research that is inclusive of TGD individuals. Other scholars may be similarly committed but are unsure about the recommended approaches for expanding data collection. Fortunately, there are a number of established and recently updated guidelines to help.
Included here is a condensed list of recommendations based on recent guidelines. For starters, it is suggested that researchers gather at least three pieces of demographic information in their research to increase the visibility of TGD individuals in their studies. The first two questions are to assess gender and sex assigned at birth, which are both recommended to capture data on these distinct constructs and to help researchers identify gender-diverse participants who may not explicitly identify as “transgender” (e.g., a person who identifies as a man but who was assigned female at birth). The first of these questions relates to gender identity. Although response options should be carefully considered and tailored for the location, region, and ideally with input from TGD individuals, commonly used response options include Man1, Woman1, Transgender Man, Transgender Woman, Non-Binary/Genderqueer, Agender, and Two-Spirit.2 The terms ‘male-to-female’ (MTF), ‘female-to-male’ (FTM), ‘transgender male/female’ are no longer recommended. The second demographic question we propose asking about is sex assigned at birth, with the options including female, male, and intersex. Of note, the terms ‘birth sex,’ ‘biological sex,’ or ‘natal birth’ are no longer recommended and may be considered off-putting or offensive to TGD individuals (American Psychological Association, 2019).3 Although different than sex or gender, the third demographic question we propose is asking participants to describe their sexual orientation. Suggested response options include lesbian/gay4, straight/heterosexual, bisexual, pansexual, queer, and asexual.5,6 For these questions, we recommend that response options use a check- all-that-apply format and include ‘Choose not to answer’ or ‘Decline to state’ as well as ‘Another Identity’ or ‘Not listed’ (with a write in option) instead of ‘Other’ to avoid alienating or “othering” individuals (The Society for the Psychology of Sexual Orientation and Gender Diversity, n.d.).
In addition to these demographic questions, other recommendations might include providing a brief explanation about why the survey is asking about gender and provide definitions for words that may need clarification (e.g., cisgender; Puckett et al., 2020). Importantly, and to promote engagement and retention of TGD individuals in research, we recommend that researchers thoughtfully review their survey instruments and protocols for binary sex or gendered language (e.g., “he,” “she,” “opposite sex”) and consider more gender-inclusive alternatives. The recommendation is that researchers consider gender-neutral language (e.g., “they,” “them”) in surveys, and include descriptions that are gender expansive when asking about participants’ partners (American Psychological Association, 2019).
Lastly, we want to acknowledge that these recommendations represent a starting point for increasing the visibility of TGD individuals in research, but they are not definitive or exhaustive; this topic is complex and certainly deserving of attention beyond this brief commentary. The language and recommendations presented in this article are evolving over time and also differ across regions, societies, and cultures. Researchers would benefit from tailoring language for their study needs and to be culturally responsive to participants’ catchment area.
In summary, TGD individuals remain largely invisible in trauma, PTSD, and treatment research. Increasing TGD visibility in research represents not only an important and inclusive step forward, but also stands to significantly improve our understanding of TGD health and facilitate essential research to promote trauma recovery and health equity among TGD individuals.
1 Another option is specifying Cisgender Man and Cisgender Woman in response options to avoid making transgender individuals feel “othered.” Transgender men are men and transgender women are women, and some TGD participants might rightfully choose Man or Woman. If the researcher would like to clearly differentiate between transgender man/woman and cisgender man/women, then adding cisgender may help. An alternative might include offering a select all that apply option as well (e.g., a transgender woman has the ability to select both woman and transgender woman). See Puckett et al. (2020) for other question and response options, such as having a second question to ask if individuals identify as transgender.
2 Two-Spirit is an umbrella term that represents various gender identities and expressions among Indigenous, Native American, Alaska Native, and First Nations people. However, terms used to explain identity and the meaning of one’s identity may differ across tribes. Some individuals identify as Two-Spirit in terms of their gender identity, but others consider it a sexual orientation, spiritual identity, or community identity. For additional information see Robinson (2020) and Thomas et al. (2021).
