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

All participants were clear that the natal sex item was asking what was on their original birth certificate and the sex they were designated at birth. All participants also mentioned that “physical anatomy” was used to designate sex on birth certificates, for example: “Penis or vagina. Male or female”. Participants frequently described their process interpreting the item as “automatic” to indicate ease of response: “I didn’t really even think about it. It was just kind of – geez, automatic reaction” (cisgender female). Gender minority participants correctly identified that the item was asking about their assigned sex at birth on their original birth certificate: “I can’t change my birth certificate in the state where I was born, so what’s on my birth certificate now is what’s on it originally” (male birth sex, female-identified).

All participants stated that they found the question clear and easy to answer. Participants most commonly used the phrase “straight forward” (77.8%, n = 28); others described it as “obvious” and “an easy question”. Three cisgender male participants (21.4%) felt the phrasing of the question stem was awkward: “It was an awkward question, just the way it was asked. But it’s very clear and concise. Just the grammar is awkward”. However, the question did not lead to inaccurate response: 100% of participants were correctly classified in their natal sex. None of these participants suggested changing the item. No cisgender female or gender minority participants remarked on phrasing awkwardness.

All participants felt the response options “Male” and “Female” were acceptable. Several participants commented that they could not think of any other response options. One participant described being diagnosed with a medically intersex condition but did not think an “intersex” option was needed because male and female reflect the options on a birth certificate.

The most common emotional response to the question was laughter, especially for participants who had not given thought to their sex at birth. A cisgender male respondent described his thought process: “I honestly didn’t need to put a whole lot of thought into that one (laughter)”. Two participants —one had skipped the gender identity item in 2010 and the other had not—expressed negative emotional reactions: “Uh, probably kind of like an eye roll type thing in my mind, ’cause uh -- I mean this whole next question got into the whole transgender, all this other stuff. I’m not a big proponent of that, I’ll say. (laughs)” (cisgender male).

Most participants (82.1%; n = 32) interpreted the gender identity item to be about their internal sense of gender, which they recognized may or may not be the same as a person’s birth sex. As one cisgender female said: “I assumed that it was a question getting at, you know, there are people that are anatomically female, but identify mentally, psychologically, all of those things, with a different gender, or with one of those other options”. Cisgender participants used phrases like “inside feeling”; transgender participants said “how I pictured myself, mentally” and “how I actually view myself”. The remaining seven participants were all cisgender and interpreted the item to be about sex: “When I was deciding what to answer, this not really a decision. I just put the answer as male, because I’m -- I don’t know -- male”. (cisgender male).

Participants described the question as “straight forward” and “obvious”. One cisgender female summarized what many participants also described: “I checked female. This was not confusing for me because I identify as female. I knew which box was for me”.

Cisgender participants were clear about the response options “Female” and “Male”, although some had difficulty articulating what the term meant to them. One cisgender male stated: “What was I thinking about? I don’t know how to answer that question. I was just thinking, ‘I’m a male. I have always been a male, and I have male parts”. Transgender participants saw “Male” and “Female” response options as a combination of biology and socialization. One participant said: “It’s a combination of sex organs, hormone structure, how you present yourself. All that”. (female birth sex, transgender-identified).

For the most part, cisgender participants understood the response option “Transgender” as a person’s internal sense of gender being different from their physiological sex: for example, “people who were born a male or a female wanting to become the opposite sex”. The key challenge identified by transgender and cross-sex identified participants was selecting the best response option to describe their gender identity. Transgender participants described “switching” responses or trying to decide between two responses, most commonly whether to check “Transgender” or to check “Male” or “Female”. For example: “I originally picked transgender, and then went back and picked female… It did say ‘feel’, so I was pretty sure that it, you know, meant, like, identify with and stuff” (male birth sex, female-identified). Another transgender participant commented: “There were only two options, obviously, that I felt like applied, and it was either male or transgender… I just chose male because like that's how I identify in the world, really. I don't – like transgender, it kind of puts me in this other category that is not equal to, but like less than”. (female birth sex, male-identified). Another transgender participant selected “Transgender” rather than “Male” to make themselves visible as a transgender person in certain settings: “I self-identify as male. But I will say I’m trans for clarity, like here, or like in a medical setting just to be sure people know what’s up…. It made sense to check trans” (female birth sex, transgender-identified).

The majority of cisgender participants (83.3%; n = 25/30) were not sure what was meant by the response option “Do not identify as female, male, or transgender”. Participants had varied ideas of who this category might include, such as: “a nonconformist”; “pan-sexual maybe”; “Um -- hermaphrodite?” An incomplete understanding of the category, however, did not affect accuracy of participant response. It was clear that participants knew which response to check for themselves, stating, for example: “The other options just didn’t apply to me” (cisgender female). Transgender participants interpreted the “Do not identify” response option as “genderqueer”. One participant described it as a response for a younger generation: “I do believe that the youth term is ‘genderqueer’… They don’t want to be determined on whether they’re male or female” (male birth sex, transgender-identified). The general consensus was “You’d know if you qualified for that [box]” (male birth sex, female-identified).

Two participants selected “Do not identify”. Both participants described feeling their gender expression was nonconforming or gender variant and stated they did not identify with gender categories: “I just don’t relate to ‘transgender’ at all. I haven’t come up with a cool new term for me or something like that… it doesn’t relate to me at all” (male birth sex, do not identify).

Only one cisgender participant commented on the number of response options: “Um, I’m surprised, actually, that there were only four options. (laughs) Yeah…I know people that might have preferred different words or different terminology” (cisgender male). The majority 77.8% (n = 7/9) of gender minority participants liked the four closed-ended response options that were provided, stating, for example, “I feel like it had a response for everybody in a way that was worded appropriately. For me, I felt like it kind of covered everything” (female birth sex, transgender-identified). Two participants suggested additional response options, although both found the current response options to be acceptable. The participant with a medically intersexed condition suggested adding another response option “intersex”. A second respondent suggested modifying “transgender” and breaking it into two separate categories “transgender, female-to-male” and “transgender, male-to-female” in order to be more specific.

One respondent wanted a write-in response (to write-in “genderqueer”): “I would love a write-in. I was a little bit, like, disappointed, but what are you gonna do? It’s like, it comes in small steps, and so, even the fact that they created a state for transgender and created a state for I don’t pick any is, you know, very different from how it was when I was a younger kid” (female birth sex, do not identify). However, the other respondent who selected “Do not identify” felt an open-ended write-in would make it more difficult to answer the question.

Overall acceptability was high: “You know, when I saw it, I thought that was awesome” (cisgender male). This was true even for participants less knowledgeable about transgender issues: “It was kind of a shock, but I was not offended. I didn’t mind answering at all” (cisgender female). Participants also described the question as being about diversity: “My thought is that it’s normal, because, uh, there’s a lot of different kind of people out there. (laughter)” (cisgender female).

Two cisgender participants expressed negativity but were not offended by the question: “I feel like there’s a lot of political sensitivity and maybe because I am in the majority, I feel like it’s a little bit overused. I don’t find the question offensive, I just sometimes think maybe we are a little bit too concerned with how people feel rather than reality. But that’s easy to say that when you feel just like the rest of the majority” (cisgender female). Gender minority participants expressed excitement about the gender identity survey item, such as this respondent: “I mean, it’s been -- been years to get to that point, so it’s kind of a big deal. And, you know, I’m excited about where it’s going” (female birth sex, do not identify).