Marie Kaniecki

PUBHLTH 508
Final Paper

Gender Identity Inclusivity in Population Health Surveys as a Structural-Level Mental Health

Intervention for the Transgender and Gender Queer Communities: An Identity Justice Approach
Though many conflate the two concepts, sex and gender identity mean different things. Whereas

sex refers to an individual’s biological sex characteristics at birth, such as chromosomes and reproductive

organs, “gender identity is each person’s deeply felt internal and individual experience of gender, which

may or mar not correspond with the sex assigned at birth. This can include the personal sense of the body

(which may involve, if freely chosen, modification of bodily appearance or function by medical, surgical

or other means) and other expressions of gender, including dress, speech, and mannerisms.” 1 Gender is

“socially constructed” and “the formation of gender identities begins at birth and is learned through many

channels, including families and social networks, community and governmental institutions, and the

media. Cultural constructs of manhood/manliness and womanhood and the supporting attitudes, beliefs,

and behaviors that express gender identities, as well as the structural forces that align economic,

educational, and other opportunities with gender, have a direct bearing on health outcomes.” 2

Transgender individuals are people whose gender identity does not match their assigned sex at

birth. Gender non-binary, gender non-conforming, or gender queer individuals indentify as both male and

female or do not identify as either a woman or a man in the traditional gender binary. In contrast, cis-

gender individuals are those whose assigned sex at birth matches their lived and experienced gender

identity. While cisgender individuals are the majority, gender identities outside the traditional male and

female identities can be found in many different cultural contexts. 1 Transgender and gender non-binary

populations experience significant disparities in mental health outcomes such as depression, anxiety, and

overall psychological distress compared to the majority cisgender population. 3 This disparity cannot be

solely attributed to gender identity or internalized feelings of gender dysphoria, but is a proxy for other

social determinants of health, such as discrimination and stigmatization of identity. 3

The World Health Organization (WHO) definition of “disparities as differences in health which

are not only unnecessary and avoidable but, in addition, are considered unfair and unjust” would suggest
that this discrimination and stigmatization be targeted for intervention to improve mental health because

they “lie along a causal pathway” which “affects health” and have “roots in an injustice.” 4 The minority

stress model suggests that social exclusion through discrimination and stigmatization on the basis of

gender identity causes minority stress for trans and non-binary people, which in turn leads to negative

psychological health outcomes directly or indirectly through negative coping mechanisms. 1

Discrimination and stigmatization may not always involve overt acts, but can be present in

microagressions and denial or erasure of identity as well. 5 These acts of discrimination, stigmatization,

and erasure occur at every level of the social-ecological framework, from interpersonal to structural.

Intersecting social determinants of health and identities can exacerbate the disparities; for

example, trans people of color are disadvantaged compared to their white counterparts. While individual

studies have been done on mental health in trans and non-binary populations, many of the studies had a

majority of white, college-educated participants even though “a growing body of evidence shows that

transwomen of color carry a disproportionately high burden of adverse social and economic outcomes,

including high rates of unemployment, homelessness, limited access to health care, stigma,

discrimination, victimization, homicide, and difficulty accessing gender-affirming medical services.” 6

Furthermore, transgender individuals are more likely to experience homelessness, unemployment,

poverty, HIV positive status, and incarceration,1,5,6 which may also be positively associated with mental

illness. When accounting for other social determinants of health, the prevalence of mental illness in the

community may in fact be underestimated.

Traditionally, large population surveys, including prominent ones used in public health research,

contain an item interchangeably called sex or gender with the only two answer options being male or

female. This not only leads to a dearth of health data on and misclassification of transgender and gender

non-binary individuals,7,8,9 but actively contributes to mental health outcomes through erasure of identity 5.

This erasure is similar to the way Arab-Americans do not have a distinct racial or ethnic category on

national surveys and are classified as white in an “outmoded view of race and ethnicity”10. A
comprehensive review of the literature found only 8 publically available datasets that included

transgender-inclusive gender identity questions8. Even surveys that do collect data on gender identity may

not follow best practice in doing so, such as conflating sexual orientation with gender identity, and not

allowing for the inherent nuances of trans and non-binary identities (i.e. a transgender woman may prefer

to select female when given the three options of male, female, or transgender or male, female, or

other).7,8,9 None of the 8 datasets included gender identity questions followed the Gender Identity in U.S.

