Transgender Health Volume 00, Number 00, 2020 ª Mary Ann Liebert, Inc. DOI: 10.1089/trgh.2020.0050 The Complexities of Categorizing Gender: A Hierarchical Clustering Analysis of Data from the First Australian Trans and Gender Diverse Sexual Health Survey Denton Callander,1,2,* Christy E. Newman,3 Martin Holt,3 Shoshana Rosenberg,4 Dustin T. Duncan,1 Mish Pony,5 Liadh Timmins,1 Vincent Cornelisse,2,6 Liz Duck-Chong,7 Binhuan Wang,8 and Teddy Cook2,7 Abstract Purpose: This study used self-reported gender among trans and gender diverse people in Australia to identify and describe broad, overarching gender categories that encompass the expansive ways in which gender can be defined and expressed. Methods: Data were collected as part of the Australian Trans and Gender Diverse Sexual Health Survey hosted in October 2018. Participant self-identification with nonexclusive gender categories were analyzed using algorithm- based hierarchical clustering; factors associated with gender clusters were identified using logistic regression an- alyses. Results: Usable data were collected from 1613 trans and gender diverse people in Australia, of whom 71.0% used two or more labels to describe their gender. Three nonexclusive clusters were identified: (i) women/trans women, (ii) men/trans men, and (iii) nonbinary. In total, 33.8% of participants defined their gender in exclusively binary terms (i.e., men/women, trans men/trans women), 40.1% in nonbinary terms, and 26.0% in both binary and non- binary terms. The following factors were associated with selecting nonbinary versus binary gender labels: pre- sumed female gender at birth (adjusted odds ratio [aOR] = 2.02, 95% confidence interval [CI] = 1.60–2.54, p < 0.001), having a majority of sexual and/or gender minority friends (aOR = 2.46, 95% CI = 1.49–3.10, p < 0.001), and having spent more than half of one’s life identifying as trans and/or gender diverse (aOR = 1.75, 95% CI = 1.37–2.23, p < 0.001). Conclusion: Trans and gender diverse people take up diverse and often multiple gender labels, which can be broadly categorized as binary and nonbinary. Systems of health care and research must be adapted to include nonbinary people while remaining amenable to further adaptation. Keywords: cluster analysis; gender identity; health informatics; nonbinary Downloaded by University Of New South Wales from www.liebertpub.com at 08/07/20. For personal use only. Introduction In recent years, the emergence of an expanding range of ways in which people express and describe gender ‘‘Certain individuals in certain times and places transcend the has generated considerable attention in both academic categories of male and female, masculine and feminine, as 2 these have been understood in Western culture since at least and public discourse. Scholars have variously sought to the later nineteenth century’’. (p. 21)1 characterize, categorize, conceptualize, and pathologize 1Mailman School of Public Health, Columbia University, New York, New York, USA. 2Kirby Institute, UNSW Sydney, Sydney, Australia. 3Centre for Social Research in Health, UNSW Sydney, Sydney, Australia. 4Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Australia. 5Scarlet Alliance, Australian Sex Workers Association, Sydney, Australia. 6Kirkton Road Centre, Sydney, Australia. 7AIDS Council of New South Wales, Sydney, Australia. 8New York University Langone Health, New York, New York, USA. *Address correspondence to: Denton Callander, PhD, Mailman School of Public Health, Columbia University, 722 W 168th Street, New York, NY 10032, USA, E-mail: [email protected] 1 2 CALLANDER ET AL. gender diversity,1,2–5 whereas mainstream commenta- third gender alongside (presumed cisgender) men tors have tended to approach it with bafflement and and women, which aside from being inaccurate does derision.6–8 Regardless of whether or not critics ques- not achieve any meaningful outcomes in terms of im- tion the authenticity and validity of gender diversity, proved data collection.20 This set of issues gives rise genders other than fixed and supposed innate notions to important questions about how clinicians, adminis- of ‘‘male’’ and ‘‘female’’ have existed back through trators, epidemiologists, researchers, and health practi- time and around the world.1 Furthermore, a growing tioners can make sense of and incorporate gender body of research has made clear that diverse experi- diversity into their work in meaningful and appropriate ences of gender are profoundly meaningful to those ways. Put another way, is it possible to simplify the ex- who embody them and that having one’s gender mis- pansive range of genders in a way that aligns with med- understood or ignored can create very real and negative ical and research systems while respecting individual implications for health and well-being.9,10 and emerging identities? Among the many characteristics and experiences of Questions about the ways in which trans and gender trans and gender diverse people, this article takes up diverse people are counted (or not) in health and med- the opportunity