transgender inequality essay

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Understanding the transgender community.

Transgender people come from all walks of life, and HRC Foundation has estimated that there are more than 2 million of us across the United States. We are parents, siblings, and kids. We are your coworkers, your neighbors, and your friends. We are 7-year-old children and 70-year-old grandparents. We are a diverse community, representing all racial and ethnic backgrounds, as well as all faith traditions.

The word “transgender” – or trans – is an umbrella term for people whose gender identity is different from the sex assigned to us at birth. Although the word “transgender” and our modern definition of it only came into use in the late 20th century, people who would fit under this definition have existed in every culture throughout recorded history.

Alongside the increased visibility of trans celebrities like Laverne Cox, Jazz Jennings or the stars of the hit Netflix series “Pose,” three out of every ten adults in the U.S. personally knows someone who is trans. As trans people become more visible, we aim to increase understanding of our community among our friends, families, and society.

What does it mean to be trans?

The trans community is incredibly diverse. Some trans people identify as trans men or trans women, while others may describe themselves as non-binary, genderqueer, gender non-conforming, agender, bigender or other identities that reflect their personal experience. Some of us take hormones or have surgery as part of our transition, while others may change our pronouns or appearance. Roughly three-quarters of trans youth that responded to an HRC Foundation and University of Connecticut survey identified with terms other than strictly “boy” or “girl.” This suggests that a larger portion of this generation’s youth are identifying somewhere on the broad trans spectrum.

What challenges do trans people face?

While trans people are increasingly visible in both popular culture and in daily life, we still face severe discrimination, stigma and systemic inequality. Some of the specific issues facing the trans community are:

• Lack of legal protection – Trans people face a legal system that often does not protect us from discrimination based on our gender identity. Despite a recent U.S. Supreme Court Decision that makes it clear that trans people are legally protected from discrimination in the workplace, there is still no comprehensive federal non-discrimination law that includes gender identity - which means trans people may still lack recourse if we face discrimination when we’re seeking housing or dining in a restaurant. Moreover, state legislatures across the country are debating – and in some cases passing – legislation specifically designed to prohibit trans people from accessing public bathrooms that correspond with our gender identity, or creating exemptions based on religious beliefs that would allow discrimination against LGBTQ+ people.
• Poverty – Trans people live in poverty at elevated rates, and for trans people of color, these rates are even higher. Around 29% of trans adults live in poverty , as well 39% of Black trans adults, 48% of Latine trans adults and 35% of Alaska Native, Asian, Native Americans and Native Hawaiian or Pacific Islander trans adults.
• Stigma, Harassment and Discrimination – About half a decade ago, only one-quarter of people in the United States supported trans rights, and support increased to 62% by the year 2019. Despite this progress, the trans community still faces considerable stigma due to more than a century of being characterized as mentally ill, socially deviant and sexually predatory. While these intolerant views have faded in recent years for lesbians and gay men, trans people are often still ridiculed by a society that does not understand us. This stigma plays out in a variety of contexts – from lawmakers who leverage anti-trans stigma to score cheap political points; to family, friends or coworkers who reject trans people upon learning about our trans identities; and to people who harass, bully and commit serious violence against trans people. This includes stigma that prevents them from accessing necessary services for their survival and well-being. Only 30% of women’s shelters are willing to house trans women. While recent legal progress has been made, 27% of trans people have been fired, not hired or denied a promotion due to their trans identity. Too often, harassment has led trans people to avoid exercising their most basic rights to vote. HRC Foundation’s research shows that 49% of trans adults, and 55% of trans adults of color said they were unable to vote in at least one election in their life because of fear of or experiencing discrimination at the polls.
• Violence Against Trans People – Trans people experience violence at rates far greater than the average person. Over a majority ( 54% ) of trans people have experienced some form of intimate partner violence, 47% have been sexually assaulted in their lifetime and nearly one in ten were physically assaulted in between 2014 and 2015. This type of violence can be fatal. At least 27 trans and gender non-conforming people have been violently killed in 2020 thus far, the same number of fatalities observed in 2019.
• Lack of Healthcare Coverage – An HRC Foundation analysis found that 22% of trans people and 32% of trans people of color have no health insurance coverage. More than one-quarter ( 29% ) of trans adults have been refused health care by a doctor or provider because of their gender identity. This sobering data reveals a healthcare system that fails to meet the needs of the trans community.
• Identity Documents – The widespread lack of accurate identity documents among trans people can have an impact on every aspect of their lives, including access to emergency housing or other public services. Without identification, one cannot travel, register for school or access many services that are essential to function in society. Many states do not allow trans people to update their identification documents to match their gender identity. Others require evidence of medical transition – which can be prohibitively expensive and is not something that all trans people want – as well as fees for processing new identity documents, which may make them unaffordable for some members of the trans community.

While advocates continue working to remedy these disparities, change cannot come too soon for trans people. Visibility – especially positive images of trans people in the media and society – continues to make a critical difference for us; but visibility is not enough and can come with real risks to our safety, especially for those of us who are part of other marginalized communities. That is why the Human Rights Campaign is committed to continuing to support and advocate for the trans community, so that the trans Americans who are and will become your friends, neighbors, coworkers and family members have an equal chance to succeed and thrive.

Related Resources

Transgender

HRC’s Brief Guide to Reporting on Transgender Individuals

Transgender, Health & Aging, Workplace

Debunking the Myths: Transgender Health and Well-Being

Bisexual, Allies, Coming Out, Transgender

Glossary of Terms

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What does the scholarly research say about the effect of gender transition on transgender well-being?

We conducted a systematic literature review of all peer-reviewed articles published in English between 1991 and June 2017 that assess the effect of gender transition on transgender well-being. We identified 55 studies that consist of primary research on this topic, of which 51 (93%) found that gender transition improves the overall well-being of transgender people, while 4 (7%) report mixed or null findings. We found no studies concluding that gender transition causes overall harm. As an added resource, we separately include 17 additional studies that consist of literature reviews and practitioner guidelines.

Bottom Line

This search found a robust international consensus in the peer-reviewed literature that gender transition, including medical treatments such as hormone therapy and surgeries, improves the overall well-being of transgender individuals. The literature also indicates that greater availability of medical and social support for gender transition contributes to better quality of life for those who identify as transgender.

Below are the 8 findings of our review, and links to the 72 studies on which they are based. Click here to view our methodology . Click here for a printer-friendly one-pager of this research analysis .

Suggested Citation : What We Know Project, Cornell University, “What Does the Scholarly Research Say about the Effect of Gender Transition on Transgender Well-Being?” (online literature review), 2018.

Research Findings

1. The scholarly literature makes clear that gender transition is effective in treating gender dysphoria and can significantly improve the well-being of transgender individuals.

2. Among the positive outcomes of gender transition and related medical treatments for transgender individuals are improved quality of life, greater relationship satisfaction, higher self-esteem and confidence, and reductions in anxiety, depression, suicidality, and substance use.

3. The positive impact of gender transition on transgender well-being has grown considerably in recent years, as both surgical techniques and social support have improved.

4. Regrets following gender transition are extremely rare and have become even rarer as both surgical techniques and social support have improved. Pooling data from numerous studies demonstrates a regret rate ranging from .3 percent to 3.8 percent. Regrets are most likely to result from a lack of social support after transition or poor surgical outcomes using older techniques.

5. Factors that are predictive of success in the treatment of gender dysphoria include adequate preparation and mental health support prior to treatment, proper follow-up care from knowledgeable providers, consistent family and social support, and high-quality surgical outcomes (when surgery is involved).

6. Transgender individuals, particularly those who cannot access treatment for gender dysphoria or who encounter unsupportive social environments, are more likely than the general population to experience health challenges such as depression, anxiety, suicidality and minority stress. While gender transition can mitigate these challenges, the health and well-being of transgender people can be harmed by stigmatizing and discriminatory treatment.

7. An inherent limitation in the field of transgender health research is that it is difficult to conduct prospective studies or randomized control trials of treatments for gender dysphoria because of the individualized nature of treatment, the varying and unequal circumstances of population members, the small size of the known transgender population, and the ethical issues involved in withholding an effective treatment from those who need it.

8. Transgender outcomes research is still evolving and has been limited by the historical stigma against conducting research in this field. More research is needed to adequately characterize and address the needs of the transgender population.

