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More than half of transgender and nonbinary people were misgendered on their death certificates, researchers said.

PMG FILE PHOTO - Marchers in the Beaverton Pride Parade in June 2019.A recent study by health officials in three Portland-area counties showed that transgender people were misgendered on their death certificates more than half the time over a 10-year period.

The researchers, epidemiologists from Multnomah, Washington and Clackamas counties, said the discrepancies amount to an erasure of a vulnerable population, adding that the issue creates inaccurate data used to inform how governments allocate resources for social services and public health programs.

They're calling for systemic changes to remove barriers to correctly identifying transgender and gender nonbinary people in public health mortality data.

"If you are a transgender person in the Portland metro area, there are no formal systems in place to ensure that your gender identity will be honored at the time of your death," said Kimberly Repp, chief epidemiologist for Washington County and a co-author of the study, in a news release. "What we learned will likely alarm anyone who identities as transgender or nonbinary — or anyone who cares about the rights of transgender and gender nonconforming people."

The first-of-its-kind research paper was published on Aug. 31 in the Journal of Public Health Management & Practice. It's available for free for two weeks starting Wednesday, Oct. 5.

The researchers used the narrative section of medical examiner reports to determine someone's gender identity.

Of 47 people identified as transgender in the Portland area who died between January 2011 and September 2021, 29 were misgendered on their official death certificates. The highest proportion of those misidentifications was among transgender women — 20 out of 33.

Those discrepancies have harmful implications for transgender people, including an estimated 9,800 transgender people in the Portland area, the researchers said.

Previous studies have shown that transgender people are at an increased risk of illicit substance use, mental health disorders and discrimination. They're also more likely to be victims of homicide and suicide, studies show.

Sixty-nine percent of the deaths in this study were suicides, according to the researchers.

Death certificates are the final record of data about someone used for reporting regional mortality data. That data is used at the national level to allocate billions of dollars in funding, the researchers said, including for programs addressing drug use, infectious disease transmission, mental health and public safety.

The misidentifications in part stem from deficiencies in how case management software used around the country and in Oregon allows medical examiners to record information.

The software includes hundreds of data fields, but in the field for someone's sex or gender, only three options are available: "male," "female" or "unsure."

The software used in Oregon allows death investigators to complete a supplemental form in which "transgender" is an option to record a person's sex in cases of suspected suicide.

They can complete the form using a person's driver's license or ID found at the scene of their death.

But few transgender people undergo the process of changing their IDs, which indicate their sex given at birth, to match their gender identity, often making the information inaccurate. Only 11% of transgender respondents in a 2015 national survey had all their IDs show their gender identity, and more than two-thirds had none of their IDs show the information, the researchers said.

Kimberly DiLeo, chief investigator with the Multnomah County Medical Examiner's Office, is calling for change.

"Our office has strongly advocated for appropriate changes within the database, and we have been proactive in training our staff to record gender identity,'' DiLeo said. "We are also working to provide formal training for the tri-county region, but without adequate tools to collect this data and changes at a national level, we are limited in what we can do."

Additionally, transgender people's next-of-kin and funeral homes can play a role in misgendering them, according to the researchers.

Funeral home directors enter information about a deceased person's sex in an official death certificate. But that's based on interviews with legal next-of-kin, who can misgender someone if they're either unaware or unsupportive of their gender identity.

"From the data standpoint, this is a simple problem to fix," said Molly Mew, a population epidemiologist with Clackamas County Public Health and a co-author of the study. "The systems just need more inclusive boxes. Death investigators, medical examiners and funeral directors often know how a decedent identifies, they just don't have anywhere to document that. The bigger challenge is the culture shift we need for people to recognize why we need good data on gender identity."

The study included recommendations from the researchers, including enacting laws that mandate the recording of gender identity, ensuring fields on death certificates and case management systems allow for more accurate recording of gender identity, requiring more training on the topic for death investigators and funeral directors, and allowing funeral directors to not rely solely on information from someone's next-of-kin.

Max Egener
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