Sampling bias in Brazilian studies on transgender and gender diverse populations: the two-step measure for assessing gender identity in surveys

Costa, Angelo Brandelli; Rosa, Letícia de Oliveira; Fontanari, Anna Martha Vaitses

doi:10.1590/0102-311X00180420

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METHODOLOGICAL ISSUES • Cad. Saúde Pública 38 (1) • 2022 • https://doi.org/10.1590/0102-311X00180420 copy

Sampling bias in Brazilian studies on transgender and gender diverse populations: the two-step measure for assessing gender identity in surveys

Viés amostral em estudos brasileiros sobre populações transgênero e não binárias: a medida de dois passos para avaliar a identidade de gênero

Muestras con sesgo en estudios brasileños sobre poblaciones transgénero o de género diverso: modelo de dos etapas para evaluar la identidad de género

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract:

Correctly recognizing gender identity in population-based surveys is essential to develop effective public health strategies to improve the living conditions of transgender and gender-diverse populations, as well as to adequately collect data on cisgender individuals. This study aims to present the two-step measure as the best strategy for assessing gender identity in Brazilian surveys, thus we performed two separate analyses. Firstly, we conducted a systematic review concerning HIV-related care among Brazilian transgender and gender-diverse populations to assess the strategy used to identify participants’ gender identity. Secondly, we re-analyzed data from a recent survey that included Brazilian transgender populations, comparing characteristics and health outcomes from the sample identified by single-item and by the two-step measure. Concerning the systematic review, from 6,585 references, Brazilian research teams published seven articles, and only one study used the two-step measure. Regarding this survey, the two-step measure recognized 567 cisgender and 773 transgender and gender diverse participants among the 1,340 participants who answered the questionnaire, whereas the single-item measure was able to recognize only 540 transgender and gender diverse people. Furthermore, 31 transgender women self-identified as “transgender men” on the single-item measure. Therefore, although scarcely used in Brazil, the two-step measure is a more accurate strategy to recognize gender identity.

Keywords:
Gender Identify; Surveys and Questionnaires; Systematic Review; Selection Bias

