Guidance for Research with Trans and Gender-Diverse People

Abstract

When engaging in research with marginalized communities, it is important for researchers to reflect on their practice and consider what steps they can take to avoid perpetuating inequality or causing harm. This article provides guidance for researchers working with trans and gender-diverse individuals from the perspective of two speech-language pathologists. Key considerations presented by the authors include the importance of engaging in reflexive research practices—thinking deeply about and acknowledging impacts of one's personal beliefs, values, and practices on one's research—and developing an awareness of factors that contribute to the trans and gender-diverse community's ongoing minority stress. Specific suggestions to redress power imbalance between the researcher and the researched community are provided. Finally, practical methods for implementing the guidance are presented: the community-based participatory research model and an example in speech-language pathology research with trans and gender-diverse individuals.

Keywords

reflexivity - community-based participatory research - minority stress - transgender - speech–language pathology

Learning Outcomes: As a result of this activity, the reader will be able to:

• Explain why researcher reflexivity is important when working with marginalized communities.

• Compare and contrast the four different kinds of reflexivity.

• Describe the concept of minority stress and the role it plays in the lives of marginalized community members.

• Provide specific examples of how researchers can perpetuate minority stress.

• Provide specific examples of research design choices that can help avoid perpetuating minority stress.

To our colleagues in research, we offer this collection of guidance from published articles, organized groups of professionals and participants, and our own experiences and practices as speech-language pathologists and researchers working with trans and gender-diverse (TGD) people. “Trans and gender diverse,” “transgender,” “trans,” and “gender diverse” are all different umbrella terms used to describe the diverse population of individuals whose gender differs from the gender they were presumed to be at birth. This terminology will be used interchangeably throughout this article with recognition that trans individuals will have different preferences for how they refer to themselves. We also acknowledge that individual and community preferences for terminology will change over time and that these terms may become outdated in the future as new terms emerge to replace them.

Reflexive Practice: What Does a Researcher Bring to a Project?

Key Points  • Without judgment, self-examine the understandings, attitudes, and beliefs you bring to a project and how these contribute to the research process.  • Consider the same for your collaborators, participants, and cultural context to the extent that all these dynamic factors influence the production of knowledge.  • Acknowledge and share these influences when presenting the research, not with apology for bias but rather embracing subjectivity and the power of reflexivity.

Reflexivity

In research contexts, the practice of reflecting not only upon what was collected but also upon how the collector may have influenced what was—and wasn't—collected is known as “reflexivity.” Reflexivity is widely accepted and encouraged in qualitative research arenas, where it is seen as a primary means of promoting rigor (Braun & Clarke 2006, 2019; Jootun et al. 2009; Leung 2015). Reflexivity is important if one believes, as we do, that “all theories about the world are grounded in a particular perspective and worldview, and all knowledge is partial, incomplete, and fallible” (Maxwell & Mittapalli 2010, p. 153). In a reflexive approach, it's acknowledged that research conclusions do not simply emerge from data in vacuum, they are the active product of a researcher's engagement with their data, something that is informed by their own knowledge, biases, and experiences (Braun & Clarke 2019). Engaging in reflexive research involves taking steps to reflect on and consider the potential impact of these influences at all stages of a research project, and reflexive practices aim to clarify these influences on data and conclusions (Olmos-Vega et al. 2022). Some researchers share their reflections in an attempt to somehow neutralize the effect of these influences, while others believe that this is impossible, sharing instead to give value to the researcher's participation in the co-construction of knowledge (Olmos-Vega et al. 2022).

Reflexive practices in research have a rich history spanning multiple decades. Although reflexivity is an ongoing process, explicit practices (e.g., reflective journaling and group discussion) are often used as a catalyst for discovery of meaning. Walsh (2003) presents one common conceptualization of reflexive practice. Walsh (2003) outlines four different (but overlapping and interrelated) kinds of reflexivity with the following prompts:

1. Personal reflexivity: How are your unique perspectives influencing the research?

2. Interpersonal reflexivity: What relationships exist and how are they influencing the research and the people involved? What are the power dynamics at play?

3. Methodological reflexivity: How are we making methodological decisions and what are their implications?

4. Contextual reflexivity: How are aspects of the context influencing the research and people involved?

In this article, guided by these four categories, we provide examples of “doing” reflexivity via narrations of how we have experienced reflexivity through our research journeys (see Koopman et al. 2020; Subramani 2019, for more in-depth discussion and examples of autoethnography) and via the inclusion of a “positionality statement.” We also encourage readers to look beyond the scope of this article to explore the historical and current aims of reflexivity in research—for example, becoming an “insider,” bringing transparency to the research methodology, serving as interpreter of knowledge, positioning self within creation of knowledge (Finlay 2002; Olmos-Vega et al. 2022)—and the different ways this can be achieved. What is key to any reflexive approach is the research team's intention to “consciously critique, appraise, and evaluate how their subjectivity and context influence the research processes” (Olmos-Vega et al. 2022, p. 2). Sikes (2004, p. 19) summarizes:

It is important for all researchers to spend some time thinking about how they are paradigmatically and philosophically positioned and for them to be aware of how their positioning—and the fundamental assumptions they hold—might influence their research related thinking in practice. This is about being a reflexive and reflective and, therefore, a rigorous researcher who is able to present their findings and interpretations in the confidence that they have thought about, acknowledged and been honest and explicit about their stance and the influence it has had upon their work.