Surveillance recommendations of a two-step method of measuring sex assigned at birth and current

gender identity.8 Therefore, incorporating trans and gender queer inclusive survey items can serve as a

structural-level intervention to address mental health disparities in this population. Strong advocacy

comprises an important part of implementation, and the current political climate suggests there may be

some amount of resistance to the intervention. 5

Based on its reputation and prominent place in public health research, The National Health

Examination Survey (NHANES) administered annually by the Centers for Disease Control and

Prevention would be an ideal survey to implement the intervention of incorporating trans and gender

queer inclusive survey items. In addition, the next NHANES should oversample from the trans and non-

binary communities, as it currently does for persons 60 and older, African Americans, Asians, and

Hispanics,11 to produce reliable statistics and facilitate greater understanding of health issues facing the

community. I hypothesize that the intervention will improve mental health among transgender and non-

binary individuals through two primary mechanisms and two additional downstream mechanisms in a

form of recognition, cultural, or identity justice. First, the intervention will affirm the identity of trans and

non-binary individuals to them and to society as a whole, working to end erasure. In addition, it will

reduce stigma among the general population through the legitimization of gender identities outside a strict

binary and serving as a simplistic form of education on the existence of different gender identities.

Further downstream, such an intervention will lead to the identification and understanding of other health

disparities in this population, which can then inform targeted interventions for other health issues, the
treatment of which can improve mental health. Finally, this intervention may lead to gender identity

inclusive items on other surveys, in part because NHANES serves as a model for other population health

surveys.8

Engagement with the trans and gender queer communities is key for implementation of the

intervention. Using their input to inform the wording and structure of survey items will lead to effective

measures acceptable to the community. A previous study found high levels of acceptability for asking

questions related to sexual orientation and gender identity on electronic health records among a regional,

racial, and age diverse group of participants. 12 While EHR serve a different purpose than surveys (i.e.

providing care rather than research), this acceptability could potentially translate to survey items as well.

Creating gender identity survey items with the proper wording and structure presents challenges and is the

subject of current research and debate. 7,8,9 Single question survey items that list trans as an option distinct

from male or female gender identities do not capture trans individuals who identify more closely with

their lived gender than with the trans identity. Current best practice suggests a two-part survey item to

capture nuances of gender identity: a question asking about sex at birth and another question asking for

current gender identity.7,8,9 While this approach has its strengths, transgender or non-binary individuals

may find birth sex to be a sensitive topic.12 Engaging with the idea of birth sex may bring up reminders of

negative mental health experiences with gender dysmorphia and the associated stigma and

discrimination,3 which could negate the impact of the intervention. However, medical professionals and

trans and gender queer individuals alike agree that this information is relevant in the context of health

care.12

Thus, inclusive wording, as determined by both members of the community and public health

researchers, will promote the most accurate responses and provide the most impact in the identity-

affirming goal of the intervention. Conversations with the community can further inform how culture

impacts understanding of gender identity as well.1,7 A useful method of engagement would be a qualitative

study with a research team with diverse gender identities involving researchers and members of the
population in the study sample. The study should utilize an iterative process to determine acceptable

wording for survey questions from the perspective of both the gender queer and trans individuals taking

the surveys and the researchers analyzing the data. Such a process will yield inclusive and respectful

questions and response options that remain feasible to code and analyze.

Those unfamiliar with social determinants of health may question the effectiveness or impact of a

structural-level intervention to improve mental health among trans and non-binary individuals involving a

survey only administered once per year. This question is warranted, especially when this population faces

myriad other issues that impact their health, such as unemployment and access to psychiatric care. 1,3,6

However, addressing the root cause of such problems through a social determinants of health approach

has been proven effective in the research. 6,13,14 An empirical study identified gender as one of the most

influential social determinants of health, with advances in gender equality associated with an increase in

life expectancy of 9.4 months.13 While in this context gender equality refers to equality between men and

women, the concept can be intuitively extended to include equity among other gender identities. 13 An

intervention providing job training for the community may improve mental health by reducing

unemployment, but it will not fully address the negative consequences to mental health that result from

discrimination and stigmatization of identity. An intervention targeting improving mental health within

the community addresses only the symptom, not the root cause of the mental health disparity. 14 Targeting

the result of the stress does not remove the stressor, and would be akin to sending a patient back into a

toxic environment that made them sick in the first place. In addition, a structural-level intervention may

produce the greatest overall impact, but it does not preclude simultaneous “multimodal” 6 public health

interventions at other levels of the social-ecological model, such as the community level. In summary,

affirmation and legitimization of identity are powerful interventions because they directly target social

determinants of health on a structural level. Though a structural approach may require a longer period of

time for the effects to manifest, it will address one of the most salient root causes of the mental health

disparity between cisgender and transgender and gender non-binary individuals.

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