Below are 51 studies that found that gender transition improves the well-being of transgender people. Click here to jump to 4 studies that contain mixed or null findings on the effect of gender transition on transgender well-being. Click here to jump to 17 studies that consist of literature reviews or guidelines that help advance knowledge about the effect of gender transition on transgender well-being.

Ainsworth and spiegel, 2010.

Ainsworth, T., & Spiegel, J. (2010). Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Quality of Life Research , 19 (7), 1019-1024.

Objectives: To determine the self-reported quality of life of male-to-female (MTF) transgendered individuals and how this quality of life is influenced by facial feminization and gender reassignment surgery. Methods: Facial Feminization Surgery outcomes evaluation survey and the SF-36v2 quality of life survey were administered to male-to-female transgender individuals via the Internet and on paper. A total of 247 MTF participants were enrolled in the study. Results: Mental health-related quality of life was statistically diminished (P < 0.05) in transgendered women without surgical intervention compared to the general female population and transwomen who had gender reassignment surgery (GRS), facial feminization surgery (FFS), or both. There was no statistically significant difference in the mental health-related quality of life among transgendered women who had GRS, FFS, or both. Participants who had FFS scored statistically higher (P < 0.01) than those who did not in the FFS outcomes evaluation. Conclusions: Transwomen have diminished mental health-related quality of life compared with the general female population. However, surgical treatments (e.g. FFS, GRS, or both) are associated with improved mental health-related quality of life.

Bailey, Ellis, & McNeil, 2014

Bailey, L., Ellis, S. J., & McNeil, J. (2014). Suicide risk in the UK trans population and the role of gender transition in decreasing suicidal ideation and suicide attempt. The Mental Health Review , 19 (4), 209-220.

Purpose: The purpose of this paper is to present findings from the Trans Mental Health Study (McNeil et al., 2012) – the largest survey of the UK trans population to date and the first to explore trans mental health and well-being within a UK context. Findings around suicidal ideation and suicide attempt are presented and the impact of gender dysphoria, minority stress and medical delay, in particular, are highlighted. Design/methodology/approach: This represents a narrative analysis of qualitative sections of a survey that utilised both open and closed questions. The study drew on a non-random sample (n 1⁄4 889), obtained via a range of UK-based support organisations and services. Findings: The study revealed high rates of suicidal ideation (84 per cent lifetime prevalence) and attempted suicide (48 per cent lifetime prevalence) within this sample. A supportive environment for social transition and timely access to gender reassignment, for those who required it, emerged as key protective factors. Subsequently, gender dysphoria, confusion/denial about gender, fears around transitioning, gender reassignment treatment delays and refusals, and social stigma increased suicide risk within this sample. Research limitations/implications: Due to the limitations of undertaking research with this population, the research is not demographically representative. Practical implications: The study found that trans people are most at risk prior to social and/or medical transition and that, in many cases, trans people who require access to hormones and surgery can be left unsupported for dangerously long periods of time. The paper highlights the devastating impact that delaying or denying gender reassignment treatment can have and urges commissioners and practitioners to prioritise timely intervention and support. Originality/value: The first exploration of suicidal ideation and suicide attempt within the UK trans population revealing key findings pertaining to social and medical transition, crucial for policy makers, commissioners and practitioners working across gender identity services, mental health services and suicide prevention.

Bar et al., 2016

Bar, M. A., Jarus, T., Wada, M., Rechtman, L., & Noy, E. (2016). Male-to-female transitions: Implications for occupational performance, health, and life satisfaction. The Canadian Journal of Occupational Therapy , 83 (2), 72-82.

Background. People who undergo a gender transition process experience changes in different everyday occupations. These changes may impact their health and life satisfaction. Purpose. This study examined the difference in the occupational performance history scales (occupational identity, competence, and settings) between male-to-female transgender women and cisgender women and the relation of these scales to health and life satisfaction. Method. Twenty-two transgender women and 22 matched cisgender women completed a demographic questionnaire and three reliable measures in this cross-sectional study. Data were analyzed using a two-way analysis of variance and multiple linear regressions. Findings. The results indicate lower performance scores for the transgender women. In addition, occupational settings and group membership (transgender and cisgender groups) were found to be predictors of life satisfaction. Implications. The present study supports the role of occupational therapy in promoting occupational identity and competence of transgender women and giving special attention to their social and physical environment.

Bodlund and Kullgren, 1996

Bodlund, O., & Kullgren, G. (1996). Transsexualism–general outcome and prognostic factors: A five-year follow-up study of nineteen transsexuals in the process of changing sex. Archives of Sexual Behavior , 25 (3), 303-316.

Nineteen transsexuals, approved for sex reassignement, were followed-up after 5 years. Outcome was evaluated as changes in seven areas of social, psychological, and psychiatric functioning. At baseline the patients were evaluated according to axis I, II, V (DSM-III-R), SCID screen, SASB (Structural Analysis of Social Behavior), and DMT (Defense Mechanism Test). At follow-up all but 1 were treated with contrary sex hormones, 12 had completed sex reassignment surgery, and 3 females were waiting for phalloplasty. One male transsexual regretted the decision to change sex and had quit the process. Two transsexuals had still not had any surgery due to older age or ambivalence. Overall, 68% (n = 13) had improved in at least two areas of functioning. In 3 cases (16%) outcome were judged as unsatisfactory and one of those regarded sex change as a failure. Another 3 patients were mainly unchanged after 5 years. Female transsexuals had a slightly better outcome, especially concerning establishing and maintaining partnerships and improvement in socio-economic status compared to male transsexuals. Baseline factors associated with negative outcome (unchanged or worsened) were presence of a personality disorder and high number of fulfilled axis II criteria. SCID screen assessments had high prognostic power. Negative self-image, according to SASB, predicted a negative outcome, whereas DMT variables were not correlated to outcome.

Bouman et al., 2016

Bouman, W. P., Claes, L., Marshall, E., Pinner, G. T., Longworth, J., et al. (2016). Sociodemographic variables, clinical features, and the role of preassessment cross-sex hormones in older trans people. The Journal of Sexual Medicine , 13 (4), 711-719.

Introduction: As referrals to gender identity clinics have increased dramatically over the last few years, no studies focusing on older trans people seeking treatment are available. Aims: The aim of this study was to investigate the sociodemographic and clinical characteristics of older trans people attending a national service and to investigate the influence of cross-sex hormones (CHT) on psychopathology. Methods: Individuals over the age of 50 years old referred to a national gender identity clinic during a 30-month period were invited to complete a battery of questionnaires to measure psychopathology and clinical characteristics. Individuals on cross-sex hormones prior to the assessment were compared with those not on treatment for different variables measuring psychopathology. Main Outcome Measures: Sociodemographic and clinical variables and measures of depression and anxiety (Hospital Anxiety and Depression Scale), self-esteem (Rosenberg Self-Esteem Scale), victimization (Experiences of Transphobia Scale), social support (Multidimensional Scale of Perceived Social Support), interpersonal functioning (Inventory of Interpersonal Problems), and nonsuicidal self-injury (Self-Injury Questionnaire). Results: The sex ratio of trans females aged 50 years and older compared to trans males was 23.7:1. Trans males were removed for the analysis due to their small number (n = 3). Participants included 71 trans females over the age of 50, of whom the vast majority were white, employed or retired, and divorced and had children. Trans females on CHT who came out as trans and transitioned at an earlier age were significantly less anxious, reported higher levels of self-esteem, and presented with fewer socialization problems. When controlling for socialization problems, differences in levels of anxiety but not self-esteem remained. Conclusion: The use of cross-sex hormones prior to seeking treatment is widespread among older trans females and appears to be associated with psychological benefits. Existing barriers to access CHT for older trans people may need to be re-examined.

Boza and Nicholson, 2014

Boza, C., & Nicholson Perry, K. (2014). Gender-related victimization, perceived social support, and predictors of depression among transgender Australians. International Journal Of Transgenderism , 15 (1), 35-52.