Engaging in reflexive research is considered an ethical responsibility of researchers (Sultana 2007). While bias can never be eliminated, unwanted effects of bias may be identified and minimized if a reflexive process reveals them. The notion of eliminating harmful bias is of particular importance when considering research conducted among marginalized populations. A great deal of research with (or sometimes “on”) TGD individuals has been conducted by cisgender individuals, often with a power imbalance and often for the sake of researcher curiosity, without considering the direct benefit of the research to the trans participants themselves or the trans community more broadly (Adams et al. 2017; Bauer et al. 2019; Tebbe & Budge 2016; Vincent 2018b). Such researchers may also unwittingly reproduce harmful stereotypes or recirculate inaccurate knowledge about these communities (Greenbank 2003; Sultana 2007). This kind of research with trans individuals is analogous to “helicopter science” or “parachute research” in which researchers from high-income countries travel to poorer countries to do research on local peoples or settings without involving local scientists or benefiting local communities, and incidentally may cause more harm than benefit (Sultana 2007). In these contexts, reflexivity is all the more important: given historical power imbalances, researchers should take additional care to reflect on their own situation, intentions, and biases, and how they can avoid incidentally making the same mistakes.

Positionality Statements

Reflexivity requires that the researcher recognizes how they are situated or positioned in the research context. It is equally important that researchers communicate this information to their research consumers, to ensure transparency and to help research consumers better understand the research in context. One way of doing this in practice is via the inclusion of a “positionality statement” in research publications. Such statements typically include information about the identities of the authors and their relationship to the research topic, project, and participant group and may range from a single sentence to multiple paragraphs, depending on the context and requirements (Holmes 2020). Researchers are encouraged to include sufficient information in their positionality statement to position themselves in relation to their specific research (Greenbank 2003; Holmes 2020; Sultana 2007). This may mean disclosing relevant aspects of one's personal background that have the potential to influence one's experiences and views, such as race, ethnicity, nationality, skin color, religious background, physical and neurological dis/ability, neurotypical/neurodivergent status, socioeconomic status, social status, education level, or more if relevant in context (Holmes 2020). A positionality statement may also involve directly disclosing more “fluid” aspects of one's identity such as one's opinions, viewpoints, ideologies, or political leanings (Holmes 2020, p. 2). Holmes (2020, p. 4) summarizes that an effective positionality statement “explains how the researcher developed and how they became the researcher they are” and that “producing a good positionality statement takes time, considerable thought, and critical reflection.” It is increasingly common for research articles to include positionality statements. For example, Journal of Social and Personal Relationships strongly encourages their inclusion, citing Roberts et al. (2020) in their rationale and guidance:

• Positionality statements make transparent in the scientific record how the identities of the authors relate to the research topic and participants.

• Such statements can easily be included as standard practice similarly to how author contributions are disclosed.

• This practice should not be limited to studies of certain populations or topics (e.g., race) but has broader benefit in any research context.

• Positionality statements encourage recognition of intersectionality (i.e., the ways in which different aspects of people's identities overlap and intersect) which is vital to healthy and representative science.

• However, authors should not be mandated to disclose aspects of their identities if they do not consent to doing so.

Our Reflexive Work

Given that a researcher's experiences, knowledge, beliefs, values, and the research topic, population, and phenomenon studied are ever-changing, reflexivity is an ongoing process and one's positionality statements tend to be study-specific (Holmes 2020). Below are some examples of questions we commonly ask ourselves as part of our own reflexive research processes, organized according to the four different kinds of reflexivity proposed by Walsh (2003):

Personal Reflexivity

• How do my attitudes (including the core values that guide my actions) and knowledge influence my research work? How do they influence my non-research (e.g., teaching, clinical) work?

• What do I believe about or associate with the populations that I'm researching? How did these beliefs come about? Are biases and preferences leading me to disrespect, dehumanize, discriminate, or harm in any way? How can I know?

• What do I know about gender? How did I come to know what I know? What else can I do to understand different perspectives?

• How do I know what I know about the people and concepts studied? Are my sources of knowledge reliable and representative of the within-group diversity that likely exists? What do I need to understand better in order to conduct research that will best serve the populations studied?

Interpersonal Reflexivity

• In what ways am I an outsider or an insider to the communities that I'm researching? How do the different aspects of my own personal identity intersect (or not) with the communities I'm researching? What do people in these communities believe or think about me?

• What other aspects of my personal identity or situation might influence the way my research population will interact with me? What will this influence be and how will our interactions be impacted? In what ways do I have power, privilege, or influence over my research population?

Methodological Reflexivity

• How can my research methods and practices best serve the community I'm researching? In what ways could they accidentally cause harm? How do I know and where can I look for guidance?

• What is needed for ethical and just treatment of people in my own communities, including my professional workplaces (research lab, classroom, office)? How do I know? What do I contribute?

Context Reflexivity

• What does my position (e.g., as a clinician, a researcher, or a teacher) contribute to how I am able to interact and learn from others?

• How do other positions I take influence my beliefs or values (e.g., for Adrienne, earning tenure, and becoming a mother/having a daughter)?

Although this article is not strictly a study—we are aiming to relay guidance rather than report research—we still see the benefit of engaging in reflexivity and communicating our own positionality. We acknowledge that our personal backgrounds are influential to how we cultivate, interpret, and convey the information in this article. We provide an example of a positionality statement below, informed by the questions above, to help a reader understand these influences.

