Development of the Gender Embodiment Scale: Trans Masculine Spectrum

Abstract

Transgender and gender diverse (TGD) people have a variety of ways of embodying their gender. We present preliminary work on The Gender Embodiment Scale for trans masculine individuals as a collaborative product from a trans-identified community-engaged team. This scale provides researchers and clinicians a survey to diversify ways gender is understood and counteracts assumptions of a singular gender experience for TGD people. This scale reflects gender embodiment as individually unique and inclusive of the body, behavior, and social treatment. Use of the scale can enhance discussion and enable assessments regarding relative importance and satisfaction across items in these domains.

Introduction

Transgender and gender diverse (TGD) people have a variety of gender experiences, gender expressions, and ways of embodying their gender. We define embodied gender as encompassing the shape of one's body, the feeling of one's body, and the behavior enacted by one's body.^1–3 Assumptions rooted in gender binarism or imposing singular narratives of what it means to be TGD can negatively impact how TGD people are treated in clinical and research settings. Counteracting assumptions is particularly important in order for clinicians to provide competent care. Learning about gender, as experienced for each individual, is one way to challenge assumptions or unconscious bias and can reduce barriers TGD people face when accessing care.⁴

Medical and mental health practices have had a history of gatekeeping and doing harm through enforcement of restrictive singular narratives of TGD experience. For example, TGD people report therapists and medical providers denying letters of support for medical gender affirmation when they do not meet binary gender and/or heteronormative expectations.^4,5 Furthermore, consistent with findings in health equity research,⁶ enforcing gender norms or strict gender binarism is associated with poorer quality care for TGD people.⁷ Our purpose here is to provide a tool to help guide discussions with trans masculine people, whether in clinical or research settings, to enhance understandings of gender embodiment. We also aim to dispel assumptions that a singular experience and embodiment of gender are homogenously experienced by all TGD individuals. Here we present preliminary work on the development of a gender embodiment scale for trans masculine individuals to enhance understanding of gender embodiment across aspects of one's body and behaviors. We have previously presented this study at numerous transgender health conferences to disseminate information about the gender embodiment scale as well as to receive feedback from researchers, clinicians, and community members.^8–11 Notably, this is not a validation study of the scale, but rather information on the initial development of items and their potential utility in clinical practice and future research studies.

Gender Embodiment

Physical gender expression (secondary sex characteristics, clothing, etc.) and behavioral ways of expressing and embodying gender are tightly integrated, impacting how gender is lived and perceived by others within specific sociocultural contexts. Authenticity to one's own gender experience and expression can be an action of resilience and resistance to social norms.¹² Particularly in the context of societal stigma, TGD people may face significant adversity, hardship, and stressors that may themselves become embodied in ways that can negatively impact health^13–15 and prevent them from expressing their gender in ways authentic to their sense of self.¹⁶ Gender is experienced and expressed for TGD people in a variety of ways integrating experiences of both the body and behavior.¹⁷ The expression of one's gender experience including through gender affirming hormonal therapy is associated with positive mental health outcomes, including lower levels of depression and anxiety and higher self-esteem.^18–20 The aim of clinical care and guidance should be to provide support for all aspects of gender affirmation and to recognize the ways that the body and behavior intertwine in lived gender experience.

Table 1 lists scale items that include these varied embodiments. On a physical level, gender embodiment may include physical changes to a person's body such as those related to exogenous administration of hormones, chest binding, and gender affirming surgeries. These items are key for those who desire to access gender affirming medical care, as certain changes and gendered characteristics may be very important to some people and not at all important to others.¹⁵ Gender is also expressed and interpreted behaviorally within social and cultural contexts, for example, through appearance, interpersonal actions, and interests. Broadening our understanding of lived gender experience thus includes recognition of diversity and that behavioral embodiments of gender may vary substantially across TGD people. To achieve this requires learning and respecting what TGD people voice as being important to their own experiences, physical traits, or gendered behaviors. Acknowledging this variability in gender embodiment is important for all TGD people, and our scale (Table 1) facilitates this for trans masculine people. Using this scale allows individuals to indicate the degree to which certain aspects of their body and behaviors are important to them, if at all, and also indicate how satisfied they feel with each.

Table 1.