3 It is recommended that researchers consider whether sex assigned at birth or gender identity are both of interest in their research studies. If sex assigned at birth is not a necessary variable in a study, it may be omitted as completing this item may be distressing or invalidating for TGD individuals. To learn more about this and ways to capture transgender identity without including sex assigned at birth, please see The Society for the Psychology of Sexual Orientation and Gender Diversity. (n.d.) and Puckett et al. (2020).
4 The term “homosexual” is still used by some individuals; however, more recently it is conceptualized as an outdated term (American Psychological Association, 2021).
5 Bisexual, pansexual, and queer are identities that often are considered to fall under the Bi+ or non-monosexual umbrella (i.e., attraction to more than one gender; Bisexual Resource Center, 2021). Although these identities may overlap, they also have important distinctions and may be associated with different experiences of stigma and discrimination (Feinstein et al., 2021). If studies have a small number of individuals that identify under the Bi+ umbrella, researchers may consider collapsing into Bi+ or non-monosexual group instead of dropping these individuals from analyses; however, this should be explicitly stated in the methods and included as a limitation.
6 Sexual orientation questions in research studies are often not inclusive of TGD individuals’ experiences. For example, TGD individuals are more likely to use terms such as ‘pansexual’ or ‘queer’ to describe their sexual orientations, which are terms that are often not included in questionnaires. To learn more about assessing sexual orientation among TGD individuals, we recommend reading Puckett et al. (2021).
Sample Demographic Questions
- Which of the following labels best describes your current gender identity?
- Man
- Woman
- Transgender Man
- Transgender Woman
- Non-Binary/ Genderqueer
- Agender
- Two-Spirit
- Prefer not to answer
- Not listed; please specify: _____________________
- What sex were you assigned at birth?
- Female/Female Assigned at Birth
- Male/Male Assigned at Birth
- Intersex
- Prefer not to answer
- Which of the following labels best describes your current sexual orientation?
- Lesbian/Gay
- Straight/Heterosexual
- Bisexual
- Pansexual
- Queer
- Asexual
- Prefer not to answer
- Not listed; please specify: _____________________
About the Authors
Kelly Harper, PhD
National Center for PTSD, Behavioral Science Division
VA Boston Healthcare System
Zig Hinds, BS
National Center for PTSD, Behavioral Science Division
VA Boston Healthcare System
Eli Benevides, BS
National Center for PTSD, Behavioral Science Division
VA Boston Healthcare System
Nicholas A. Livingston, PhD
National Center for PTSD, Behavioral Science Division
VA Boston Healthcare System
Department of Psychiatry, Boston University School of Medicine
Additional Recommended Resources
American Psychological Association. (2019). Bias-free language. http://apastyle.apa.org/style-grammar-guidelines/bias-free-language
American Psychological Association. (2021). Inclusive language guidelines. https://www.apa.org/about/apa/equity-diversity-inclusion/language-guidelines.pdf
Association of Behavioral Cognitive Therapies, Sexual and Gender Minorities Special Interest Group. (n.d.). Resources. http://www.abctsgmsig.com/resources.html
Puckett, J. A., Brown, N. C., Dunn, T. Mustanski, B., & Newcomb, M. E. (2020). Perspectives from transgender and gender diverse people on how to ask about gender. LGBT Health, DOI: 10.1089/lgbt.2019.0295
Pruden, H., & Salway, T. (2020, October 29). Meet the methods series: “What and who is Two-Spirit?” in health research. Canadian Institutes of Health Research. https://cihr-irsc.gc.ca/e/52214.html
Robinson M. (2020). Two-Spirit Identity in a Time of Gender Fluidity. Journal of Homosexuality, 67(12), 1675–1690. https://doi.org/10.1080/00918369.2019.1613853
The Society for the Psychology of Sexual Orientation and Gender Diversity. (n.d.). Nonbinary Fact Sheet [Fact sheet]. American Psychological Association. https://www.apadivisions.org/division-44/resources/nonbinary-fact-sheet.pdf
References
American Psychological Association. (2019). Gender. http://apastyle.apa.org/style-grammar-guidelines/bias-free-language/gender.
