Figure 3.
Examples of 2 ways to ask for identification of transgender identity: direct method (1-step) and indirect method (2-step); indicates different options that may be used to similar effect in certain circumstances. In general, it should be clear that this information is not a proxy for karyotype or organ inventory, which should be ascertained independently (see “Additional Considerations”). However, it is important to include for providers, researchers, and patients, as patients might not have karyotype- or organ inventory–based knowledge and tests may be unaffordable, unavailable, or unnecessarily invasive. Note 1: For neonates and infants for which gender identity has not yet developed, a medical provider could enter “unknown,” “uncertain,” “undifferentiated,” or “none.” Note 2: This may only be appropriate in some jurisdictions as the original birth certificate may no longer officially exist (such as in Germany). It does resolve ambiguity in a situation wherein a patient has been issued a new birth certificate with an updated gender marker. Additionally, there may be values and options for this question that differ significantly by jurisdiction. Note 3: “X” is allowed in some jurisdictions, such as in New York City, Washington DC, New Jersey, California, etc. and has been recently approved for federal documentation in the U.S.170 While occasionally intersex is considered a gender identity or as an assigned gender at birth, this is commonly thought of as inappropriate, because intersex people can have many different gender identities or assigned genders at birth (some intersex people do identify their gender identity as “intersex” or “hermaphrodite” [typically as a form of reclamation], but these identifications can adequately be covered by “A gender not listed [please specify]” in most cases).171 For more information on intersex-inclusive question design, see “Intersex Data Collection: Your Guide to Question Design.”172 It is also important to note that birth certificates may change to not include gender markers or may not be consistent from jurisdiction to jurisdiction.111,173,174 Therefore, a two-step is simply a better proxy to gender- and/or sex-related information than a one-step, which may be replaced in the future with more accurate models incorporating information like hormonal milieau.