Out Positionality Statements

At the outset, our worldview that trans and non-binary people exist hinges on some broad underlying beliefs. First, biological “sex” characteristics do not determine one's gender. Second, gender as a concept and what we associate with different gender categories are socially-culturally constructed. As such, gender interacts with other social categories (e.g., race, age). This is an oversimplification of a complex topic that it is not possible to fully explore within the scope of this article (both authors consider the process of establishing and communicating one's gender to be a complex, multifaceted process and readers may wish to refer to Azul and Hancock (2020) for a more detailed discussion of this topic). However, for the purposes of this article, these two points are key as they presuppose the existence of individuals who adopt gender identities that are different from that which they were assigned at birth based on their anatomy, or that fall outside of traditional, established, gender categories (e.g., “non-binary” trans individuals who do not identify neatly as either “male” or “female”).

We are both speech-language pathologists who value helping people communicate and feel better about themselves. We both practice and advocate for a “person-centered care” approach. We also both value the role of empirical research in clinical care and have professional research responsibilities. How we came to these attitudes is also informative. It is at this level that our experiences diverge.

From Sterling: I am a certified practicing speech pathologist, voice clinician, research coordinator, lecturer, and PhD candidate at La Trobe University in Melbourne, Australia. Since receiving my qualification in 2016, I've been working almost exclusively in the area of gender-affirming voice training, and my personal research interests skew practical—whether our training works, how we can increase service access in the community, and how we can make our services more safe, inclusive, and supportive of our diverse caseload. I also have lived experience as non-binary trans person which informs my work. I would describe my identity as non-binary transmasculine, with some fluidity and variation in how I feel at any given moment. Although I identify and generally present myself as “masculine” of center, I don't feel that the “male” label works for me—perhaps because my personal journey to get here has been so different to a cisgender man. In frank discussion I might express that I think gender as an entire concept is a scam. Unfortunately, it's a scam that I clearly buy into as I take steps to look, sound, and present myself in a certain way. As a trans person—and particularly a non-binary person—I've also been on the receiving end of discrimination, harassment, and microaggressions. In health contexts I often don't see my preferred identity or pronouns on forms, I read literature that doesn't acknowledge I exist, and I have medical professionals ask me invasive questions that aren't relevant to my current care. I've had to lie about my identity and present myself as an uncomplicated trans man to “grease the wheels” and get the care I need. These experiences inform my work and research as I try to make sure I don't recreate these experiences for others. It's also important that I acknowledge that outside of my trans status, I'm relatively privileged in comparison to many people, trans or otherwise. I have stable employment, I'm in good health, I'm neurotypical, I'm white, I'm nonreligious, I have university degrees, and I was raised in a comfortable middle-class family in suburban Australia who have been supportive of my gender identity and my career. I'm also regularly perceived to be a cisgender man by people I interact with in my daily life. I recognize that these factors come with privilege. In my work I try to do my best to recognize how this limits my perspective and to engage with and elevate the voices of people with different experiences to my own. When it comes to enacting this in my research, though, I'm relatively inexperienced. I'm an early career researcher with a background primarily in quantitative research. Qualitative research philosophies, the importance of reflexivity, and specific practices such as including positionality statements in work are relatively new to me and I still have a lot to learn.

From Adrienne. Each study or presentation that I do involves a version or portion of the broad positionality statement that follows, but for purposes of this article, I felt it necessary to examine a broad context. I am a licensed speech-language pathologist and associate professor at The George Washington (GW) University in Washington, DC, United States. I am a white-European, straight, cisgender woman who grew up in a suburban, upper-middle class, Christian family in the southern part of the United States during the 1980s and 1990s—during which time I did not give much thought to people in the LGBTQ community. I began university knowing I desired a life helping people communicate so they could build and maintain connections with others, although at the time I thought it would be people with neurological disease or disorders of language and so trained accordingly. As opportunities to work with TGD people arose with my move to work at GW and my questions could not be quenched by the sparse research literature available at the time, I began to apply my clinical and research education to investigate the role of voice and communication in the lives of TGD people. Compassion for a marginalized group turned into admiration as I listened carefully and processed the needs and perspectives of TGD people over time. Despite learning more from individuals in the TGD community, cultural norms and assumptions about my assigned role and capacity to teach and facilitate learning—in both the clinical and academic contexts—fostered a power differential that has since become something for me to work and advocate against, as you will see in my publications and the guidelines below. Ultimately I decided the power differential was impeding meaningful work because it did not align with my faith-based beliefs regarding the equal value of all people and my conceptualization of communication as a tool for relationships, both of which existed long before I went to university to pursue a profession in this area and continue to color my goals. I strive to support dignity and communication effectiveness for trans and non-binary people through my research, teaching, and advocacy. I remain curious and question assumptions—my own and others'—with the help of a community. Now collaborations with research colleagues across disciplines, around the world, and with varied sociocultural experiences form a rich environment for production and dissemination of knowledge to advance this area of health care. My current research projects include improving access to care for multiple marginalized people in the United States and developing the Voice and Communication Situation Questionnaire for and with gender-diverse people presumed female at birth.

Minority Stress: What Does a Marginalized Population Bring to a Project?

Key Points  • Reflect on the experiences of your participants and when working with marginalized groups consider the impact of minority stress.   • Recognize that researchers and clinicians have positions of privilege and power. This means we can benefit communities with our research, but it also means that we can incidentally cause harm.   • Reflect on how you can avoid perpetuating minority stress and how your project is beneficial for the community you are researching.