American Psychological Association. (2019). Sexual orientation. http://apastyle.apa.org/style-grammar-guidelines/bias-free-language/sexual-orientation
Bisexual Resource Center. (2021). What is Bisexuality? https://biresource.org/what-is-bisexuality/
Feinstein, B. A., Hurtado, M., Jr., Dyar, C., & Davila, J. (2021). Disclosure, minority stress, and mental health among bisexual, pansexual, and queer (Bi+) adults: The roles of primary sexual identity and multiple sexual identity label use. Psychology of Sexual Orientation and Gender Diversity. https://doi.org/10.1037/sgd0000532
Flentje, A., Bacca, C. L., & Cochran, B. N. (2015). Missing data in substance abuse research? Researchers' reporting practices of sexual orientation and gender identity. Drug and Alcohol Dependence, 147, 280–284. https://doi.org/10.1016/j.drugalcdep.2014.11.012
Gates, G. J., & Herman, J. L. (2014). Transgender Military Service in the United States. https://williamsinstitute.law.ucla.edu/wp-content/uploads/Trans-Military-Service-US-May-2014.pdf
Heck, N. C., Mirabito, L. A., LeMaire, K., Livingston, N. A., & Flentje, A. (2017). Omitted data in randomized controlled trials for anxiety and depression: A systematic review of the inclusion of sexual orientation and gender identity. Journal of consulting and clinical psychology, 85(1), 72–76. https://doi.org/10.1037/ccp0000123
Hendricks, M. L., & Testa, R. J. (2012). A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the Minority Stress Model. Professional Psychology: Research and Practice, 43(5), 460–467. https://doi.org/10.1037/a0029597
Herman, J. L., Flores, A. R., Brown, T. N., Wilson, B. D., & Conron, K. J. (2017). Age of individuals who identify as transgender in the United States (pp. 1-13). eScholarship, University of California.
Livingston, N. A., Lynch, K. E., Hinds, Z., Gatsby, E., DuVall, S. L., & Shipherd, J. C. (2022). Identifying Posttraumatic Stress Disorder and Disparity Among Transgender Veterans Using Nationwide Veterans Health Administration Electronic Health Record Data. LGBT health, 10.1089/lgbt.2021.0246. Advance online publication. https://doi.org/10.1089/lgbt.2021.0246
Puckett, J. A., Brown, N. C., Dunn, T. Mustanski, B., & Newcomb, M. E. (2020). Perspectives from transgender and gender diverse people on how to ask about gender. LGBT Health, DOI: 10.1089/lgbt.2019.0295
Puckett, J. A., Glozier, K., Kimball, D., & Giffel, R. (2021). A systematic review of sexuality measurement in transgender and gender diverse populations. Psychology of Sexual Orientation and Gender Diversity, 8(3), 276-291. https://doi.org/10.1037/sgd0000523
Robinson M. (2020). Two-Spirit Identity in a Time of Gender Fluidity. Journal of Homosexuality, 67(12), 1675–1690. https://doi.org/10.1080/00918369.2019.1613853
The Society for the Psychology of Sexual Orientation and Gender Diversity. (n.d.). Nonbinary Fact Sheet [Fact sheet]. American Psychological Association. https://www.apadivisions.org/division-44/resources/nonbinary-fact-sheet.pdf
Thomas, M., McCoy, T., Jeffries, I., Haverkate, R., Naswood, E., Leston, J., & Platero, L. (2021). Native American Two Spirit and LGBTQ health: a systematic review of the literature. Journal of Gay & Lesbian Mental Health, 1-36. https://doi.org/10.1080/19359705.2021.1913462