Review of 2021 Census Topics

Include options for gender to enable assessment of the true prevalence of individuals identifying as transgender or gender diverse in the 2021 Census (not an opt-in option which people are unlikely to answer). Differentiate this from sex (i.e. At birth, what was the person's sex? Options: female, male, intersex?)

Obtaining data on individuals who identify as transgender or gender diverse is critical to inform health service provision for this marginalised population. In a medical setting, we have seen a 10-fold rise in individuals identifying as transgender between 2011 to 2016 and similar rates are seen worldwide. This is thought to be related to increasing social acceptance and understanding of gender rather than an increase in incidence given the considerable scientific evidence that gender is biologically based and gender variant individuals have existed throughout history.

Obtaining accurate data on the prevalence of those who identify as a gender different to their birth-assigned sex will provide data to support policy development and health service delivery. Prevalence and location of individuals will allow the design and distribution of adequate health services to areas of need and adequate allocation of resources for this population who currently experience significant discrimination and health inequity as a result.

Furthermore, as medical research in the transgender field is in its infancy, this data will have widespread citations in medical research to allow for grant applications and development of appropriate research studies tailored to this population.

In a medical setting, we have seen a 10-fold rise in individuals identifying as transgender between 2011 to 2016 and similar rates are seen worldwide. Based on conservative estimates of 0.6 - 1.2%, we estimate that approximately 150000 - 300000 Australians may identify as trans and gender diverse.

We understand that in the 2016 Census, special procedures were introduced for the first time to enable a respondent to complete an alternative online form containing three response options to the Sex question: Male, Female and Other (please specify). This online form was available to households or individual respondents on an opt-in basis by contacting the Census Inquiry Service or submitting an online assistance request. This was incredibly challenging for transgender individuals and transgender community feedback was that they were unaware of the complex procedure to specify their gender identity. It also does not provide information on birth-assigned sex which is also important.

Some 1,260 people were considered to have provided a valid and intentional sex/gender diverse response (sex/gender because many did not give enough information to determine which). This is a rate of 5.4 per hundred thousand people - a very small proportion, and most certainly an inaccurate number of people with sex/gender other than male or female.

The decision to have this opt-in special procedure was implemented because of uncertainty about how the general public would respond to a question with an explicit 'other' option. This is not logical whatsoever as those that identify as cisgender male or female, would only select male or female. It is standard for most health services and businesses to have other options on gender forms, and in fact facebook has over 50 options.

Given fear of disclosure, collection of prevalence data needs to be at a census, population-based level and estimates from small cohorts (i.e. online samples, school samples) are inherently biased. Data on prevalence of those who identify as transgender will be enhanced with combination with other characteristics such as socioeconomic status, location of residence which will inform policy and health service delivery.

We propose the following simple, easy to understand questions which we have asked of various medical research populations in the community:

A. At birth, what was the person's sex?
- Female
- Male
- Intersex

For Question B, we propose 2 possible questions.
Option 1.
B. What is the person's current gender identity?
- Female
- Male
- Trans female/Trans woman
- Trans male/Trans man
- Gender non-binary
- Gender queer
- Gender neutral
- Agender
- Other – please state


Alternative option 2 which may well be simpler.
B. Is this person's gender different to their birth sex?
- Yes, their current gender identity is the same as their birth-assigned sex.
- No, their current gender identity is different to their birth-assigned sex.

Note; there are many gender identities and only the most common are listed in option 1. above. We suggest avoiding having only ‘male’, ‘female’ and ‘other’. The use of the word “other” as a gender category is “othering” and segregating. It actively casts people who are not one of the main two categories as outsiders, which suggests lesser status or importance.

Trans and gender diverse individuals exist and are humans like everyone else. They are not intrusive, offensive or controversial. There is considerable scientific evidence that gender identity is biologically based and this is supported by multiple international and national medical societies.

It is not logical that people asked this question would be offended. For those that do not identify as transgender (cisgender people), it is a straightforward process to simply select male or female. It is common place in the Australian community for health services and even many businesses to have other options on gender forms to be inclusive of individuals who identify as trans and gender diverse. Social media site Facebook has over 50 options for gender (we are not proposing this many).

Regardless of whether an individual accepts trans and gender diverse individuals or not, they will be able to answer the simple questions that we propose.

Furthermore, including gender options outside of the traditional binary of male and female highlights also the existence of these identities and if the Australian population was not so so regularly confronted with a simple choice — “Are you male or female?” — our thinking about gender wouldn’t be so binary and more accepting of others.

As medical researchers, we strive to design questions which can be coded efficiently.
We propose the following simple, easy to understand questions which we have asked of various medical research populations in the community:

A. At birth, what was the person's sex?
- Female
- Male
- Intersex

For Question B, we propose 2 possible questions.
Option 1.
B. What is the person's current gender identity?
- Female
- Male
- Trans female/Trans woman
- Trans male/Trans man
- Gender non-binary
- Gender queer
- Gender neutral
- Agender
- Prefer not to say
- Other – please state

Having the above most common gender options identified in our 2018 Australian survey of over 900 transgender individuals, will minimise any coding required for the Other option.

Alternative option 2 will not require any coding, and all those that respond No can be classified as trans or gender diverse.

B. Is this person's gender different to their birth sex?
- Yes, their current gender identity is the same as their birth-assigned sex.
- No, their current gender identity is different to their birth-assigned sex.

As mentioned, gender, a human trait, is biologically based, and trans and gender diverse individuals have existed throughout history. What has changed in the last 10 years is increased social acceptance and that society does not define individuals based on gender as much as in the past. This has led to a rapid increase in demand for transgender healthcare. Of most concern are that health statistics for this population are alarming; including medically diagnosed depression in 70%, anxiety in 40% and suicide attempts in 43%, rates far higher than the general Australian population. Health services are currently insufficient to meet demand. There is no accurate population-based data on prevalence of those who identify as transgender in Australia. Given fear of disclosure, collection of prevalence data needs to be at a census, population-based level and estimates from small cohorts (i.e. online samples, school samples) are inherently biased.

Ongoing prevalence data will support research over time to accurately address and monitor these critical health issues over time. There is most certainly a continuing need for data on this topic in the future.

Given fear of disclosure, collection of prevalence data needs to be at a census, population-based level and estimates from small cohorts (i.e. online samples, school samples) are inherently biased. Current studies worldwide estimate that between 0.6 to 3% of the population identify as transgender, however often many statistical manipulations have been performed to arise at these estimates. Given that there is no census data, and that many survey responses may not be reliable due to fear of identifying as transgender or disagreement on what "transgender means", these estimates are inaccurate. As we do not know the true prevalence, going uncounted essentially results in this population being overlooked and underserved resulting in individuals who identify as trans and gender diverse being dismissed as "just a choice" which is inaccurate.

Quantifying a community at the city or even the state level isn’t enough — national statistics are necessary to truly understand the number of transgender Australians and their needs.

Austin Health is a tertiary referral hospital in Victoria. Led by international-recognised clinician-scientists and medical specialists, Trans Medical Research Group based in the Department of Medicine (Austin Health), The University of Melbourne provides strategic leadership in transgender health to achieve health equity and well-being through:
1) Medical research to find best treatments and developing a greater understanding of trans health issues.
2) Education of medical professionals to improve access to healthcare.
3) Improving clinical service delivery and
4) Advocacy to decrease stigma for all transgender and gender diverse individuals.
Members of the Trans Medical Research group are trans and gender diverse and we view active engagement with the transgender community as an essential part of our activities.