Assessment of Transgender and Gender Nonbinary Adults
The APA website published: Psychological and Neuropsychological Assessment with Transgender and Gender Nonbinary Adults. I am providing the text with some information in bold:
Currently, there is not ample literature (or peer-reviewed consensus) about how to score psychological tests with transgender, gender nonbinary, or gender diverse clients. This is especially true when an assessment scale utilizes normative data to place clients on a scale based on the performance of cisgender individuals.
Here are some key points to consider when administering or conducting an assessment with transgender, gender nonbinary, or gender diverse adults (Keo-Meier & Fitzgerald, 2017):
What is the functional purpose of the assessment being done? (i.e., what assessment question(s) is/are being addressed?)
What is the current identity and transition status of the client?
Is there any aspect of the client’s identity and transition status that may affect scoring? If so, what are the key factors with which scorers should be aware?
Has the client obtained medical transition interventions? Is the client taking gender affirming hormone therapy? Has the client pursued gender-affirming surgical interventions?
The client’s transition status may have implications for any tests that use norms based on sex/gender. For example, there is evidence that exogenous hormone treatment may impact cognitive abilities in these clients, although it is far from conclusive. Some authors have suggested waiting to complete any testing until the client has undergone three months of hormone treatment in order to allow hormone levels to reach the level commonly observed in those of their identified gender levels commonly observed in cisgender males/females (Meyer et al., 1986).
Many gender diverse people may neither have interest in medical transition nor seek medical interventions pertaining to gender identity. It is important to address each client’s gender identity status as unique and consider the facets of medical and non-medical transition or identity actualization.
Psychologists are encouraged to AVOID using any norms with transgender, gender nonbinary or gender diverse clients that are developed along binary gender categories only. Assessments with cisgender-normed tools could unintentionally harm the client.
Many cisgender-normed assessments fail to accurately represent transgender, gender nonbinary, and gender diverse people. For example, one prospective study, that examined Minnesota Multiphasic Personality Inventory (MMPI) scoring results in a sample of transgender men, revealed that the male and female scoring templates produced different results for the same client (Keo-Meier et al., 2015).
In addition to providing potentially inaccurate data, use of gender-based norms may over-pathologize the transgender and gender diverse client. For example, the MMPI-2nd edition is commonly used in evaluations which have a significant impact on personnel selection and custody hearings, areas where transgender, gender nonbinary and gender diverse people experience bias and discrimination.
Scale elevations are interpreted as clinically significant and used to support mental health diagnoses and inform treatment. Compared with cisgender controls, transgender clients show elevations on several scales, especially earlier in their identity development and, as applicable, transition process (Borgogna et al., 2019). This is due, in large part, to experiences of gender dysphoria as well as stigma, and other social and familial stressors and should not be conflated with higher rates of mental health diagnoses in this population overall. These elevations, however, may also decrease if the client progresses in a medical transition and presents with gender transition stability (Tomita et al., 2019).
Transgender, gender nonbinary and gender diverse clients may present for psychological assessment for the same reasons as cisgender clients. These assessments may be necessary in order to obtain appropriate supports or treatment. However, in the case of clients who do not identify as cisgender, use of gender in the scoring procedure may harm the patient or provide inaccurate results. For those tests that do rely on gender-based norms, the approach taken to scoring should depend on the reason for the assessment and factors such as how long the person has lived in their identified gender and any current gender-affirming medical interventions (e.g., hormone therapy). It is prudent to consider the client’s experience of gender dysphoria at the time of the assessment and any influence this could have on results (particularly when evaluating reported psychological distress).
Given the lack of appropriate norms specific to this patient population, qualitative clinical interviews and symptom inventories for transgender, gender nonbinary and gender diverse clients may be preferable to using cisgender-normed assessments for transgender and non-binary clients. If possible, use a non-gender normed tool.
Few, if any tests have been normed or validated with transgender, nonbinary or gender diverse people. Many tests or scales are not gender-based and can therefore be utilized in the same fashion with all clients regardless of gender identity.
Psychologists do not have a standard for determining what scoring template to use. Providers should remember clients possess intersectional identities and that identity and self-definition are both shaped by multi-faceted social contexts for each client (American Psychological Association, 2017).
If the psychologist has no other options than using a cisgender-normed assessment with transgender, gender nonbinary or gender diverse clients, it is recommended providers score the test using both norms (once as if the client was male and a second time as if the client was female) and compare results. Then, consider the treatment implications in the context of the client's affirmed gender. If producing a report for another stakeholder, it is prudent to include a note that any results based on these tests should be interpreted with caution for many of the reasons shared here.
When utilizing tests that require use of gender-based norms, consider whether the test norms pertain to gender identity or evidence-based biological sex differences
For example, in the case of interest testing, a client’s gender identity is most salient when interpreting results. However, some neuropsychological tests (e.g., motor or continuous performance tasks) have demonstrated biological sex-based performance differences that need to be considered when interpreting the results for a client who is transgender or nonbinary (Strauss et al., 2006).
When gender-based norms are unavoidable, it has been recommended that the performance of transgender clients be scored using both gender norms and the clinician should determine which are most appropriate in the context of the referral question and the needs of the client (Trittschuh et al., 2018). Once the client’s performance has been scored based on norms of both genders, it is helpful to determine if there is a significant difference between the two scores. In some cases, there may be no meaningful difference when scored with either gender (e.g. if scores from either gender norm set fall within the same confidence interval) and this can therefore be stated in the results.
If scoring a measure using both gender norms is not advisable, due to the nature of the instrument or assessment question, it is recommended the client choose (or choose in consultation with the psychologist) which gender would be the most appropriate for comparison purposes. In cases where the client’s affirmed gender exists within a gender binary, if the person has lived in their affirmed gender for at least one year, in many cases it is clinically appropriate to use the cisgender-normed scale for the identified gender (Keo-Meier et al., 2015).
In summary, psychologists must exercise awareness of the current limitations in test development and assessment with clients who are transgender, gender nonbinary or gender diverse. Psychologists should above all avoid harm in performing assessments with transgender, gender nonbinary and gender diverse clients with consideration of the specific functional reason(s) for the assessment (i.e., is the assessment addressing matters of identity, biological influences of sex-based structures or hormones, both or neither) and what is in the best interests of the client.
This tip sheet is not meant to be a comprehensive set of guidelines for assessment of clients who are transgender, gender nonbinary, or gender diverse. It should serve only as a starting point for clinicians, who should seek appropriate consultation and supervision to obtain competence in performing any type of assessment with this client population.
This resource was developed by the APA Committee on Sexual Orientation and Gender Diversity with contributions from Elizabeth Baumann, PhD; Sarah E. Burgamy, PsyD; Seth Pardo, PhD; Brett Parmenter, PhD; Stephen Sireci, PhD; and Stephanie Towns, PsyD, ABPP.