Which box to check: Assessment norms for gender and the implications for transgender and nonbinary populations

In the field of psychology and beyond, there are a multitude of psychological and neuropsychological assessments that have been validated for use with a wide variety of populations. These assessments aid psychologists and other professionals in clarifying diagnoses, determining cognitive capacity, identifying challenges in intellectual and executive functioning and screening for risk of suicide and harm to others, among other uses. Many of these assessments and measures have been statistically normed for various demographic specifications, including female and male genders. However, these assessment norms have been validated primarily for cisgender females and males, unless the measure has been created to specifically investigate transgender populations, a narrow application.  This presents a challenge for those assessing, treating and researching transgender populations and may be contributing to harm in an already marginalized group.

The difficulty that arises when interpreting assessments for transgender and nonbinary gender individuals is figuring out which box to check, if any. For example, both the Hopkins Adult Reading Test and the Minnesota Multiphasic Personality Inventory (MMPI-2) require an examiner to select whether the examinee is male or female. This categorization can change the score for the individual depending on which identification is selected. This query leaves examiners questioning how statistical gender norms are applied to those who transition their gender, or to those who do not identify as solely male or female.

It is known that undergoing hormone therapy or having sexual reassignment surgery to transition one's gender can change the physiology and psychology of an individual (Davis & Colton Meier, 2014; Luders et al., 2009 ). This raises the question of how these statistical gender norms can then be applied to populations whose characteristics no longer fit the traditional understanding of gender. To achieve statistical norms for various populations, persons historically have been able to check the box that defines them as either female or male. The reason for creating testing norms for specific populations is to take into account personal differences based on various aspects of culture, including gender. However, it remains unknown whether these differences can be attributed to hormones, physiology, brain differences or other factors such as enzymes in the body. Due to this dearth of knowledge, it is unknown if the changes that occur when a person medically transitions suggest that they should be categorized as the gender they transition to or the sex they were assigned at birth. Further, the question remains about how to address assessment norms for those who do not identify solely as male or female.

A History of Assessing Without “Norms”

Despite the lack of research on assessment norms for gender minority individuals, extant literature chronicles a history of researchers administering psychological tests to transsexual individuals and those with gender dysphoria to describe these populations. A review by Lothstein (1984) states that 41 research studies about the psychological assessment of transsexual individuals had been published prior to their article. In the review, the author summarizes the themes revealed about gender minority persons through these efforts, including interpretations of projective drawings as well as Wechsler Adult Intelligence Scale and MMPI-2 results. Because research on transgender and gender nonconforming persons is a relatively new area of study, the research articles included in Lothstein's analysis were conducted in absence of any knowledge about what scores are normative for people who have transitioned genders or who do not identify with a binary gender identity. In addition, the early stages of this research leave investigators without culturally competent tools for assessing the experience of gender minority persons and research continues to be conducted with little description of how researchers overcome the scoring challenges that present when an examinee identifies as a gender that differs from the sex they were assigned at birth. The potential problematic outcomes of not having norms for transgender or nonbinary individuals and not knowing which gender norms to use may result in misdiagnosis, biases in assessing, misgendering or potentially outing an individual's gender identity or biology to others reading the assessment report.

Although some articles make reference to the difficulties in measuring psychopathology among persons with gender dysphoria, these same studies provide little to no justification for using “norms corresponding to the biological sex” of participants rather than an examinee's identified gender (Gómez-Gil, Vidal-Hagemeijer, & Salamero, 2008, p. 369). Other literature fails to mention their gender categorization when describing their procedures or limitations entirely (e.g., de Vries, Baudewijntje, Steensma, Doreleijers, & Cohen-Kettenis, 2011).

Problems with Assessing Transgender and Nonbinary Populations

There are a number of unique considerations when assessing transgender individuals as well.  Keo-Meier et al. (2015) found that after taking testosterone, transgender men were more closely matched in their scores to their identity-matched gender group (i.e., healthy males) than they were at baseline. The authors noted that when using the male template on transgender men at baseline (before starting hormone therapy), they had more elevated scores on certain scales when compared with cisgender males. These scores become more similar after the start of hormone therapy. These data are extremely important for clinicians when assessing transgender individuals because the stage of transition an individual is in may impact their scores significantly. Researchers also note that elevations in measures may be the result of minority stress or gender dysphoria, which can ease after transition, rather than mental illness. This points to the need for research and training not only in assessing transgender individuals but also in interpreting the data by considering unique factors, such as the impact of minority stress and gender dysphoria in contributing to elevated scores. It also highlights the problems associated with choosing a male or female template when working with transgender individuals.