Item List from the Embodiment of Gender Scale: Trans Masculine Spectrum

(1) Being on testosterone	(22) Having a haircut that others perceive as a man's/masculine
(2) “Top”/chest surgery/mastectomy/chest reconstruction	(23) Playing any particular role during sex
(3) Chest binding/chest compression	(24) How I am perceived in terms of my age
(4) A voice change/drop in my voice	(25) Having the ability to cry/or crying less often
(5) Having a hysterectomy (removal of uterus)	(26) Showing my emotions in front of others
(6) Having an oophorectomy (removal of one or both ovaries)	(27) Being blunt in my social interactions
(7) My menstruation status (whether you menstruate or not)	(28) Feeling and coming across as confident
(8) Fertility status (whether fertile or not)	(29) Playing/watching/keeping up with sports
(9) Any “bottom” surgery (i.e., metoidioplasty or phalloplasty or other)	(30) Dating or getting in romantic relationships primarily with cis women
(10) Wearing a packer/prosthetic in everyday life	(31) Dating or getting in romantic relationships primarily with cis men
(11) Having facial hair	(32) Dating or getting in romantic relationships primarily with trans or gender diverse people
(12) Having body hair	(33) Coming across as assertive in social interactions
(13) The amount of hair on my head/scalp	(34) Connecting socially and making friends with cis men
(14) Fat redistribution to put less fat on my hips/changing the shape of my body	(35) Connecting socially and having friendships with cis women
(15) The amount of muscle on my upper body	(36) Connecting socially and having friendships with trans and/or gender diverse people
(16) Wearing a prosthetic/strap-on during sex	(37) Being consistently read by strangers as a cis man
(17) The level of my libido/sex drive	(38) Being read by strangers as trans and/or gender diverse
(18) My appetite/how much I eat	(39) Feeling accepted in gender-segregated spaces specified for “men only”
(19) My ability to feel/recognize physical sensations in my body	(40) Feeling accepted in gender-segregated spaces specified for “women only”
(20) Having mannerisms/movement that are perceived as masculine	(41) Feeling accepted in spaces specified for trans and/or gender diverse people
(21) Having a job that is seen as masculine	(42) Feeling accepted in spaces specified for LGBTQ+ people

Clinicians can have clients identify additional areas that they would like to reflect on or may remove items that are not applicable to their client. Each item begins with the phrase, “In terms of my gender …” For each item, respondents provide answers in two parts: Part 1—Is Not Important (1), Somewhat Important (2), or Very Important (3); Part 2—Currently I feel Very Dissatisfied (1), Dissatisfied (2), Neither Dissatisfied nor Satisfied (3), Satisfied (4), Very Satisfied (5). Follow-up questions elicit details as needed (e.g., surgical status).

Scale Development

This scale was produced through a combination of research and clinical practice. The original Gender Embodiment Scale emerged, was implemented, and published as part of the Transition Experience Study, which included in-depth interviews and biomarker sampling with 65 trans masculine-identified people who were accessing gender affirming hormonal therapy (i.e., testosterone).¹⁵ To develop the scale for that study, a small pilot study was conducted that involved open-ended interviews with trans-identified participants to discuss their experience of gender embodiment, gendered behaviors, social treatment, and satisfaction with each of these. The original scale that was developed thus aimed to inspire discussion and capture gender embodiment as individually unique by asking participants to indicate which characteristics were important and weighting levels of satisfaction accordingly. Analyses of data from this study reveal associations between levels of satisfaction, anxiety, and depression for trans masculine people.⁸

Simultaneously, the gender algorithm was in development based on psychotherapy with TGD people, which formulated gender as an equation.³ The expression of the equation comprises multifaceted aspects of body and behavior and their level of importance to the individual, which reveals information about the individual's core experience of their gender. The algorithm is a theoretical and practical tool for exploring gender personally and in clinical settings. These facets of embodiment served as the basis for some of the items in the scale. All of the mentioned studies served as a foundation for the current scale development.

Based on these studies and observations, we found that for most TGD people, gender affirmation reflects a complex process that is unique for each person; body characteristics and behavior retain varying degrees of importance and satisfaction varies across these gendered areas. Moreover, experiences of gender embodiment change over the life course for TGD people just as for cisgender people. This scale can enhance understanding of this dynamic process through individual items that assess levels of importance and satisfaction, inclusion of social treatment, and overall scores indicating levels of satisfaction weighted to reflect items of importance to each individual.