STUDY (YEAR)	MAIN OBJECTIVE	QUOTE	SAMPLING STRATEGY	METHOD TO RECOGNIZE GENDER IDENTITY
Castro et al. ²⁶26. Castro R, Ribeiro-Alves M, Corrêa RG, Derrico M, Lemos K, Grangeiro JB, et al. The men who have sex with men HIV care cascade in Rio de Janeiro, Brazil. PLoS One 2016; 11:e0157309. (2016)	To assess the HIV-care cascade among MSM and TW newly diagnosed with HIV infection.	“Data collected at HIV testing sites included: data and venue of the test; date of birth; age; city of residence; gender; sex orientation…” (p. 3).	TLS	Unclear
Costa et al. ¹⁶16. Costa AB, Fontanari AMV, Catelan RF, Schwarz K, Stucky JL, Rosa Filho HT, et al. HIV-related healthcare needs and access barriers for Brazilian transgender and gender diverse people. AIDS Behav 2018; 22:2534-42. (2018)	To report HIV-related healthcare needs and access barriers among transgender people.	“Gender identity was evaluated using the two-question method, and subjects were considered eligible to participate if they reported a gender different from that assigned to them at birth” (p. 2536).	FBS and internet	Two-step measure
Grinsztejn et al. ²⁹29. Grinsztejn B, Hoagland B, Moreira RI, Kallas EG, Madruga JV, Goulart S, et al. Retention, engagement, and adherence to pre-exposure prophylaxis for men who have sex with men and transgender women in PrEP Brasil: 48 week results of a demonstration study. Lancet HIV 2018; 5:e136-45. (2018)	PrEP retention, engagement, and adherence, trends in sexual behavior, and incidence of HIV and STIs among MSM and TW.	There were no mentions of questions concerning gender identity.	TLS and FBS	Unclear
Hoagland et al. ²⁴24. Hoagland B, De Boni RB, Moreira RI, Madruga JVR, Kallas EG, Goulart SP, et al. Awareness and willingness to use pre-exposure prophylaxis (PrEP) among men who have sex with men and transgender women in brazil. AIDS Behav 2017; 21:1278-87. (2017)	PrEP awareness and willingness among MSM and TW.	“Gender was self-reported and dichotomized to Male and Trans women” (p. 1279).	TLS and FBS	Single-item measure
Hoagland et al. ²⁵25. Hoagland B, Moreira R, De Boni R, Kallas EG, Madruga JV, Vasconcelos R, et al. High pre-exposure prophylaxis uptake and early adherence among men who have sex with men and transgender women at risk for HIV infection: the PrEP Brasil demonstration project. J Int AIDS Soc 2017; 20:21472. (2017)	PrEP uptake and early adherence among MSM and TW.	“Gender was considered as Male or Transgender women” (p. 3).	TLS and FBS	Single-item measure
Jalil et al. ²⁷27. Jalil EM, Wilson EC, Luz PM, Velasque L, Moreira RI, Castro CV, et al. HIV testing and the care continuum among transgender women: population estimates from Rio de Janeiro, Brazil. J Int AIDS Soc 2017; 20:21873. (2017)	To estimate population-level indicators of the HIV cascade of care continuum among TW.	“To participate, individuals had to self-identify as a Transgender woman” (p. 2).	RDS	Peer-identification
Pinheiro Júnior et al. ²⁸28. Pinheiro Júnior F, Kendall C, Martins T, Mota RMS, Macena RHM, Glick J, et al. Risk factors associated with resistance to HIV testing among transwomen in Brazil. AIDS Care 2016; 28:92-7. (2015)	To identify risk factors associated with resistance to HIV testing among TW.	“The sample was selected from a list of members maintained by the only transwoman focused NGO…” (p. 1). “Each seed and study participant received three coupons to distribute to Transgender Woman they know by name and have seen in the past 30 days” (p. 2).	RDS	Peer-identification

Sociodemographic	All participants		Single-item measure		Two-step measure
Sociodemographic	N	%	n	%	n	%
Total	1,340		540		773
Age (years)
≥ 45	77	5.7	30	5.6	40	5.2
35-44	132	9.9	74	13.7	95	12.3
25-34	354	26.4	140	25.9	221	28.6
≤ 24	777	58.0	296	54.8	417	53.9
Ethnicity
White	943	70.4	369	68.3	543	70.2
Non-white	397	29.6	171	31.7	230	29.8
Education
Elementary school or less	120	9.0	61	11.3	87	11.3
High school	806	60.1	343	63.5	491	63.5
Undergraduate	321	24.0	111	20.6	155	20.1
Graduate	93	6.9	25	4.6	40	5.2
Brazilian state
São Paulo	890	66.4	368	68.1	523	67.7
Rio Grande do Sul	450	33.6	172	31.9	250	32.3
Relationship
Single	629	46.9	255	47.2	380	49.2
Monogamous relationship	576	43.0	217	40.2	310	40.1
Polygamous or open relationship	135	10.1	68	12.6	83	10.7
Self-reported psychiatric diagnosis (lifetime)
Yes	150	11.2	108	20.0	149	19.3
No	1,190	88.8	432	80.0	624	80.7

Single-item measure	Travesti	Two-step measure
Single-item measure	Travesti	Gender-diverse person	Transgender women	Cisgender women	Transgender men	Cisgender men	Total
Travesti	93	0	0	0	0	0	93
Other	0	119	0	0	0	0	119
Transgender women	0	0	172	0	0	0	172
Women	0	0	162	308	0	0	470
Transgender men	0	0	31	0	125	0	156
Men	0	0	0	0	71	259	330
Total	93	119	365	308	196	259	1,340

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[1] Correspondence
A. B. Costa Pontifícia Universidade Católica do Rio Grande do Sul. Av. Ipiranga 6681, Porto Alegre, RS 90619-900, Brasil. angelo.costa@pucrs.br