The lack of a consistent, agreed-upon method for categorizing the gender of persons who identify differently than the sex they were assigned at birth presents a significant limitation to researchers who are attempting to enhance understanding of gender minority populations. Some researchers have used biological sex as a method of categorizing a person's gender.  While this may seem to be a valid approach to overcoming this issue, it appears inconsistent with recent findings about transgender persons. Emerging research has shown that the brains of transgender individuals are similar to the brains of persons whose gender they identify with, regardless of whether hormone therapy was received or not ( Cantor, 2011) . In addition, there is some evidence suggesting changes in physiology when receiving hormone therapy ( Luders et al., 2009; Pol et al., 2006) . This minimal research suggests that it may be more effective to categorize persons as their identified gender when administering psychological assessments (Keo-Meier et al., 2015). However, this research is still in its beginning stages, and it is not known whether these changes are consistent with extant assessment norms on cisgender persons, continuing the debate about how today's researchers should address this decision. The potential for harm to transgender and nonbinary individuals is obvious when examining the problems that arise when norms for these populations do not exist, yet these individuals are still being assessed without these considerations.

Many assessments have been statistically normed for people of different races, educational backgrounds, ethnicities, age cohorts and countries. While it is unacceptable, it is understandable that with transgender research being relatively new, there are no norms for transgender or nonbinary populations for most assessments personality, psychopathology, neuropsychology or intelligence. As it stands, psychologists are forced to make decisions in assessments based on little evidence and may be contributing to harm in an already vulnerable population.  Assessments on transgender individuals may currently be over- or underestimating levels of distress, symptoms or cognitive function based on lack of norms and lack of knowledge about the impact of minority stress and gender dysphoria on the transgender individual. Though this is a new field of study, it is imperative that changes in obtaining assessment norms are made due to the growing visibility and acceptance of transgender people in the general public.

Forensic Psychology

Research on forensic violence risk assessment and treatment of transgender individuals is practically nonexistent. On the whole, risk assessments and treatment for offenders are normed on cisgender populations with no special considerations for transgender or nonbinary populations.  However, without appropriate assessments and treatments, transgender offenders are subject to the possibility of discrimination and inappropriate sentencing and treatment while in a system already documented to disproportionately cause harm to transgender offenders through denial of hormones, housing by gender assigned at birth and greatly heightened risk for sexual assault and time spent in solitary confinement (Giresi & Groscup, 2006; Sexton, Jenness & Sumner, 2010).  It is essential that forensic psychology not add to this bias and victimization through inappropriate assessment.

It is apparent from the literature that gender does matter when assessing for risk. Most structured violence risk assessments have been standardized using male offenders and male psychiatric patients and, the majority of studies comparing the validity of violence risk instruments have been restricted to men. Because of this, there has been a great deal of discussion related to the validity and predictive accuracy of risk assessment instruments for female offenders (Coid et al., 2009; Harris, Rice, & Cormier, 2002; Hastings, Krishnan, Tangney, & Stuewig, 2011; Walters, 2006). If assessments may not be appropriate for women, how could we expect them to validly assess transgender populations? Further, transgender individuals may have unique risk and protective factors that have not been weighed in assessment.  Without valid instruments for transgender individuals, use of these measures incur the possibility of incorrectly predicting violent reoffending and other forensic risks, possibly resulting in inappropriate judicial sentencing.

Using cisgender and binary gender categories in forensic assessment also has treatment implications for transgender and nonbinary individuals. There are significant differences between men and women in treatment needs and criminal pathways (Bonta, Pang, & Wallace-Capretta, 1995). Violence, criminality and recidivism involve factors that differ by gender.  Additionally, there may be treatment factors and approaches that are specific to transgender populations. Thus, treatment for transgender offenders cannot be correctly identified without appropriate assessment for those with transgender identities. 

As a result of the dramatic underrepresentation of transgender populations in forensic psychology research, the field risks continuing to contribute to injustice, marginalization and even victimization of transgender and nonbinary populations involved in the criminal justice system.

Clinical and Research Implications

The lack of appropriately normed assessments, and the prevalence of binary gender categorization in scoring, presents challenges for researchers attempting to further the knowledge of issues facing gender minority populations. If the research goal among professionals investigating these populations is to produce valid data about participants, then the assessments used and the procedure of gender categorization must be appropriately normed and be informed by differences between differing gender identities and experiences. Without doing so, the community of professionals in LGBTQ psychology cannot state with a reasonable degree of scientific certainty that the research truly describes the nuanced identities we purport to represent. In addition to these research implications, assessments are critical in clarifying complex diagnostic presentations, evaluating intellectual and cognitive functioning and other functions that assist in guiding and informing treatment in clinical settings. To ignore the implications of differing gender identities (e.g., transitional processes such as hormone replacement therapy or sexual reassignment surgery; budding research about the physiology and psychology of those persons whose gender identity differs from the sex they were assigned at birth; and the existence of gender nonconforming and nonbinary gender identities) is to accept that treatment will be directed in an uninformed manner that lacks cultural competence.  At worst, inappropriate assessment instruments may result in failure to detect symptoms or psychological problems or to assign pathology inappropriately.

Until proper norms are available for transgender and nonbinary individuals, clinicians should consider the stage of transition an individual is in (prehormone treatment vs. posthormone treatment) and how this may impact results as well as the impact of gender dysphoria, victimization and discrimination. Clinicians may consider examination of scores based both male and female templates for transgender and nonbinary individuals or use clinical judgment or client preference to score assessments in a culturally competent manner. For conducting research, researchers may need to examine both female and male templates when scoring for transgender and nonbinary samples in addition to comparing with cisgendered controls. There is a strong need for assessments to be normed on these populations to provide culturally competent care and research and to avoid providing incorrect data or potentially harmful treatment recommendations.