Minority Stress

Trans individuals are widely documented to experience poorer mental and physical health and greater prevalence of social issues in comparison to both the general population as well as other LGBTQIA+ (lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual/agender/aromantic) populations (Coleman et al. 2022; Reisner et al. 2016; Valentine & Shipherd 2018; Zeeman et al. 2019). These experiences are a result of minority stress rather than an inherent part of the trans experience (Hendricks & Testa 2012). Minority stress refers to the unique stressors faced by members of a marginalized community as a result of belonging to that community (Meyer 2003). For individuals who are multiply marginalized—that is, they belong to multiple minority groups at once—these stressors are multiplied (Hendricks & Testa 2012; Nordmarken 2014). These stressors may include experiences of discrimination, harassment, abuse, rejection, victimization, nonaffirmation, or more subtle “microagressions”: “brief, unthinking slights, snubs, insults, or other indignities, frequently embedded within a stream of communication” (Nordmarken 2014, p. 129; Testa et al. 2015). For populations such as TGD individuals who do experience minority stress, it is these experiences that are thought to contribute to imbalances in population health and well-being (Hendricks & Testa 2012, p. 462):

Trans people, like the general population, have general life stressors that may result in a wide range of reasons for presenting to a psychologist for care. However, on top of general life stressors, trans people are subjected to alarmingly high rates of discrimination, violence, and rejection related to their gender identity or expression. We understand the higher prevalence of mental disorders in trans individuals to be related to these experiences.

Harmful Practices

Well-intentioned researchers are not immune from perpetuating minority stress. Even in broadly supportive environments, trans individuals may experience subtle institutional processes or microaggressions that discount, discredit, or denigrate their identities and experiences (Fiani & Han 2019; Reisner et al. 2016; Zeeman et al. 2019). The experiences described by Sterling in their positionality statement are widely documented—for example, many non-binary trans individuals find frustration with data collection measures where there are only “male” or “female” options (Kronk et al. 2022; Safer et al. 2016). Researchers, research processes, and research outputs may also cause harm and perpetuate minority stress by adhering to or reinforcing social stereotypes that degrade or erase the humanity of participants. Traditional assumptions about gender (e.g., there are only two genders, your gender is based on your sex characteristics at birth) and gender presentation (e.g., someone who identifies as a woman must look, sound, and act certain way) contribute to the “othering” of trans individuals within their societies (Hendricks & Testa 2012; Hughto et al. 2015). This can lead to trans individuals being perceived as subversive, dangerous, “other” rather than a normal, healthy facet of a rich and diverse society. These prevailing views harm all trans individuals, but in particular trans individuals who do not fit neatly within established social categories (i.e., those who identify as a gender other than “male” or “female,” or whose gender expression differs from society's typical expectations regarding masculinity/femininity) (Hughto et al. 2015). Signals that the researcher is not sensitive to the effects of such views, or perhaps is perpetuating these views, put the participants in a vulnerable position and contribute to minority stress.

Supportive Actions

Researchers have positions of power and privilege that can be used to directly benefit the trans community. One direct way that researchers can benefit the TGD community is by supporting the development of gender-affirming healthcare services—such as voice training—that support clients to live authentically as their gender and are known to have a tangible positive impact on the well-being, quality of life, and mental health of TGD individuals (Coleman et al. 2022). However, to truly address the health inequalities faced by trans individuals, it is important to go beyond this and address systematic minority stress. Addressing minority stress should be proactive: researchers should consider both the ways in which their project will benefit the community, but also the ways in which it has the potential to cause harm. Returning to the first section of this article, the first step to this process is always reflexivity—considering the biases and assumptions you may unwittingly bring to a project at its outset and how these may influence its design. Conducting research that places a spotlight on trans individuals and explores their experiences in a non-pathologizing, non-stigmatizing way that does not incidentally reinforce stereotypical assumptions about gender is a key step toward increasing social awareness of this community and reducing the stigma they face within society. The remainder of this article will present some specific recommendations for conducting research with TGD individuals, informed by existing guidelines as well as the experiences of the authors, before concluding with a summary of one model for conducting culturally safe and responsive research with marginalized communities—Community-Based Participatory Research (CBPR)—and an example from experience.

Designing Research Projects with Trans and Gender-Diverse Participants

Key Points  • Recognize and value the individual complexity of TGD participants in research design and reporting.  • Do not make assumptions about your participants' goals, preferences, or experiences. Draw on principles of person-centered care.  • Utilize methods and measures that are fit for purpose, and that prioritize participant's well-being, agency, and self-determination over social conformity.  • Consider how your actions can impact both individual participants as well as contribute to broader social change.

Embrace Diversity, Individuality, and Complexity

The TGD community is not a monolith. Trans individuals may identify broadly within the traditional gender categories of their society, or they may identify beyond these categories (Coleman et al. 2022; Fiani & Han 2019; Matsuno & Budge 2017). For some trans individuals, gender identity may be stable while for others it may be mutable, changeable, or contextual. Some trans individuals may be able to summarize their gender in a single word, while others may take a full paragraph. Others may eschew labels entirely.