This study examined mental health outcomes, gender-related victimization, perceived social support, and predictors of depression among 243 transgender Australians (n= 83 assigned female at birth, n= 160 assigned male at birth). Overall, 69% reported at least 1 instance of victimization, 59% endorsed depressive symptoms, and 44% reported a previous suicide attempt. Social support emerged as the most significant predictor of depressive symptoms (p>.05), whereby persons endorsing higher levels of overall perceived social support tended to endorse lower levels of depressive symptoms. Second to social support, persons who endorsed having had some form of gender affirmative surgery were significantly more likely to present with lower symptoms of depression. Contrary to expectations, victimization did not reach significance as an independent risk factor of depression (p=.053). The pervasiveness of victimization, depression, and attempted suicide represents a major health concern and highlights the need to facilitate culturally sensitive health care provision.

Budge et al., 2013

Budge, S. L., Katz-Wise, S. L., Tebbe, E. N., Howard, K. A. S., Schneider, C. L., et al. (2013). Transgender emotional and coping processes: Facilitative and avoidant coping throughout gender transitioning. The Counseling Psychologist , 41 (4), 601-647.

Eighteen transgender-identified individuals participated in semi-structured interviews regarding emotional and coping processes throughout their gender transition. The authors used grounded theory to conceptualize and analyze the data. There were three distinct phases through which the participants described emotional and coping experiences: (a) pretransition, (b) during the transition, and (c) posttransition. Five separate themes emerged, including descriptions of coping mechanisms, emotional hardship, lack of support, positive social support, and affirmative emotional experiences. The authors developed a model to describe the role of coping mechanisms and support experienced throughout the transition process. As participants continued through their transitions, emotional hardships lessened and they used facilitative coping mechanisms that in turn led to affirmative emotional experiences. The results of this study are indicative of the importance of guiding transgender individuals through facilitative coping experiences and providing social support throughout the transition process. Implications for counselors and for future research are discussed.

Cardoso da Silva et al., 2016

Cardoso da Silva, D., Schwarz, K., Fontanari, A.M.V., Costa, A.B., Massuda, R., et al. (2016). WHOQOL-100 Before and after sex reassignment surgery in Brazilian male-to-female transsexual individuals. Journal of Sexual Medicine , 13 (6), 988-993.

Introduction: The 100-item World Health Organization Quality of Life Assessment (WHOQOL-100) evaluates quality of life as a subjective and multidimensional construct. Currently, particularly in Brazil, there are controversies concerning quality of life after sex reassignment surgery (SRS). Aim: To assess the impact of surgical interventions on quality of life of 47 Brazilian male-to-female transsexual individuals using the WHOQOL-100. Methods: This was a prospective cohort study using the WHOQOL-100 and sociodemographic questions for individuals diagnosed with gender identity disorder according to criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The protocol was used when a transsexual person entered the ambulatory clinic and at least 12 months after SRS. Main Outcome Measures: Initially, improvement or worsening of quality of life was assessed using 6 domains and 24 facets. Subsequently, quality of life was assessed for individuals who underwent new surgical interventions and those who did not undergo these procedures 1 year after SRS. Results: The participants showed significant improvement after SRS in domains II (psychological) and IV (social relationships) of the WHOQOL-100. In contrast, domains I (physical health) and III (level of independence) were significantly worse after SRS. Individuals who underwent additional surgery had a decrease in quality of life reflected in domains II and IV. During statistical analysis, all results were controlled for variations in demographic characteristics, without significant results. Conclusion: The WHOQOL-100 is an important instrument to evaluate the quality of life of male-to-female transsexuals during different stages of treatment. SRS promotes the improvement of psychological aspects and social relationships. However, even 1 year after SRS, male-to-female transsexuals continue to report problems in physical health and difficulty in recovering their independence.

(Due to a citation error, this study was initially listed twice.)

Castellano et al., 2015

Castellano, E., Crespi, C., Dell’Aquila, R., Rosato, C., Catalano, V., et al. (2015). Quality of life and hormones after sex reassignment surgery.  Journal of Endocrinological Investigation , 38 (12), 1373-1381.

Background: Transpeople often look for sex reassignment surgery (SRS) to improve their quality of life (QoL). The hormonal therapy has many positive effects before and after SRS. There are no studies about correlation between hormonal status and QoL after SRS. Aim: To gather information on QoL, quality of sexual life and body image in transpeople at least 2 years after SRS, to compare these results with a control group and to evaluate the relations between the chosen items and hormonal status. Subjects and methods: Data from 60 transsexuals and from 60 healthy matched controls were collected. Testosterone, estradiol, LH and World Health Organization Quality of Life (WHOQOL-100) self-reported questionnaire were evaluated. Student’s t test was applied to compare transsexuals and controls. Multiple regression model was applied to evaluate WHOQOL’s chosen items and LH. Results: The QoL and the quality of body image scores in transpeople were not statistically different from the matched control groups’ ones. In the sexual life subscale, transwomen’s scores were similar to biological women’s ones, whereas transmen’s scores were statistically lower than biological men’s ones (P = 0.003). The quality of sexual life scored statistically lower in transmen than in transwomen (P = 0.048). A significant inverse relationship between LH and body image and between LH and quality of sexual life was found. Conclusions: This study highlights general satisfaction after SRS. In particular, transpeople’s QoL turns out to be similar to Italian matched controls. LH resulted inversely correlated to body image and sexual life scores.

Colizzi, Costa, & Todarello, 2014

Colizzi, M., Costa, R. & Todarello, O. (2014). Transsexual patients’ psychiatric comorbidity and positive effect of cross-sex hormonal treatment on mental health: Results from a longitudinal study.  Psychoneuroendocrinology , 39 , 65-73.

The aim of the present study was to evaluate the presence of psychiatric diseases/symptoms in transsexual patients and to compare psychiatric distress related to the hormonal intervention in a one year follow-up assessment. We investigated 118 patients before starting the hormonal therapy and after about 12 months. We used the SCID-I to determine major mental disorders and functional impairment. We used the Zung Self-Rating Anxiety Scale (SAS) and the Zung Self-Rating Depression Scale (SDS) for evaluating self-reported anxiety and depression. We used the Symptom Checklist 90-R (SCL-90-R) for assessing self-reported global psychological symptoms. Seventeen patients (14%) had a DSM-IV-TR axis I psychiatric comorbidity. At enrollment the mean SAS score was above the normal range. The mean SDS and SCL-90-R scores were on the normal range except for SCL-90-R anxiety subscale. When treated, patients reported lower SAS, SDS and SCL-90-R scores, with statistically significant differences. Psychiatric distress and functional impairment were present in a significantly higher percentage of patients before starting the hormonal treatment than after 12 months (50% vs. 17% for anxiety; 42% vs. 23% for depression; 24% vs. 11% for psychological symptoms; 23% vs. 10% for functional impairment). The results revealed that the majority of transsexual patients have no psychiatric comorbidity, suggesting that transsexualism is not necessarily associated with severe comorbid psychiatric findings. The condition, however, seemed to be associated with subthreshold anxiety/depression, psychological symptoms and functional impairment. Moreover, treated patients reported less psychiatric distress. Therefore, hormonal treatment seemed to have a positive effect on transsexual patients’ mental health.

Colizzi et al., 2013

Colizzi. M., Costa, R., Pace, V., & Todarello, O. (2013). Hormonal treatment reduces psychobiological distress in gender identity disorder, independently of the attachment style. The Journal of Sexual Medicine , 10 (12), 3049–3058.

Introduction: Gender identity disorder may be a stressful situation. Hormonal treatment seemed to improve the general health as it reduces psychological and social distress. The attachment style seemed to regulate distress in insecure individuals as they are more exposed to hypothalamic–pituitary–adrenal system dysregulation and subjective stress. Aim: The objectives of the study were to evaluate the presence of psychobiological distress and insecure attachment in transsexuals and to study their stress levels with reference to the hormonal treatment and the attachment pattern. Methods: We investigated 70 transsexual patients. We measured the cortisol levels and the perceived stress before starting the hormonal therapy and after about 12 months. We studied the representation of attachment in transsexuals by a backward investigation in the relations between them and their caregivers. Main Outcome Measures: We used blood samples for assessing cortisol awakening response (CAR); we used the Perceived Stress Scale for evaluating self‐reported perceived stress and the Adult Attachment Interview to determine attachment styles. Results: At enrollment, transsexuals reported elevated CAR; their values were out of normal. They expressed higher perceived stress and more attachment insecurity, with respect to normative sample data. When treated with hormone therapy, transsexuals reported significantly lower CAR (P < 0.001), falling within the normal range for cortisol levels. Treated transsexuals showed also lower perceived stress (P < 0.001), with levels similar to normative samples. The insecure attachment styles were associated with higher CAR and perceived stress in untreated transsexuals (P < 0.01). Treated transsexuals did not expressed significant differences in CAR and perceived stress by attachment. Conclusion: Our results suggested that untreated patients suffer from a higher degree of stress and that attachment insecurity negatively impacts the stress management. Initiating the hormonal treatment seemed to have a positive effect in reducing stress levels, whatever the attachment style may be.

