Putting the “T” in LBGT: A transgender
question pilot test in the California
Health Interview Survey
David Grant, Matthew Jans, Royce Park, and Ninez A. Ponce
UCLA Center for Health Policy Research
Gary Gates, Jody Herman, and Bianca Wilson
UCLA Williams Institute
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Gender identity (GI) measurement
 Question: Is it possible to reliably measure gender identity in a
population-based telephone health survey?
 Vehicle: California Health Interview Survey (CHIS)
 Test: 4 versions of gender identity questions
 Two “2-step” versions
 Two “1-step” versions
 Results: Promising
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Gender identity measurement
 CHIS has a history of illuminating health and health-related
information for underserved and “invisible” groups
 Asian ethnic groups: Chinese, Filipino, Korean, South Asian, Vietnamese,
Cambodian, Japanese
 Latino ethnic groups: Mexican, Salvadoran, Guatemalan, European,
South American
 Linguistically-defined groups: Chinese, Korean, Vietnamese, Tagalog
 Non-citizens
 Lesbian, Gay, Bisexual (LGB)
 How to expand to include the “T” -- Transgender?
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Gender identity measurement, cont.
 Transgender certainly an “invisible” group (often by choice)…
 0.3% of US adults (Gates 2011)
 0.5% of adults in Massachusetts (Conron 2012)
 Few probability surveys measure GI
 Little evidence on transgender disparities
 Mass. BRFSS (Conron 2012)
 Higher unemployment and higher poverty
 Higher educational attainment
 Higher smoking rates
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What to ask?
 In consultation and collaboration with experts from the
Williams Institute, 4 GI questions were selected for testing
 Two “1-step” versions
 Define “transgender”
 Ask “are you transgender?” (yes or no)
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GI pilot test questions: One-step
One-step Version 1
Some people describe themselves as transgender when they
experience a different gender identity from their sex at birth. For
example, a person born into a male body, but who feels female or
lives as a woman. Do you consider yourself to be transgender?
One-step Version 2
Sex is what a person is born. Gender is how a person feels. When a
person’s sex and gender do not match, they might think of
themselves as transgender. Are you transgender?
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What to ask?
 Two “2-step” versions
 Sex assigned at birth (male or female)
 Current gender identity (male, female, or transgender)
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GI pilot test questions: Two-step
Two-step Version 1
1. What sex were you assigned at birth, on your original birth
certificate?
2. Do you currently describe yourself as male, female, or
transgender?
Two-step Version 2
1. What sex were you assigned at birth, on your original birth
certificate?
2. Do you currently describe yourself as male, female,
transgender, are you not sure yet, or do you not know what
this question means?
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The test and results
 Adult respondents age 18 to 70 interviewed in English or
Spanish
 Random assignment to one of the four GI versions
 Midpoint of interview following Qs on sexual orientation
 N = 2,828
 Combined frequencies
Gender Identity
Not transgender
Transgender
Not ascertained
Total
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Number
2,783
9
36
2,828
Percent
98.4%
0.3%
1.3%
100.0%
GI test results: frequencies
1-step version 1
Not transgender
Transgender
Not ascertained
Total
Number
678
2
2
682
Percent
99.4%
0.3%
0.3%
100.0%
1-step version 2
Not transgender
Transgender
Not ascertained
Total
Number
718
2
17
737
Percent
97.4%
0.3%
2.3%
100.0%
2-step version 1
Not transgender
Transgender
Not ascertained
Total
Number
683
2
5
690
Percent
99.0%
0.3%
0.7%
100.0%
2-step version 2
Not transgender
Transgender
Not ascertained
Total
Number
704
3
12
719
Percent
97.9%
0.4%
1.7%
100.0%
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GI test results
 Monitoring demonstrated few problems in administering
the GI questions, or for respondents to answer them
(Jans)
 Frequency review suggests low levels of nonresponse for
two versions (1-step version 1 and 2-step version 1)
 Review of break-off data (hang-ups) showed several
break-offs during this questionnaire section but NONE
during or immediately after the GI items
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Which version performed best?
 2-step version 1 was the consensus best performer
 Short, quick, and clear questions that are easy to
administer and answer
 Allows Respondent to self identify with their current
gender status as male, female or transgender (not always
possible in the 1-step versions)
 Allows measurement of T through those that report:
1. “Transgender” or
2. Current gender identity that is different than their sex
assigned at birth (“off-the-diagonal” responses)
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Two-step tweaks
 Add response categories (male/female) to stem of first
question
 Original: What sex were you assigned at birth, on your
original birth certificate?
 Revised: On your original birth certificate, was your
sex assigned as male or female?
 Given low-frequency and potential for coding errors, add
a short confirmation question for “off-the-diagonal”
responses:
 Just to confirm, you were assigned {M/F} at birth and
now describe yourself as {M/F}. Is that correct?
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Tweaks continued…
 Re-think and conceptualize “gender” in surveys
 How to handle sex/gender-based skips, such as questions
on prostate cancer testing? Gender identity or sex
assigned at birth?
 Standard transition to section on men’s health:
 These next questions are about men’s health.
 For confirmed transgender male-to-female respondents,
use alternative transition language:
 These next questions may be relevant to you because
you were assigned male at birth. If not, let me know
and I will skip them.
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Moving forward…
 Add revised 2-step GI questions and confirmation item to
full adult CHIS sample in 2015-2016 in all interview
languages (English, Spanish, Chinese, Korean, Tagalog,
and Vietnamese)
 Continue to monitor performance through recorded
interviews (in all languages) and review of data
 Monitor need for confirmation of “T” assignment
 Estimate identifying ~60-100 transgender adults per year
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Conclusion
 Pleasantly surprised how easy the GI questions were to
administer
 Expect that YES, GI can be reliably measured on
population health surveys such as CHIS
 Very limited data on Transgender population, especially
from probability-based surveys
 Continue to build knowledge base of both survey
capability and Transgender health inequities
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Thank you
dgrant@ucla.edu
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