Accessing Community Input

This scale is unique in that it was developed by a team of trans-identified researchers and clinicians for use in multiple settings. Community input was obtained through the pilot study during initial development and again assessed through feedback during implementation with 65 trans-identified study participants.¹⁵ The gender algorithm was formulated and modified through discussion with TGD patients in psychotherapy over many years. A focus group was also conducted in August 2017 in Long Beach, CA, with seven trans participants who had ever accessed testosterone to affirm their gender, to obtain feedback and guidance to refine language and edit items to more accurately reflect a variety of experiences and perspectives.

Clinical Application

The development of this scale provides a much-needed tool for research and clinical work with trans masculine clients to facilitate more client-centered therapy. A scale of this kind can enable exploration of an individual's gender embodiment with more complexity and alignment with the lived experiences of trans masculine people. This will improve clinicians' knowledge and reduce conscious and unconscious emotional reactions affecting clinical interventions, particularly regarding degrees of importance and levels of satisfaction with aspects of the body and behavior.³ It can also activate clients to share how they think and feel about their own gendered experience in a more nuanced manner. The scale can be used as a guide for deepening clinical material supporting recognition that body and behavior are intertwined in their importance for gender identity and expression. Clinicians can implement this tool to assist clients in improving satisfaction with aspects of their gender experience that are important to them. In relation to timing of interventions, this is especially important because clients are often pressed to make timing-based decisions based on both internal and external factors.^3,21 For example, deciding when one might begin testosterone therapy is often informed by challenges of medically and publicly transitioning at work; in some cases, chest surgery might best precede hormonal therapy or vice versa.

This scale can help refocus clinical work to create and support individualized patient-led care, as opposed to following generalized protocols that may not fit everyone's needs. Furthermore, clinicians can invite clients to develop items not captured on the list but that are important for their individual experience or to remove those that they do not feel reflect their experiences. Clients should be empowered to modify the scale to fit their experiences rather than be expected to feel that all items fit for them. Clinicians should not use the tool to make decisions about whether to support a client's gender affirmation or to gatekeep in any way. This scale is intended to respect individual autonomy in one's gender experience and as such, using this tool to enforce expectations on clients or using responses as a rationale to deny care would be problematic and counter to its purpose.

Future Directions

Future directions include validating this scale in a large diverse sample. Validating this measure may be challenging as gender embodiment and the aspects that are important to a person's gender vary across people. Next steps also include the development of additional versions of the scale for trans feminine and nonbinary TGD people, some of whom may not view themselves within trans masculine and trans feminine spectrums. Finally, additional assessments of the utility of the scale could be achieved through interviews with therapists, clients, medical providers, and researchers.

Conclusions

In research and clinical work inclusive of TGD people, enhancing recognition of the ways the body, behavior, and social treatment intertwine in gender embodiment can reduce cissexism, internalized stigma, and shame by illuminating that there is not one way to be TGD. Both the body and behaviors are important for understanding gender experiences of TGD people and this scale can be used as a clinical tool to facilitate discussions and enhance understandings about gender embodiment. As the purpose of gender affirmation is authenticity and not assimilation, this scale allows trans masculine people to identify what fits for their specific experience. This scale can help ensure providers are challenging their own cisnormative and heteronormative ideas about transmaculine people's experiences and diversifying their understandings of gender embodiment. This may also further assist trans masculine people and therapists to identify areas on which to focus therapy. It may offer a path toward best practices by undermining investigator and/or medical provider assumptions in research and health care settings.

Abbreviation Used

TGD

transgender and gender diverse

Author Disclosure Statement

None of the authors have any conflicts of interest to disclose.

Funding Information

The Transition Experience Study was funded through NSF Dissertation Improvement Grant number 0751969 and Williams Institute Grant number 5R21HD051178-05.

Cite this article as: DuBois LZ, Puckett JA, Langer SJ (2022) Development of the gender embodiment scale: trans masculine spectrum, Transgender Health 7:4, 287–291, DOI: 10.1089/trgh.2020.0088.