Colton-Meier et al., 2011

Colton-Meier, S. L., Fitzgerald, K. M., Pardo, S. T., & Babcock, J. (2011). The effects of hormonal gender affirmation treatment on mental health in female-to-male transsexuals. Journal of Gay & Lesbian Mental Health , 15 (3), 281-299.

Hormonal interventions are an often-sought option for transgender individuals seeking to medically transition to an authentic gender. Current literature stresses that the effects and associated risks of hormone regimens should be monitored and well understood by health care providers (Feldman & Bockting, 2003). However, the positive psychological effects following hormone replacement therapy as a gender affirming treatment have not been adequately researched. This study examined the relationship of hormone replacement therapy, specifically testosterone, with various mental health outcomes in an Internet sample of more than 400 self-identified female-to-male transsexuals. Results of the study indicate that female-to-male transsexuals who receive testosterone have lower levels of depression, anxiety, and stress, and higher levels of social support and health related quality of life. Testosterone use was not related to problems with drugs, alcohol, or suicidality. Overall findings provide clear evidence that HRT is associated with improved mental health outcomes in female-to-male transsexuals.

Costantino et al., 2013

Costantino, A., Cerpolini, S., Alvisi, S., Morselli, P. G., Venturoli, S., & Meriggiola, M. C. (2013). A prospective study on sexual function and mood in female-to-male transsexuals during testosterone administration and after sex reassignment surgery. Journal of Sex & Marital Therapy , 39 (4), 321-335.

Testosterone administration in female-to-male transsexual subjects aims to develop and maintain the characteristics of the desired sex. Very little data exists on its effects on sexuality of female-to-male transsexuals. The aim of this study was to evaluate sexual function and mood of female-to-male transsexuals from their first visit, throughout testosterone administration and after sex reassignment surgery. Participants were 50 female-to-male transsexual subjects who completed questionnaires assessing sexual parameters and mood. The authors measured reproductive hormones and hematological parameters. The results suggest a positive effect of testosterone treatment on sexual function and mood in female-to-male transsexual subjects.

Davis and Meier, 2014

Davis, S. A. & Meier, S. C. (2014). Effects of testosterone treatment and chest reconstruction surgery on mental health and sexuality in female-to-male transgender people. International Journal of Sexual Health , 26 (2), 113-128.

Objectives: This study examined the effects of testosterone treatment with or without chest reconstruction surgery (CRS) on mental health in female-to-male transgender people (FTMs). Methods: More than 200 FTMs completed a written survey including quantitative scales to measure symptoms of anxiety and depression, feelings of anger, and body dissatisfaction, as well as qualitative questions assessing shifts in sexuality after the initiation of testosterone. Fifty-seven percent of participants were taking testosterone and 40% had undergone CRS. Results: Cross-sectional analysis using a between-subjects multivariate analysis of variance showed that participants who were receiving testosterone endorsed fewer symptoms of anxiety and depression as well as less anger than the untreated group. Participants who had CRS in addition to testosterone reported less body dissatisfaction than both the testosterone-only or the untreated groups. Furthermore, participants who were injecting testosterone on a weekly basis showed significantly less anger compared with those injecting every other week. In qualitative reports, more than 50% of participants described increased sexual attraction to nontransgender men after taking testosterone. Conclusions: Results indicate that testosterone treatment in FTMs is associated with a positive effect on mental health on measures of depression, anxiety, and anger, while CRS appears to be more important for the alleviation of body dissatisfaction. The findings have particular relevance for counselors and health care providers serving FTM and gender-variant people considering medical gender transition.

De Cuypere et al., 2006

De Cuypere, G., Elaut, E., Heylens, G., Maele, G. V., Selvaggi, G., et al. (2006). Long-term follow-up: Psychosocial outcome of Belgian transsexuals after sex reassignment surgery. Sexologies , 15 (2), 126-133.

Background: To establish the benefit of sex reassignment surgery (SRS) for persons with a gender identity disorder, follow-up studies comprising large numbers of operated transsexuals are still needed. Aims: The authors wanted to assess how the transsexuals who had been treated by the Ghent multidisciplinary gender team since 1985, were functioning psychologically, socially and professionally after a longer period. They also explored some prognostic factors with a view to refining the procedure. Method: From 107 Dutch-speaking transsexuals who had undergone SRS between 1986 and 2001, 62 (35 male-to-females and 27 female-to-males) completed various questionnaires and were personally interviewed by researchers, who had not been involved in the subjects’ initial assessment or treatment. Results: On the GAF (DSM-IV) scale the female-to-male transsexuals scored significantly higher than the male-to-females (85.2 versus 76.2). While no difference in psychological functioning (SCL-90) was observed between the study group and a normal population, subjects with a pre-existing psychopathology were found to have retained more psychological symptoms. The subjects proclaimed an overall positive change in their family and social life. None of them showed any regrets about the SRS. A homosexual orientation, a younger age when applying for SRS, and an attractive physical appearance were positive prognostic factors. Conclusion: While sex reassignment treatment is an effective therapy for transsexuals, also in the long term, the postoperative transsexual remains a fragile person in some respects.

Dhejne et al., 2014

Dhejne, C., Öberg, K., Arver, S., & Landén, M. (2014). An analysis of all applications for sex reassignment surgery in sweden, 1960-2010: Prevalence, incidence, and regrets. Archives of Sexual Behavior , 43 (8), 1535-1545.

Incidence and prevalence of applications in Sweden for legal and surgical sex reassignment were examined over a 50-year period (1960-2010), including the legal and surgical reversal applications. A total of 767 people (289 natal females and 478 natal males) applied for legal and surgical sex reassignment. Out of these, 89 % (252 female-to-males [FM] and 429 male-to-females [MF]) received a new legal gender and underwent sex reassignment surgery (SRS). A total of 25 individuals (7 natal females and 18 natal males), equaling 3.3 %, were denied a new legal gender and SRS. The remaining withdrew their application, were on a waiting list for surgery, or were granted partial treatment. The incidence of applications was calculated and stratified over four periods between 1972 and 2010. The incidence increased significantly from 0.16 to 0.42/100,000/year (FM) and from 0.23 to 0.73/100,000/year (MF). The most pronounced increase occurred after 2000. The proportion of FM individuals 30 years or older at the time of application remained stable around 30 %. In contrast, the proportion of MF individuals 30 years or older increased from 37 % in the first decade to 60 % in the latter three decades. The point prevalence at December 2010 for individuals who applied for a new legal gender was for FM 1:13,120 and for MF 1:7,750. The FM:MF sex ratio fluctuated but was 1:1.66 for the whole study period. There were 15 (5 MF and 10 MF) regret applications corresponding to a 2.2 % regret rate for both sexes. There was a significant decline of regrets over the time period.

Eldh, Berg, & Gustafsson, 1997

Eldh, J., Berg, A., Gustafsson, M. (1997). Long-term follow up after sex reassignment surgery. Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery , 27 (1), 39-45.

A long-term follow up of 136 patients operated on for sex reassignment was done to evaluate the surgical outcome. Social and psychological adjustments were also investigated by a questionnaire in 90 of these 136 patients. Optimal results of the operation are essential for a successful outcome. Personal and social instability before operation, unsuitable body build, and age over 30 years at operation correlated with unsatisfactory results. Adequate family and social support is important for postoperative functioning. Sex reassignment had no influence on the person’s ability to work.

Fisher et al., 2014

Fisher, A. D., Castellini, G., Bandini, E., Casale, H., Fanni, E., et al. (2014). Cross‐sex hormonal treatment and body uneasiness in individuals with gender dysphoria. The Journal of Sexual Medicine , 11 (3), 709–719.