How trans people choose to express their identity is equally diverse. Just as all cisgender individuals who belong to a particular gender will vary significantly in their personal styles and the way they present themselves to the world, so too will trans individuals (Coleman et al. 2022; Fiani & Han 2019; Matsuno & Budge 2017). Two trans women may have very different goals for how they express their femininity. A non-binary individual may wish to present themselves in a way that society would perceive as traditionally masculine. This diversity also extends to the way in which individuals may wish to be attributed to gender by others in their community (Fiani & Han 2019; Matsuno & Budge 2017). A trans woman who does not choose to present themselves in a traditionally feminine manner may still (rightly) wish to be addressed as a woman. A non-binary individual who presents themselves as typically masculine may still wish to be recognized by others as non-binary and addressed using neutral rather than masculine pronouns. Desired gender expression and gender attribution may also be contextually variable—for example, someone who is non-binary may only openly present themselves as such in contexts where they feel safe from discrimination, harassment, or microaggressions (Fiani & Han 2019; Garrison 2018). A key point made by trans advocates is the notion that the validity of someone's gender identity—and their desires for how they are addressed by others in society—should not be contingent on looking, sounding, or presenting themself in a certain way (Garrison 2018; Vincent 2019). Practices such as asking—rather than assuming—how an individual identifies and how they would like to be addressed are encouraged for this reason (Coleman et al. 2022; Vincent 2019). Adopting this line of thinking is an important step in reframing social understandings of gender and expanding currently limiting stereotypes and understandings of traditional gender categories, that is, what it means to be a “man” or a “woman.”

Guidelines for conducting research with trans individuals frequently highlight that acknowledging this complexity is a key step toward conducting affirming, collaborative, non-stigmatizing research with trans communities (Adams et al. 2017; Coleman et al. 2022; Tebbe & Budge 2016; Vincent 2018b). Researchers should reflect on whether they are meeting participants at face value, or whether they may have incidentally made assumptions about their participant's identities, preferences, or needs. More broadly, there is significant value in research that simply shines a light on this diversity and helps challenge the assumptions made by those consuming the research, as this can only help to create more space and foster respect for trans individuals in our societies (Hughto et al. 2015; Linander et al. 2019). Further suggestions for how to account for this complexity are outlined in the section “Consider Your Research Methods.”

A Person-Centered Approach to Research

A person-centered approach is key when providing care for the TGD community (or conducting research relating to the provision of this care). Person-centered care aims to account for the kind of individual variation described in the paragraph earlier, emphasizing that a “one-size fits all” approach to healthcare is rarely as effective as one that addresses individual needs (Ekman et al. 2011). One defining feature of person-centered care is that agency is assigned to individuals in their healthcare journey (Ekman et al. 2011). In this approach, a person's individual goals are prioritized and developed through collaboration with those providing care, in contrast to a model in which care is “prescribed” based on the judgment of the healthcare provider with limited consultation with the person. In other words, power is shared or given to the person rather than the care provider. Person-centered care is considered best practice in a range of healthcare settings but has particular benefit in the context of gender-affirming care where individual needs are so diverse. In gender-affirming voice training, for example, the process of collaborative goal-setting and tailoring training to each client's individual needs, goals, preferences, and abilities is seen as key (Adler et al. 2019; Azul et al. 2022; Hancock & Siegfriedt 2020; Mills et al. 2020).

Unfortunately, this approach is not universal. In a research study of a person-centered gender affirming voice training program, participants reported that they were surprised by the fact that the research project did address their individual goals (Quinn et al. 2021). Participants in this study appreciated that they were attended to as individuals and were not forced to meet a uniform stereotypical standard—something that many had anticipated based on their past experiences of accessing gender-affirming care in other contexts (Quinn et al. 2021). These experiences are not uncommon—many trans individuals experience gender-affirming healthcare which pushes people to express their gender in only stereotypical ways (Fiani & Han 2019; Garrison 2018; Linander et al. 2019). Stereotypical assumptions about gender limit the ways in which trans individuals are encouraged to explore and express their gender, and lead to gatekeeping of services to only those trans individuals who conform to social norms (Garrison 2018; Linander et al. 2019).

While the preceding discussion relates to the provision of healthcare in general, these principles can be adapted to research contexts. A participant-centered approach to research may involve turning the reigns over to the participant or a research team member who is representing the participant's perspective (e.g., a research advisory board). It may also mean creating space in research programs to recognize and attend to participants as individuals, and in research with TGD individuals avoiding the assumption participants with the same gender identity will naturally share the same goals for their gender expression and gender attribution from others.

Prioritize Well-Being and Not “Passing”

Historically, much of the research shaping gender-affirming healthcare has aimed at helping trans individuals “pass” as a certain gender within their society—that is, to be recognized as a certain gender and to not be identified as trans or gender diverse (Coleman et al. 2022; Tebbe & Budge 2016). This may still be a goal of many trans individuals seeking gender-affirming care, whether this relates to their own intrinsic desire to embody the gender identity that they feel suits them, or out of fear that not “passing” puts them at personal risk (Fiani & Han 2019; Garrison 2018). Other trans individuals may not wish to pass at all (Galupo et al. 2021; Matsuno & Budge 2017). What is critical is that these choices are made by the trans individual and are not assumed or prescribed by individuals in positions of power in healthcare or research contexts. As Linander et al. (2019, p. 35) argue, work with TGD individuals should be:

… more confirming and less conforming in its practice. With the use of confirming, we want to emphasize an approach … in which the needs and wishes of the individuals seeking care are in focus and guide the medical practices. Hopefully, a confirming approach can increase the self-determination regarding gender performance and the quality of care.

