Using a Two-Step Method to Measure Transgender Identity in Latin America/the Caribbean, Portugal, and Spain

Abstract

Few comparative data are available internationally to examine health differences by transgender identity. A barrier to monitoring the health and well-being of transgender people is the lack of inclusion of measures to assess natal sex/gender identity status in surveys. Data were from a cross-sectional anonymous online survey of members (n > 36,000) of a sexual networking website targeting men who have sex with men in Spanish- and Portuguese-speaking countries/ territories in Latin America/the Caribbean, Portugal, and Spain. Natal sex/gender identity status was assessed using a two-step method (Step 1: assigned birth sex, Step 2: current gender identity). Male-to-female (MTF) and female-to-male (FTM) participants were compared to non-transgender males in age-adjusted regression models on socioeconomic status (SES) (education, income, sex work), masculine gender conformity, psychological health and well-being (lifetime suicidality, past-week depressive distress, positive self-worth, general self-rated health, gender related stressors), and sexual health (HIV-infection, past-year STIs, past-3 month unprotected anal or vaginal sex). The two-step method identified 190 transgender participants (0.54%; 158 MTF, 32 FTM). Of the 12 health-related variables, six showed significant differences between the three groups: SES, masculine gender conformity, lifetime suicidality, depressive distress, positive self-worth, and past-year genital herpes. A two-step approach is recommended for health surveillance efforts to assess natal sex/gender identity status. Cognitive testing to formally validate assigned birth sex and current gender identity survey items in Spanish and Portuguese is encouraged.

Inequities in access to HIV prevention services for transgender men: results of a global survey of men who have sex with men

“…Finally, measures were based on self-report, were not formally validated, and only reflect perceptions of stigma and accessibility; these measures are also subject to recall bias. The two-step method for identifying trans respondents has been evaluated in English, Spanish, and Portuguese [26,34], but its validity across diverse cultures and languages remains to be established [35]. …”

“…Trans respondents were identified using a two-step method [26]; current gender identity and assigned sex at birth were ascertained. Those who reported a female natal sex and identified either as male or as trans men (parenthetically defined for respondents as female-to-male trans people) were classified as trans MSM.…”

Substance use and treatment of substance use disorders in a community sample of transgender adults

“…Gender was assessed using a two-step method asking two items: (1) assigned sex at birth (female, male) and (2) current gender identity (man, woman, female-to-male (FTM)/trans man, male-to-female (MTF)/trans woman, genderqueer, gender variant, gender-nonconforming, other; Reisner et al, 2014b, 2014c). The two items were cross-tabulated to categorize participants as female-to-male (FTM) spectrum or male-to-female (MTF) spectrum according to their natal sex and current gender identity.…”

Towards ‘reflexive epidemiology’: Conflation of cisgender male and transgender women sex workers and implications for global understandings of HIV prevalence

“…However, when possible, more progressive research recommendations (Institute of Medicine, 2011; World Health Organization, 2014) suggest the necessary separation of gender identity and sexual orientation in both measurement and reporting. To both increase visibility and methodologically reduce the potential for misclassification, the two-step method, which asks about natal-sex and current gender identity, is a recommended strategy for measurement of both natal sex and current gender identity (Reisner et al, 2014; Singer, 2015). However, these best practices are not always possible, for example in meta-analyses where conflations or shifting definitions of population categories reported in individual studies cannot be overcome.…”