Introduction: Cross‐sex hormonal treatment (CHT) used for gender dysphoria (GD) could by itself affect well‐being without the use of genital surgery; however, to date, there is a paucity of studies investigating the effects of CHT alone. Aims: This study aimed to assess differences in body uneasiness and psychiatric symptoms between GD clients taking CHT and those not taking hormones (no CHT). A second aim was to assess whether length of CHT treatment and daily dose provided an explanation for levels of body uneasiness and psychiatric symptoms. Methods: A consecutive series of 125 subjects meeting the criteria for GD who not had genital reassignment surgery were considered. Main Outcome Measures: Subjects were asked to complete the Body Uneasiness Test (BUT) to explore different areas of body‐related psychopathology and the Symptom Checklist‐90 Revised (SCL‐90‐R) to measure psychological state. In addition, data on daily hormone dose and length of hormonal treatment (androgens, estrogens, and/or antiandrogens) were collected through an analysis of medical records. Results: Among the male‐to‐female (MtF) individuals, those using CHT reported less body uneasiness compared with individuals in the no‐CHT group. No significant differences were observed between CHT and no‐CHT groups in the female‐to‐male (FtM) sample. Also, no significant differences in SCL score were observed with regard to gender (MtF vs. FtM), hormone treatment (CHT vs. no‐CHT), or the interaction of these two variables. Moreover, a two‐step hierarchical regression showed that cumulative dose of estradiol (daily dose of estradiol times days of treatment) and cumulative dose of androgen blockers (daily dose of androgen blockers times days of treatment) predicted BUT score even after controlling for age, gender role, cosmetic surgery, and BMI. Conclusions: The differences observed between MtF and FtM individuals suggest that body‐related uneasiness associated with GD may be effectively diminished with the administration of CHT even without the use of genital surgery for MtF clients. A discussion is provided on the importance of controlling both length and daily dose of treatment for the most effective impact on body uneasiness.

Glynn et al., 2016

Glynn, T. R., Gamarel, K. E., Kahler, C. W., Iwamoto, M., Operario, D., & Nemoto, T. (2016). The role of gender affirmation in psychological well-being among transgender women. Psychology Of Sexual Orientation And Gender Diversity , 3 (3), 336-344.

High prevalence of psychological distress, including greater depression, lower self-esteem, and suicidal ideation, has been documented across numerous samples of transgender women and has been attributed to high rates of discrimination and violence. According to the gender affirmation framework (Sevelius, 2013), access to sources of gender-affirmative support can offset such negative psychological effects of social oppression. However, critical questions remain unanswered in regards to how and which aspects of gender affirmation are related to psychological well-being. The aims of this study were to investigate the associations among 3 discrete areas of gender affirmation (psychological, medical, and social) and participants’ reports of psychological well-being. A community sample of 573 transgender women with a history of sex work completed a 1-time self-report survey that assessed demographic characteristics, gender affirmation, and mental health outcomes. In multivariate models, we found that social, psychological, and medical gender affirmation were significant predictors of lower depression and higher self-esteem whereas no domains of affirmation were significantly associated with suicidal ideation. Findings support the need for accessible and affordable transitioning resources for transgender women to promote better quality of life among an already vulnerable population. However, transgender individuals should not be portrayed simplistically as objects of vulnerability, and research identifying mechanisms to promote wellness and thriving is necessary for future intervention development. As the gender affirmation framework posits, the personal experience of feeling affirmed as a transgender person results from individuals’ subjective perceptions of need along multiple dimensions of gender affirmation. Thus, personalized assessment of gender affirmation may be a useful component of counseling and service provision for transgender women.

Gomez-Gil et al., 2012

Gomez-Gil, E., Zubiaurre-Elorz, L., Esteva, I., Guillamon, A., Godas, T., Cruz Almaraz, M., Halperin, I., Salamero, M. (2012). Hormone-treated transsexuals report less social distress, anxiety and depression. Psychoneuroendocrinology , 37 (5), 662-670.

Introduction: The aim of the present study was to evaluate the presence of symptoms of current social distress, anxiety and depression in transsexuals. Methods: We investigated a group of 187 transsexual patients attending a gender identity unit; 120 had undergone hormonal sex-reassignment (SR) treatment and 67 had not. We used the Social Anxiety and Distress Scale (SADS) for assessing social anxiety and the Hospital Anxiety and Depression Scale (HADS) for evaluating current depression and anxiety. Results: The mean SADS and HADS scores were in the normal range except for the HAD-Anxiety subscale (HAD-A) on the non-treated transsexual group. SADS, HAD-A, and HAD-Depression (HAD-D) mean scores were significantly higher among patients who had not begun cross-sex hormonal treatment compared with patients in hormonal treatment (F = 4.362, p = .038; F = 14.589, p = .001; F = 9.523, p = .002 respectively). Similarly, current symptoms of anxiety and depression were present in a significantly higher percentage of untreated patients than in treated patients (61% vs. 33% and 31% vs. 8% respectively). Conclusions: The results suggest that most transsexual patients attending a gender identity unit reported subclinical levels of social distress, anxiety, and depression. Moreover, patients under cross-sex hormonal treatment displayed a lower prevalence of these symptoms than patients who had not initiated hormonal therapy. Although the findings do not conclusively demonstrate a direct positive effect of hormone treatment in transsexuals, initiating this treatment may be associated with better mental health of these patients.

Gomez-Gil et al., 2014

Gómez-Gil, E., Zubiaurre-Elorza, L., de Antonio, E. D., Guillamon, A., & Salamero, M. (2014). Determinants of quality of life in Spanish transsexuals attending a gender unit before genital sex reassignment surgery. Quality of Life Research , 23 (2), 669-676.

Purpose: To evaluate the self-reported perceived quality of life (QoL) in transsexuals attending a Spanish gender identity unit before genital sex reassignment surgery, and to identify possible determinants that likely contribute to their QoL. Methods: A sample of 119 male-to-female (MF) and 74 female-to-male (FM) transsexuals were included in the study. The WHOQOL-BREF scale was used to evaluate self-reported QoL. Possible determinants included age, sex, education, employment, partnership status, undergoing cross-sex hormonal therapy, receiving at least one non-genital sex reassignment surgery, and family support (assessed with the family APGAR questionnaire). Results: Mean scores of all QoL domains ranged from 55.44 to 63.51. Linear regression analyses revealed that undergoing cross-sex hormonal treatment, having family support, and having an occupation were associated with a better QoL for all transsexuals. FM transsexuals have higher social domain QoL scores than MF transsexuals. The model accounts for 20.6 % of the variance in the physical, 32.5 % in the psychological, 21.9 % in the social, and 20.1 % in the environment domains, and 22.9 % in the global QoL factor. Conclusions: Cross-sex hormonal treatment, family support, and working or studying are linked to a better self-reported QoL in transsexuals. Healthcare providers should consider these factors when planning interventions to promote the health-related QoL of transsexuals.

Gorin-Lazard et al., 2012

Gorin‐Lazard, A., Baumstarck, K., Boyer, L., Maquigneau, A., Gebleux, S., Penochet, J., Pringuey, D., Albarel, F., Morange, I., Loundou, A., Berbis, J., Auquier, P., Lançon, C. and Bonierbale, M. (2012). Is hormonal therapy associated with better quality of life in transsexuals? A cross‐sectional study. The Journal of Sexual Medicine , 9 (2), 531–541.

Introduction: Although the impact of sex reassignment surgery on the self‐reported outcomes of transsexuals has been largely described, the data available regarding the impact of hormone therapy on the daily lives of these individuals are scarce. Aims: The objectives of this study were to assess the relationship between hormonal therapy and the self‐reported quality of life (QoL) in transsexuals while taking into account the key confounding factors and to compare the QoL levels between transsexuals who have, vs. those who have not, undergone cross‐sex hormone therapy as well as between transsexuals and the general population (French age‐ and sex‐matched controls). Methods: This study incorporated a cross‐sectional design that was conducted in three psychiatric departments of public university teaching hospitals in France. The inclusion criteria were as follows: 18 years or older, diagnosis of gender identity disorder (302.85) according to the Diagnostic and Statistical Manual, fourth edition text revision (DSM‐IV TR), inclusion in a standardized sex reassignment procedure following the agreement of a multidisciplinary team, and pre‐sex reassignment surgery. Main Outcome Measure. QoL was assessed using the Short Form 36 (SF‐36). Results: The mean age of the total sample was 34.7 years, and the sex ratio was 1:1. Forty‐four (72.1%) of the participants received hormonal therapy. Hormonal therapy and depression were independent predictive factors of the SF‐36 mental composite score. Hormonal therapy was significantly associated with a higher QoL, while depression was significantly associated with a lower QoL. Transsexuals’ QoL, independently of hormonal status, did not differ from the French age‐ and sex‐matched controls except for two subscales of the SF‐36 questionnaire: role physical (lower scores in transsexuals) and general health (lower scores in controls). Conclusion: The present study suggests a positive effect of hormone therapy on transsexuals’ QoL after accounting for confounding factors. These results will be useful for healthcare providers of transgender persons but should be confirmed with larger samples using a prospective study design.