Researchers and clinicians also have the power to shift care away from the need to “pass” at all. The fact that trans individuals need to “pass” at all to be safe and free from harassment, discrimination, and abuse speaks to the fact that current practice is not adequately addressing those social forces which contribute to these issues in the first place (Hughto et al. 2015; Linander et al. 2019). Individuals in positions of power providing gender-affirming care in which “passing” is the only measure of success should critically consider whether their practices are reinforcing the social structures that contribute to trans minority stress in the first place. As an alternative, care providers can actively help deconstruct these barriers by creating space for trans individuals to explore what their gender means to them as an individual and how they would like to express this for their own sake. Even for trans individuals for whom “passing” is a primary goal, clinicians and researchers may still leverage their relative power and privilege to start these discussions and begin to create space for trans individuals to prioritize their own needs. Outcome measures in this context may shift away from how trans individuals are perceived by others to these individuals' self-reported feelings of satisfaction, self-authenticity, and gender euphoria. If clinicians and researchers do not take these steps, they risk reproducing existing, restrictive narratives that there is a right and a wrong way to “do” gender.

Consider Your Research Methods

The suggestions presented in the preceding paragraphs have for the most part been very broad. In research contexts, acting on these suggestions will generally take the form of careful research design—ensuring that specific aspects of your methods help maximize the safety, autonomy, dignity, and well-being of your participants. Some specific ideas are presented here.

• Consider your language choices. Language has the potential to constitute a microaggression, or to inadvertently cause harm by reinforcing traditional, restrictive ideas about gender (Adams et al. 2017; Bauer et al. 2019; Tebbe & Budge 2016; Vincent 2018a, 2018b). For example, describing something as “female anatomy” has the implication that all people who are female have certain anatomy—an implication that erases the existence of trans individuals who do not fit this mold (Vincent 2018a). As another example, the term “gender affirmation” is now commonly used instead of “transition.” “Transition” has lost favor along with phrases like “born a man/woman” and “female to male/male to female” as they connote that trans individuals are changing from one gender to another, when it is now more commonly felt that trans individuals are simply taking steps to affirm the gender that they are (Vincent 2018a). There are multiple guidelines for preferred terminology when working with trans individuals (e.g., ACON 2019; Vincent 2018a); however, an important caveat here is again that the community is not a monolith: individual sub-communities and individuals themselves will likely have their own unique preferences, and therefore consultation and collaboration are key (Vincent 2018a). Given that language in this field is constantly evolving and changing, it is also recommended that researchers “conduct Internet searches for contemporary trans language” and “participate in online forums and social media sites (e.g., Reddit, Facebook) where issues surrounding language are discussed at length among trans community members” (Tebbe & Budge 2016, p. 998).

• Engage in respectful record keeping. At an individual participant level, it is critical to have systems in place to record preferences for language choice when it comes to describing their identity and experiences. It is also critical to have systems in place to capture things like chosen names, pronouns, and titles (Deutsch & Buchholz 2015; Kronk et al. 2022). As noted previously, language choice can constitute a direct microaggression—if you know someone's preferences but fail to use them, this is at best a sign of disrespect and at worst an action that can cause a trans individual psychological harm (Coleman et al. 2022). Systems put in place must once again be fit for complexity here, as individuals' preferences may change over time or vary depending on context. Researchers may also need to consider how they can circumvent restrictive systems. In many contexts, for example, it may be a legal or institutional requirement to use a participant's legal name (Deutsch & Buchholz 2015; Kronk et al. 2022). If this is the case, it is important to ensure that there are additional systems in place to make sure that this name is only used when necessary—and that if there is ever a possible choice, or option for flexibility, that it should not be required. This may also involve advocacy on the part of researchers and clinicians to change existing policy or procedures. Additionally, respect should not stop when a trans individual or trans participant goes out of the door. It is critical to ensure that you respect trans individuals' preferences for their names, pronouns, and terms of reference even when they are not present, including in professional correspondence, reports, and research outputs. When it is a legal or institutional requirement to collect data related to biological sex characteristics, it is important that these questions are framed in such a way that they do not conflate these characteristics with gender (to avoid reinforcing that people with certain genders must have certain kinds of bodies, as described earlier) and that the language utilized is up-to-date and respectful. Researchers will benefit from reading published guidelines regarding how to sensitively collect data and record data when working with the trans community (e.g., Deutsch & Buchholz 2015; Kronk et al. 2022). Once again, this may require researchers and clinicians to engage in advocacy to update and improve existing systems.

• Use methods fit for capturing complexity. As highlighted, given the diversity of trans individual identities and experiences, it is important that methods for collecting and interpreting data are fit for purpose. This may mean utilizing self-report fields instead of set categories for describing gender (Deutsch & Buchholz 2015; Kronk et al. 2022). It may mean creating additional space for participants to describe their experiences and clarify their goals. Collecting information about client identities, goals for gender expression, and goals for gender attribution separately acknowledges that these responses are not assumed to be identical. Use of qualitative or mixed-methodological research—schools which have the added benefit of encouraging reflexivity as a form of rigor—may also help shine a light on participant diversity and explore how your participants' personal experiences and backgrounds may have influenced your research outcomes.

• Go back to basics. Are you up to date with common terminology used within the TGD community? Are people with diverse bodies and gender identities represented in your research resources and materials? Are there bathrooms in your facility suitable for participants who don't identify as men or women? Are all research staff educated on how to interact respectfully with TGD individuals? Are there visible signs that diversity is celebrated in your workplace? There are a wealth of easily searchable and accessible guidelines (e.g., “Trans 101” programs and resources) developed by or in consultation with the TGD community that can provide a starting point for anyone who is aiming to interact with trans individuals in an affirming manner.