References

Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Hamilton, A., & Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the U.S. transgender population. American Journal of Public Health, 103, 943-951.   doi:10.2105/AJPH.2013.301241

Bonta, J., Pang, B., & Wallace-Capretta, S. (1995). Predictors of recidivism among incarcerated female offenders.The Prison Journal, 75, 277-294. doi:10.1177/0032855595075003002

Cantor, J. M. (2011). New MRI studies support the Blanchard typology of male-to-female transsexualism. Archives of Sexual Behavior, 40(5), 863-864.

Coid, J., Yang, M., Ullrich, S., Zhang, T., Roberts, C., Rogers, R.D., et al. (2009). Gender differences in structured risk assessment: Comparing the accuracy of five instruments. Journal of Consulting and Clinical Psychology, 77(2), 337-348. doi:10.1037/a0015155

Colton Meier, S. L., Fitzgerald, K. M., Pardo, S. T., & Babcock, J. (2011). The effects of hormonal gender affirmation treatment on mental health in female-to-male transsexuals. Journal of Gay & Lesbian Mental Health, 15(3), 281-299.

Davis, S. A., & Colton Meier, S. (2014). Effects of testosterone treatment and chest reconstruction surgery on mental health and sexuality in female-to-male transgender people. International Journal of Sexual Health, 26(2), 113-128.

De Vries, A. L. C., Kreukels, B. P. C., Steensma, T. D., Doreleijers, T. A. H., & Cohen-Kettenis, P. T. (2011). Comparing adult and adolescent transsexuals: An MMPI-2 and MMPI-A study. Psychiatry Research, 186(2-3), 414-418.

Giresi, M., & Groscup, J. (2006) Incarcerated transgender people: More research on transgender inmates is needed to help the forensic system. Monitor on Psychology, 37(3).

Gómez-Gil, E., Vidal-Hagemeijer, A., & Salamero, M. (2008). MMPI-2 characteristics of transsexuals requesting sex reassignment: Comparison of patients in prehormonal and presurgical phases. Journal of Personality Assessment, 90(4), 368-374.

Harris, G. T., Rice, M. E., Cormier, C. A. (2002). Prospective replication of the Violence Risk Appraisal Guide in predicting violent recidivism among forensic patients. Law and Human Behavior, 26(4), 377-394. doi:10.1023/A:1016347320889

Hastings, M. E., Krishnan, S., Tangney, J. P., & Stuewig. (2011). Predictive and incremental validity of the Violence Risk Appraisal Guide scores with male and female jail inmates. Psychological Assessment, 23(1), 174-183. doi:10.1037/a0021290

Hendricks, M. L., & Testa, R. J. (2012). A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the minority stress model. Professional Psychology: Research and Practice, 43, 460-467. doi:10.1037/a0029597

Keo-Meier, C. L., Herman, L. I., Reisner, S. L., Pardo, S. T., Sharp, C., & Babcock, J. C. (2015). Testosterone treatment and MMPI–2 improvement in transgender men: A prospective controlled study. Journal of consulting and clinical psychology, 83(1), 143.

Lothstein, L. M. (1984). Psychological testing with transsexuals: A 30 year review. Journal of Personality Assessment, 48(5), 500-507.

Luders, E., Sánchez, F. J., Gaser, C., Toga, A. W., Narr, K. L., Hamilton, L. S., & Vilain, E. (2009). Regional gray matter variation in male-to-female transsexualism. Neuroimage, 46(4), 904-907.

Pol, H. E. H., Cohen-Kettenis, P. T., Van Haren, N. E., Peper, J. S., Brans, R. G., Cahn, W., et al. (2006). Changing your sex changes your brain: influences of testosterone and estrogen on adult human brain structure. European Journal of Endocrinology, 155 (Suppl. 1), S107-S114.

Sexton, L., Jenness, V., & Sumner, J.M. (2010). Where the margins meet: A demographic assessment of transgender inmates in men's prisons. Justice Quarterly, 27(6), 835-866.

Slabbekoorn, D., Van Goozen, S., Gooren, L., & Cohen-Kettenis, P. (2001). Effects of cross-sex hormone treatment on emotionality in transsexuals. International Journal of Transgenderism, 5(3).

Van Goozen, S. H., Cohen-Kettenis, P. T., Gooren, L. J., Frijda, N. H., & Van de Poll, N. E. (1994). Activating effects of androgens on cognitive performance: Causal evidence in a group of female-to-male transsexuals. Neuropsychologia, 32(10), 1153-1157.

Walters, G. D. (2006). Risk-appraisal versus self-report in the prediction of criminal justice outcomes: A meta-analysis. Criminal Justice and Behavior, 33(3), 279-304. doi:10.1177/0093854805284409

Zhou, J. N., Hofman, M. A., Gooren, L. G., & Swaab, D. F. (1997). A sex difference in the human brain and its relation to transsexuality. International Journal of Transgenderism,1(1).