Gorin-Lazard et al., 2013

Gorin-Lazard, A., Baumstarck, K., Boyer, L., Maquigneau, A., Penochet, J. C., et al. (2013). Hormonal therapy is associated with better self-esteem, mood, and quality of life in transsexuals. Journal of Nervous and Mental Disease , 201 (11), 996–1000.

Few studies have assessed the role of cross-sex hormones on psychological outcomes during the period of hormonal therapy preceding sex reassignment surgery in transsexuals. The objective of this study was to assess the relationship between hormonal therapy, self-esteem, depression, quality of life (QoL), and global functioning. This study incorporated a cross-sectional design. The inclusion criteria were diagnosis of gender identity disorder (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) and inclusion in a standardized sex reassignment procedure. The outcome measures were self-esteem (Social Self-Esteem Inventory), mood (Beck Depression Inventory), QoL (Subjective Quality of Life Analysis), and global functioning (Global Assessment of Functioning). Sixty-seven consecutive individuals agreed to participate. Seventy-three percent received hormonal therapy. Hormonal therapy was an independent factor in greater self-esteem, less severe depression symptoms, and greater “psychological-like” dimensions of QoL. These findings should provide pertinent information for health care providers who consider this period as a crucial part of the global sex reassignment procedure.

Hess et al., 2014

Hess, J., Neto, R. R., Panic, L., Rübben, H., & Senf, W. (2014). Satisfaction with male-to-female gender reassignment surgery: Results of a retrospective analysis. Deutsches Ärzteblatt International , 111 (47), 795–801.

Background: The frequency of gender identity disorder is hard to determine; the number of gender reassignment operations and of court proceedings in accordance with the German Law on Transsexuality almost certainly do not fully reflect the underlying reality. There have been only a few studies on patient satisfaction with male-to-female gender reassignment surgery. Methods: 254 consecutive patients who had undergone male-to-female gender reassignment surgery at Essen University Hospital’s Department of Urology retrospectively filled out a questionnaire about their subjective postoperative satisfaction. Results: 119 (46.9%) of the patients filled out and returned the questionnaires, at a mean of 5.05 years after surgery (standard deviation 1.61 years, range 1–7 years). 90.2% said their expectations for life as a woman were fulfilled postoperatively. 85.4% saw themselves as women. 61.2% were satisfied, and 26.2% very satisfied, with their outward appearance as a woman; 37.6% were satisfied, and 34.4% very satisfied, with the functional outcome. 65.7% said they were satisfied with their life as it is now. Conclusion: The very high rates of subjective satisfaction and the surgical outcomes indicate that gender reassignment surgery is beneficial. These findings must be interpreted with caution, however, because fewer than half of the questionnaires were returned.

Heylens et al., 2014

Heylens, G., Verroken, C., De Cock, S., T’Sjoen, G., & De Cuypere, G. (2014). Effects of different steps in gender reassignment therapy on psychopathology: a prospective study of persons with a gender identity disorder. The Journal of Sexual Medicine , 11 (1), 119–126.

Introduction: At the start of gender reassignment therapy, persons with a gender identity disorder (GID) may deal with various forms of psychopathology. Until now, a limited number of publications focus on the effect of the different phases of treatment on this comorbidity and other psychosocial factors. Aims: The aim of this study was to investigate how gender reassignment therapy affects psychopathology and other psychosocial factors. Methods: This is a prospective study that assessed 57 individuals with GID by using the Symptom Checklist‐90 (SCL‐90) at three different points of time: at presentation, after the start of hormonal treatment, and after sex reassignment surgery (SRS). Questionnaires on psychosocial variables were used to evaluate the evolution between the presentation and the postoperative period. The data were statistically analyzed by using SPSS 19.0, with significance levels set at P < 0.05. Main Outcome Measures: The psychopathological parameters include overall psychoneurotic distress, anxiety, agoraphobia, depression, somatization, paranoid ideation/psychoticism, interpersonal sensitivity, hostility, and sleeping problems. The psychosocial parameters consist of relationship, living situation, employment, sexual contacts, social contacts, substance abuse, and suicide attempt. Results: A difference in SCL‐90 overall psychoneurotic distress was observed at the different points of assessments (P = 0.003), with the most prominent decrease occurring after the initiation of hormone therapy (P < 0.001). Significant decreases were found in the subscales such as anxiety, depression, interpersonal sensitivity, and hostility. Furthermore, the SCL‐90 scores resembled those of a general population after hormone therapy was initiated. Analysis of the psychosocial variables showed no significant differences between pre‐ and postoperative assessments. Conclusions: A marked reduction in psychopathology occurs during the process of sex reassignment therapy, especially after the initiation of hormone therapy.

Imbimbo et al., 2009

Imbimbo, C., Verze, P., Palmieri, A., Longo, N., Fusco, F., Arcaniolo, D., & Mirone, V. (2009). A report from a single institute’s 14-year experience in treatment of male-to-female transsexuals. The Journal of Sexual Medicine , 6 (10), 2736–2745.

Introduction: Gender identity disorder or transsexualism is a complex clinical condition, and prevailing social context strongly impacts the form of its manifestations. Sex reassignment surgery (SRS) is the crucial step of a long and complex therapeutic process starting with preliminary psychiatric evaluation and culminating in definitive gender identity conversion. Aim: The aim of our study is to arrive at a clinical and psychosocial profile of male-to-female transsexuals in Italy through analysis of their personal and clinical experience and evaluation of their postsurgical satisfaction levels SRS. Methods: From January 1992 to September 2006, 163 male patients who had undergone gender-transforming surgery at our institution were requested to complete a patient satisfaction questionnaire. Main Outcome Measures: The questionnaire consisted of 38 questions covering nine main topics: general data, employment status, family status, personal relationships, social and cultural aspects, presurgical preparation, surgical procedure, and postsurgical sex life and overall satisfaction. Results: Average age was 31 years old. Seventy-two percent had a high educational level, and 63% were steadily employed. Half of the patients had contemplated suicide at some time in their lives before surgery and 4% had actually attempted suicide. Family and colleague emotional support levels were satisfactory. All patients had been adequately informed of surgical procedure beforehand. Eighty-nine percent engaged in postsurgical sexual activities. Seventy-five percent had a more satisfactory sex life after SRS, with main complications being pain during intercourse and lack of lubrication. Seventy-eight percent were satisfied with their neovagina’s esthetic appearance, whereas only 56% were satisfied with depth. Almost all of the patients were satisfied with their new sexual status and expressed no regrets. Conclusions: Our patients’ high level of satisfaction was due to a combination of a well-conducted preoperative preparation program, competent surgical skills, and consistent postoperative follow-up.

Johansson et al., 2010

Johansson, A., Sundbom, E., Höjerback, T., & Bodlund, O. (2010). A five-year follow-up study of Swedish adults with gender identity disorder. Archives of Sexual Behavior , 39 (6), 1429-1437.