• Ensure that you are investigating suitable programs. If you are investigating, for example, a clinical program, it is important to consider whether this program is truly person-centered, prioritizing individual client goals, and prioritizing client well-being. If you are investigating interventions which aim to help clients “pass,” it is important to interrogate this idea. Ensure that this is truly a participant goal and not an incidental assumption of the researchers. If it is a participant goal, treat it with nuance (e.g., even for individuals who wish to “pass” as women, this can look very different), create space for participants to freely explore their goals within the context of the project, and utilize outcome measures that also prioritize client's well-being and autonomy.

• Apply considerations beyond direct research with trans communities. Researchers not directly conducting projects about trans experiences should remember that trans individuals exist within the broader community and will access general healthcare. Therefore, with a large enough sample size you will likely have trans participants whether you have recruited for them or not (and whether they tell you or not).

• Consider multiple marginalization. Many trans individuals will have multiple intersecting identities and so their needs will not be sufficiently met by one set of recommendations alone (Hendricks & Testa 2012; Nordmarken 2014). Look beyond the scope of this article to consider how you can support participants with other marginalized identities.

• Redress power imbalances. Consider ways in which you can collaborate with community, elevate community voices, respect community wisdom, and compensate community members for their work. Shift the balance of power and privilege away from yourself and toward marginalized communities. Consider using models such as CBPR, detailed below.

How Researchers and Community Members Can Come Together

Key Points  • Balance power in the relationship between researchers and community members by working together to develop a research question addressing a social or health need.  • Build trust over time by consistently demonstrating commitment to power-sharing.  • Consider CBPR as one model for mutually beneficial, action-oriented research.

The Historic Power Imbalance

The history of research in TGD health is one of power imbalance. Much research has been conducted without TGD individuals in roles that could ensure the research was conducted with care and was meaningful and beneficial to the TGD participants offering their unpaid effort and vulnerability (Tebbe & Budge 2016). The lack of compensation is a significant factor given the social/financial equalities often faced by the community (Coleman et al. 2022). Ongoing, formative involvement from people within the population under study is critical to redress this historic power imbalance and because perspectives and needs of community cannot be determined without their input, these elements will differ between individuals/communities, and these points change across time (Adams et al. 2017; Bauer et al. 2019; Tebbe & Budge 2016; Vincent 2018b). This involvement could take many forms, from an in-community principal investigator to a paid community advisory board that consults on several projects. More broadly, TGD community members should be paid/incentivized to take on the roles of researchers, editors, peer reviewers, and more to promote systematic change—and any TGD community members who do contribute their effort, wisdom, and vulnerability to research projects should be sufficiently compensated (Adams et al. 2017; Bauer et al. 2019; Tebbe & Budge 2016; Vincent 2018b).

Power Sharing in Practice

For researchers working with marginalized groups, it is only after the researcher understands the power dynamics created by their own positionality and the community's experiences and culture (i.e., practices reflexivity and cultural humility) that an authentic attempt at re-distributing power can begin, as described in Adrienne's position statement. Based on interviews with 11 academic-community partnerships yielding longitudinal studies, Jagosh et al. (2015) found that a sense of trust based on commitment to power-sharing is a mechanism for sustained efforts toward health improvement, creation of additional spin-off projects, and achieving systemic transformations. In their model, trust is built over time, waxing and waning as conflict is experienced and resolved, and is affected by pre-existing factors (e.g., history of oppression and research abuse) and the level of commitment and skill around working through differences toward a shared goal (Jagosh et al. 2015). While navigating group dynamics, trust is built by adhering to agreed-upon roles and processes for shared decision-making and working together. Explicit strategies for shared leadership, two-way communication, and constructive conflict resolution contribute to strong partnerships and effectively promote health equity (Ward et al. 2018). These principles and ideas form the basis for CBPR.

Community-Based Participatory Research

CBPR is action-oriented research based on the community's self-reported needs and supported by the researcher's expertise and resources (Holt & Asagbra 2021). The partnership is mutually beneficial as shared learning and co-creation of knowledge occurs. The community's positionality is not only included—it is sought after, valued, and centered in all phases of the research. CBPR is an approach focused on minimizing the traditional power differential between the researcher and researched group by asking (Cornwall & Jewkes 1995; Muhammad et al. 2015):

• How are the various parties involved (i.e., holding power) in creating the new knowledge?

• Who has the knowledge to define the research problem and questions?

• What frameworks are used to interpret the data and how were these created?

• Who owns and acts on the results?

• How are the results shared and used for change?

• Who benefits from the project?

Ideally the answers to these questions would reveal a “collegiate” relationship with researchers and community members mutually engaged in learning and acting for change. Other types of participation include “collaborative” in which they work together but projects are primarily managed by researchers, “consultative” in which the community's opinions are sought and utilized in formation of the project, and “contractual” in which the community's participation is limited to being participants (Cornwall & Jewkes 1995). “Collegiate” and “collaborative” processes focused on informing and taking action may be called “Participatory Action Research” or “Participatory Research.”