to explore the complexities of under- ical research go well beyond the theoretical. Countless standing and categorizing gender in health and research studies have documented disparities in health out- systems. We take gender to mean an individual’s inter- comes and care facing trans and gender diverse peo- nal sense of themselves and their inner relationship to ple,21,22 which are exacerbated by their erasure in the gendered social environments within which they health research and clinical settings.21,23–25 As health live. Furthermore, the concept of gender manifests practitioners and researchers seek to understand and through its expression to others, whether affirmed by respond to the needs and experiences of trans and gen- or not, and developed, and redeveloped in response to der diverse people, empirical research is needed to help social, cultural, and political moments. Although it conceptualize the evolving range of genders embodied may be tempting to think about categories of ‘‘sex’’ by diverse communities of people internationally. This and ‘‘gender’’ as immutable or ‘‘of nature,’’ they are article describes an empirically driven system for cate- strongly influenced by society and culture and have gorizing gender using data collected by the largest and continue to change within scientific, socioecologi- study of trans and gender diverse people conducted cal, political, and cultural discourse.11 to-date in Australia. Although gender diversity may seem like a recent phenomenon, historical examples of it can be found Methods from around the world.12–14 Twentieth century ap- Study design proaches to gender in Western systems of medicine In 2018, a national online, anonymous, and cross- have been shaped significantly by the European colonial sectional survey was conducted of trans and gender di- project, which in many cases sought explicitly to control verse people in Australia, known as the Australian and eradicate gender diversity among Indigenous com- Trans and Gender Diverse Sexual Health Survey.26 munities.15–18 This system of control was reinforced by The study team comprised epidemiologists, social sci- Downloaded by University Of New South Wales from www.liebertpub.com at 08/07/20. For personal use only. scientific and medical discourses of the last two centu- entists, clinicians, journalists, health promotion spe- ries, which were invested in categorizing human experi- cialists, and community advocates who worked to ences and bodies as simplistically as possible without promote the health and well-being of trans and gender attending to power, culture, and other social consider- diverse people in Australia. ations that ultimately gave shape, motive, and dissent to the process and the categories they produced.19 Participants and recruitment Given that gender exists in an incredibly broad range Individuals were eligible to participate if they were liv- of ways that are increasingly understood as fluid and ing in Australia, at least 16 years old, and were a gender contextual, it is perhaps not surprising that most med- other than what was presumed for them at birth. Peo- ical and research systems continue to ignore or experi- ple whose gender aligned with the gender presumed for ence anxiety toward gender diversity. Where such them at birth (i.e., cisgender) were not eligible to partic- systems have adapted to better recognize gender diver- ipate. Participants were informed that whether they sity, they have often made the mistake of offering one had undergone or were planning to undertake social, additional option of ‘‘transgender’’ as, apparently, a legal, or medical gender affirmation was immaterial CATEGORIZING GENDER 3 to eligibility. Participants were also informed that they Table 1. Self-Reported Gender Among Trans and Gender could withdraw by discontinuing the survey at any Diverse People, Stratified by Gender Presumed at Birth point, with survey completion taken as a marker of Gender presumed at birth, n (%) consent. Gender Female Male Unspecified Recruitment employed a multifaceted strategy that identitya (n = 985) (n = 618) (n = 10) Total directed potential participants to a dedicated study Man 343 (34.8) 27 (4.4) — 370 (22.9) webpage, through which they could find out about Woman 57 (5.8) 328 (53.1) 6 (60.0) 391 (24.2) the study, assess their eligibility, and gain access to Trans man 416 (42.2) 5 (0.8) 3 (30.0) 424 (26.3) Trans woman 1 (0.1) 424 (68.6) 10 (100.0) 435 (27.0) the survey. Study advertisements were distributed Trans masculine 324 (32.9) 5 (0.8) — 329 (20.4) online through existing networks on social media Trans feminine 19 (1.9) 209 (33.8) — 228 (14.1) Nonbinary 535 (54.3) 176 (28.5) — 711 (44.1) along with paid advertisements on Facebook and Genderqueer 301 (30.6) 106 (17.2) — 407 (25.2) Instagram. Digital and print copies of study advertise- Agender 137 (13.9) 35 (5.7) — 172 (10.7) Sistergirl — 14 (2.3) 1 (10.0) 15 (0.9) ments were also sent to organizations that provided Brotherboy 17 (1.7) 1 (0.2) — 18 (1.1) services or support to trans and gender diverse people.