This follow-up study evaluated the outcome of sex reassignment as viewed by both clinicians and patients, with an additional focus on the outcome based on sex and subgroups. Of a total of 60 patients approved for sex reassignment, 42 (25 male-to-female [MF] and 17 female-to-male [FM]) transsexuals completed a follow-up assessment after 5 or more years in the process or 2 or more years after completed sex reassignment surgery. Twenty-six (62%) patients had an early onset and 16 (38%) patients had a late onset; 29 (69%) patients had a homosexual sexual orientation and 13 (31%) patients had a non-homosexual sexual orientation (relative to biological sex). At index and follow-up, a semi-structured interview was conducted. At follow-up, 32 patients had completed sex reassignment surgery, five were still in process, and five—following their own decision—had abstained from genital surgery. No one regretted their reassignment. The clinicians rated the global outcome as favorable in 62% of the cases, compared to 95% according to the patients themselves, with no differences between the subgroups. Based on the follow-up interview, more than 90% were stable or improved as regards work situation, partner relations, and sex life, but 5–15% were dissatisfied with the hormonal treatment, results of surgery, total sex reassignment procedure, or their present general health. Most outcome measures were rated positive and substantially equal for MF and FM. Late-onset transsexuals differed from those with early onset in some respects: these were mainly MF (88 vs. 42%), older when applying for sex reassignment (42 vs. 28 years), and non-homosexually oriented (56 vs. 15%). In conclusion, almost all patients were satisfied with the sex reassignment; 86% were assessed by clinicians at follow-up as stable or improved in global functioning.

Keo-Meier et al., 2015

Keo-Meier, C. L., Herman, L. I., Reisner, S. L., Pardo, S. T., Sharp, C., & Babcock, J. C. (2015). Testosterone treatment and MMPI-2 improvement in transgender men: A prospective controlled study. Journal of Consulting and Clinical Psychology, 83 , 143-156.

Objective: Most transgender men desire to receive testosterone treatment in order to masculinize their bodies. In this study, we aimed to investigate the short-term effects of testosterone treatment on psychological functioning in transgender men. This is the 1st controlled prospective follow-up study to examine such effects. Method: We examined a sample of transgender men (n = 48) and nontransgender male (n = 53) and female (n = 62) matched controls (mean age = 26.6 years; 74% White). We asked participants to complete the Minnesota Multiphasic Personality Inventory (2nd ed., or MMPI–2; Butcher, Graham, Tellegen, Dahlstrom, & Kaemmer, 2001) to assess psychological functioning at baseline and at the acute posttreatment follow-up (3 months after testosterone initiation). Regression models tested (a) Gender × Time interaction effects comparing divergent mean response profiles across measurements by gender identity; (b) changes in psychological functioning scores for acute postintervention measurements, adjusting for baseline measures, comparing transgender men with their matched nontransgender male and female controls and adjusting for baseline scores; and (c) changes in meeting clinical psychopathological thresholds. Results: Statistically significant changes in MMPI–2 scale scores were found at 3-month follow-up after initiating testosterone treatment relative to baseline for transgender men compared with female controls (female template): reductions in Hypochondria (p < .05), Depression (p < .05), Hysteria (p < .05), and Paranoia (p < .01); and increases in Masculinity–Femininity scores (p < .01). Gender × Time interaction effects were found for Hysteria (p < .05) and Paranoia (p < .01) relative to female controls (female template) and for Hypochondria (p < .05), Depression (p < .01), Hysteria (p < .01), Psychopathic Deviate (p < .05), Paranoia (p < .01), Psychasthenia (p < .01), and Schizophrenia (p < .01) compared with male controls (male template). In addition, the proportion of transgender men presenting with co-occurring psychopathology significantly decreased from baseline compared with 3-month follow-up relative to controls (p < .05). Conclusions: Findings suggest that testosterone treatment resulted in increased levels of psychological functioning on multiple domains in transgender men relative to nontransgender controls. These findings differed in comparisons of transgender men with female controls using the female template and with male controls using the male template. No iatrogenic effects of testosterone were found. These findings suggest a direct positive effect of 3 months of testosterone treatment on psychological functioning in transgender men.

Kraemer et al., 2008

Kraemer, B., Delsignore, A., Schnyder, U., & Hepp, U. (2008). Body image and transsexualism. Psychopathology , 41 (2), 96-100.

Background: To achieve a detailed view of the body image of transsexual patients, an assessment of perception, attitudes and experiences about one’s own body is necessary. To date, research on the body image of transsexual patients has mostly covered body dissatisfaction with respect to body perception. Sampling and Methods: We investigated 23 preoperative (16 male-to-female and 7 female-to-male transsexual patients) and 22 postoperative (14 male-to-female and 8 female-to-male) transsexual patients using a validated psychological measure for body image variables. Results: We found that preoperative transsexual patients were insecure and felt unattractive because of concerns about their body image. However, postoperative transsexual patients scored high on attractiveness and self-confidence. Furthermore, postoperative transsexual patients showed low scores for insecurity and concerns about their body. Conclusions: Our results indicate an improvement of body image concerns for transsexual patients following standards of care for gender identity disorder. Follow-up studies are recommended to confirm the assumed positive outcome of standards of care on body image.

Landen et al., 1998

Landén, M., Wålinder, J., Hambert, G., & Lundström, B. (1998). Factors predictive of regret in sex reassignment. Acta Psychiatrica Scandinavica , 97 (4), 284-289.

The objective of this study was to evaluate the features and calculate the frequency of sex-reassigned subjects who had applied for reversal to their biological sex, and to compare these with non-regretful subjects. An inception cohort was retrospectively identified consisting of all subjects with gender identity disorder who were approved for sex reassignment in Sweden during the period 1972-1992. The period of time that elapsed between the application and this evaluation ranged from 4 to 24 years. The total cohort consisted of 218 subjects. The results showed that 3.8% of the patients who were sex reassigned during 1972-1992 regretted the measures taken. The cohort was subdivided according to the presence or absence of regret of sex reassignment, and the two groups were compared. The results of logistic regression analysis indicated that two factors predicted regret of sex reassignment, namely lack of support from the patient’s family, and the patient belonging to the non-core group of transsexuals. In conclusion, the results show that the outcome of sex reassignment has improved over the years. However, the identified risk factors indicate the need for substantial efforts to support the families and close friends of candidates for sex reassignment.

Lawrence, 2003

Lawrence, A. A. (2003). Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Archives of Sexual Behavior , 32 (4), 299-315.

This study examined factors associated with satisfaction or regret following sex reassignment surgery (SRS) in 232 male-to-female transsexuals operated on between 1994 and 2000 by one surgeon using a consistent technique. Participants, all of whom were at least 1-year postoperative, completed a written questionnaire concerning their experiences and attitudes. Participants reported overwhelmingly that they were happy with their SRS results and that SRS had greatly improved the quality of their lives. None reported outright regret and only a few expressed even occasional regret. Dissatisfaction was most strongly associated with unsatisfactory physical and functional results of surgery. Most indicators of transsexual typology, such as age at surgery, previous marriage or parenthood, and sexual orientation, were not significantly associated with subjective outcomes. Compliance with minimum eligibility requirements for SRS specified by the Harry Benjamin International Gender Dysphoria Association was not associated with more favorable subjective outcomes. The physical results of SRS may be more important than preoperative factors such as transsexual typology or compliance with established treatment regimens in predicting postoperative satisfaction or regret.

Lawrence, 2006

Lawrence, A. A. (2006). Patient-reported complications and functional outcomes of male-to-female sex reassignment surgery. Archives of Sexual Behavior , 35 (6), 717-727.

This study examined preoperative preparations, complications, and physical and functional outcomes of male-to-female sex reassignment surgery (SRS), based on reports by 232 patients, all of whom underwent penile-inversion vaginoplasty and sensate clitoroplasty, performed by one surgeon using a consistent technique. Nearly all patients discontinued hormone therapy before SRS and most reported that doing so created no difficulties. Preoperative electrolysis to remove genital hair, undergone by most patients, was not associated with less serious vaginal hair problems. No patients reported rectal-vaginal fistula or deep-vein thrombosis and reports of other significant surgical complications were uncommon. One third of patients, however, reported urinary stream problems. No single complication was significantly associated with regretting SRS. Satisfaction with most physical and functional outcomes of SRS was high; participants were least satisfied with vaginal lubrication, vaginal touch sensation, and vaginal erotic sensation. Frequency of achieving orgasm after SRS was not significantly associated with most general measures of satisfaction. Later years of surgery, reflecting greater surgeon experience, were not associated with lower prevalence rates for most complications or with better ratings for most physical and functional outcomes of SRS.

Lobato et al., 2006

Lobato M. I., Koff, W. J., Manenti, C., da Fonseca Seger, D., Salvador, J., et al. (2006). Follow-up of sex reassignment surgery in transsexuals: a Brazilian cohort.  Archives of Sexual Behavior, 35(6) , 711–715.