While an admirable and ethical aim, CBPR is not without challenges. Communities may be skeptical of the researcher, the value of the research, and/or the process, requiring time to build trust and negotiate in good faith. The community is unlikely to be homogenous in their needs, values, and ideas; so, efforts to capture variation and avoid generalizing attributes to the entire community are needed. Members may feel excluded from the research if their views are not ultimately adopted in the research, while other members become alienated from their community through association with the project. Witteman et al. (2018) compiled 12 lessons learned during the partnered research they conducted for a Patient-Centered Outcome Research Institute (PCORI)-funded project. They can be summarized as follows:

• Establish and maintain a culture of mutual respect by having in-person meeting early in the project, introducing yourselves with stories not titles, stating individual and project goals explicitly, and offering orientation to stakeholders and purpose of the project.

• Actively involve all team members by providing financial support equitably (i.e., no unpaid volunteering required), recognizing all types of contributions and efforts, inviting people to roles and privately checking-in with people who are quiet to arrange best way to include all perspectives.

• Facilitate good communication by thinking carefully about terminology such as labels that convey values, and jargon and acronyms. Consider strategic use of small homogeneous group discussions prior to large heterogenous group discussions and visual supports such as a map of the project.

Evolution of a Research Agenda

The following description of how the second author attempts to center the TGD community and take action toward social change is offered as an illustration of how it can happen in a typical university setting. This is certainly not a prescription, as it is imperfect. The purpose of the research is related to identifying and addressing barriers to voice and communication support encountered by TGD people of color. Ideally, the initial problem would be identified in formal and compensated collaboration with the community rather than during a discussion about them, regardless of how informed by published data and existing relationships the researchers may be. In this case, our initial understanding of the problem was accurate but not as specific as it became after listening to community focus groups. Additionally, the community representatives providing crucial perspective for the research design and data interpretation in various phases were not always the same, which hindered the development of trust and candid relationship, particularly given the PI and most of the student researchers were cisgender and white-European. Nonetheless, as each phase lead to another, the TGD community is increasingly centered in the creation of knowledge and developed action responses.

This line of research began a few years ago when I (Adrienne) gathered a group of students in the Masters SLP program in Washington, DC, to explore why the TGD clients in our university clinic (i.e., 40–70 years old, white, trans women paying in cash) were not representative of our local trans community. A literature search quickly expanded to be about TGD people who were also people of color, or experiencing socio-economic challenges, adolescent, elderly, disabled, or a variety of other conditions and situations. I called the project “Trans AND” based on our common search terms. The students and I learned about intersectionality and health consequences of belonging to multiple marginalized groups. We found a lot of statistics as well as records of lived experiences. Yet there was little available to provide certainty about why, for example, we did not have any Black TGD people in our university voice clinic when we had 10 to 12 white-European trans women there each semester. Although this group included people who identified as belonging in some of these communities, we recognized the limitations of our group size and the fact that none of us were seeking voice and communication services prevented us from arriving at a satisfactory answer. Thus, we endeavored to survey TGD people about why they did or did not access our services, with intention to use survey results to guide appropriate action for addressing any barriers to voice and communication care. We considered a few models about barriers to care and selected one that was comprehensive and fit well with what we had read about barriers in trans healthcare specifically (Levesque et al. 2013). In hindsight, I would have spent more time looking for models derived from input by communities more like the ones we were engaging. The survey questions were organized according to the five types of barriers to care in the Levesque et al. (2013) model, but we all agreed it would be helpful for intended-users to critique the survey (i.e., “consult” the community).

By the next year, the “consult” plan turned into “collaborate” and we used researcher funding to work with focus group facilitators who were members of the community. Specifically, we recruited “non-white and non-cis” folks. In the groups, people discussed their own understanding of healthcare services related to gender and then critiqued the survey draft. The discussion was transcribed, analyzed using a qualitative, grounded theory approach by a research team which included students who were within the community but not in the focus groups. The results of listening to the community about their access and barriers to care are reported in Hancock and Downs (2021).

A survey, drastically revised after input from the focus groups, was distributed across the United States using electronic and paper version in order to see if trends identified by the trans people of color in Washington, DC, reflected national data. Responses were sufficient to reveal disparities between white and black TGD people for their rate of access, knowledge of options, and desire to receive services (Hancock et al. 2019). While this information was being prepared for review for publication, the researchers did not wait to act according to the gained knowledge. A free workshop for training a feminine-sounding voice was offered in collaboration with a popular community health center. The back of the flyer for the event was a page of educational material because lack of knowledge of options was a significant barrier to effective healthcare outcomes according to both the focus groups and survey. The design of the first workshop was planned and executed by the clinical research team, but the next workshop will be a collaboration that includes other professions and a member of the queer community from the very initial stages of planning.

Building these “collegiate” relationships for CBPR that identify and address the structural barriers to voice and communication support for TGD people has taken years, a number of hard-working—and in most cases unpaid—students and community members, and a researcher with university-provided resources of time and money. The process has included a lot of learning about reflexivity for studying a population as an outsider, conducting qualitative research, and person-centered practices applied to research contexts. Much of this learning occurred in collaborations between the researcher and community members.

Conclusion

The recommendations provided in this article provide only some considerations and examples for research work with TGD clients. CBPR is only one model for ensuring participants' needs are met. We encourage you to look beyond this article and engage with the rich and growing body of work related to how we can best support TGD individuals—and other marginalized communities—in research contexts and beyond. We also hope that readers of this article recognize that though there are many steps researchers can take as individuals to support TGD's well-being, it is equally important for individuals in positions of power to tackle inequality at a deeper, systemic level, by taking steps such as providing research funding and inviting TGD editors and authors. This can begin to dismantle historic power imbalances and tackle minority stress at its source.

Conflict of Interest

None declared.

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Publication History

Article published online:
07 March 2023