This study examined the impact of sex reassignment surgery on the satisfaction with sexual experience, partnerships, and relationship with family members in a cohort of Brazilian transsexual patients. A group of 19 patients who received sex reassignment between 2000 and 2004 (18 male- to-female, 1 female-to-male) after a two-year evaluation by a multidisciplinary team, and who agreed to participate in the study, completed a written questionnaire. Mean age at entry into the program was 31.21 ± 8.57 years and mean schooling was 9.2 ± 1.4 years. None of the patients reported regret for having undergone the surgery. Sexual experience was considered to have improved by 83.3% of the patients, and became more frequent for 64.7% of the patients. For 83.3% of the patients, sex was considered to be pleasurable with the neovagina/neopenis. In addition, 64.7% reported that initiating and maintaining a relationship had become easier. The number of patients with a partner increased from 52.6% to 73.7%. Family relationships improved in 26.3% of the cases, whereas 73.7% of the patients did not report a difference. None of the patients reported worse relationships

Manieri et al., 2014

Manieri, C., Castellano, E., Crespi, C., Di Bisceglie, C., Dell’Aquila, C., et al. (2014). Medical treatment of subjects with gender identity disorder: The experience in an Italian public health center. International Journal Of Transgenderism , 15 (2), 53-65.

Hormonal treatment is the main element during the transition program for transpeople. The aim of this paper is to describe the care and treatment of subjects, highlighting both the endocrine-metabolic effects of the hormonal therapy and the quality of life during the first year of cross-sex therapy in an Italian gender team. We studied 83 subjects (56 male-to-female [MtF], 27 female-to-male [FtM]) with hematological and hormonal evaluations every 3 months during the first year of hormonal therapy. MtF persons were treated with 17βestradiol and antiandrogens (cyproterone acetate, spironolactone, dutasteride); FtM persons were treated with transdermal or intramuscular testosterone. The WHO Quality of Life questionnaire was administered at the beginning and 1 year later. Hormonal changes paralleled phenotype modifications with wide variability. Most of both MtF and FtM subjects reported a statistically significant improvement in body image (p < 0.05). In particular, MtF subjects reported a statistically significant improvement in the quality of their sexual life and in the general quality of life (p < 0.05) 1 year after treatment initiation. Cross-sex therapy seems to be free of major risks in healthy subjects under clinical supervision during the first year. Selected subjects show an optimal adaptation to hormone-induced neuropsychological modifications and satisfaction regarding general and sexual life.

Megeri and Khoosal, 2007

Megeri, D., & Khoosal, D. (2007). Anxiety and depression in males experiencing gender dysphoria. Sexual & Relationship Therapy , 22 (1), 77-81.

Objective: The aim of the study was to compare anxiety and depression scores for the first 40 male to female people experiencing gender dysphoria attending the Leicester Gender Identity Clinic using the same sample as control pre and post gender realignment surgery. Hypothesis: There is an improvement in the scores of anxiety and depression following gender realignment surgery among people with gender dysphoria (male to female – transwomen). Results: There was no significant change in anxiety and depression scores in people with gender dysphoria (male to female) pre- and post-operatively.

Nelson, Whallett, & Mcgregor, 2009

Nelson, L., Whallett, E., & McGregor, J. (2009). Transgender patient satisfaction following reduction mammaplasty. Journal of Plastic, Reconstructive & Aesthetic Surgery , 62 (3), 331-334.

Aim: To evaluate the outcome of reduction mammaplasty in female-to-male transgender patients. Method: A 5-year retrospective review was conducted on all female-to-male transgender patients who underwent reduction mammaplasty. A postal questionnaire was devised to assess patient satisfaction, surgical outcome and psychological morbidity. Results: Seventeen patients were identified. The senior author performed bilateral reduction mammaplasties and free nipple grafts in 16 patients and one patient had a Benelli technique reduction. Complications included two haematomas, one wound infection, one wound dehiscence and three patients had hypertrophic scars. Secondary surgery was performed in seven patients and included scar revision, nipple reduction/realignment, dog-ear correction and nipple tattooing. The mean follow-up period after surgery was 10 months (range 2–23 months). Twelve postal questionnaires were completed (response rate 70%). All respondents expressed satisfaction with their result and no regret. Seven patients had nipple sensation and nine patients were satisfied with nipple position. All patients thought their scars were reasonable and felt that surgery had improved their self-confidence and social interactions. Conclusion: Reduction mammaplasty for female-to-male gender reassignment is associated with high patient satisfaction and a positive impact on the lives of these patients.

Newfield et al., 2006

Newfield, E., Hart, S., Dibble, S., & Kohler, L. (2006). Female-to-male transgender quality of life. Quality of Life Research , 15 (9), 1447-1457.

Objectives: We evaluated health-related quality of life in female-to-male (FTM) transgender individuals, using the Short-Form 36-Question Health Survey version 2 (SF-36v2). Methods: Using email, Internet bulletin boards, and postcards, we recruited individuals to an Internet site ( http://www.transurvey.org ), which contained a demographic survey and the SF36v2. We enrolled 446 FTM transgender and FTM transsexual participants, of which 384 were from the US. Results: Analysis of quality of life health concepts demonstrated statistically significant (p<0.0\) diminished quality of life among the FTM transgender participants as compared to the US male and female population, particularly in regard to mental health. FTM transgender participants who received testosterone (67%) reported statistically significant higher quality of life scores (/?<0.01) than those who had not received hormone therapy. Conclusions: FTM transgender participants reported significantly reduced mental health-related quality of life and

Padula, Heru, & Campbell, 2016

Padula, W. V., Heru, S. & Campbell, J. D. (2016). Societal implications of health insurance coverage for medically necessary services in the U.S. transgender population: A cost-effectiveness analysis. Journal of General Internal Medicine , 31 ( 4), 394-401.

Background: Recently, the Massachusetts Group Insurance Commission (GIC) prioritized research on the implications of a clause expressly prohibiting the denial of health insurance coverage for transgender-related services. These medically necessary services include primary and preventive care as well as transitional therapy. Objective: To analyze the cost-effectiveness of insurance coverage for medically necessary transgender-related services. Design: Markov model with 5- and 10-year time horizons from a U.S. societal perspective, discounted at 3 % (USD 2013). Data on outcomes were abstracted from the 2011 National Transgender Discrimination Survey (NTDS). Patients: U.S. transgender population starting before transitional therapy. Interventions: No health benefits compared to health insurance coverage for medically necessary services. This coverage can lead to hormone replacement therapy, sex reassignment surgery, or both. Main Measures: Cost per quality-adjusted life year (QALY) for successful transition or negative outcomes (e.g. HIV, depression, suicidality, drug abuse, mortality) dependent on insurance coverage or no health benefit at a willingness-to-pay threshold of $100,000/QALY. Budget impact interpreted as the U.S. per-member-per-month cost. Key Results: Compared to no health benefits for transgender patients ($23,619; 6.49 QALYs), insurance coverage for medically necessary services came at a greater cost and effectiveness ($31,816; 7.37 QALYs), with an incremental cost-effectiveness ratio (ICER) of $9314/QALY. The budget impact of this coverage is approximately $0.016 per member per month. Although the cost for transitions is $10,000–22,000 and the cost of provider coverage is $2175/year, these additional expenses hold good value for reducing the risk of negative endpoints —HIV, depression, suicidality, and drug abuse. Results were robust to uncertainty. The probabilistic sensitivity analysis showed that provider coverage was cost-effective in 85 % of simulations. Conclusions: Health insurance coverage for the U.S. transgender population is affordable and cost-effective, and has a low budget impact on U.S. society. Organizations such as the GIC should consider these results when examining policies regarding coverage exclusions.

Parola et al., 2010

Parola, N., Bonierbale, M., Lemaire, A., Aghababian, V., Michel, A., & Lançon, C. (2010). Study of quality of life for transsexuals after hormonal and surgical reassignment. Sexologies , 19 (1), 24-28.

Aim: The main objective of this work is to provide a more detailed assessment of the impact of surgical reassignment on the most important aspects of daily life for these patients. Our secondary objective was to establish the influence of various factors likely to have an impact on the quality of life (QoL), such as biological gender and the subject’s personality. Methods: A personality study was conducted using Eysenck Personality Inventory (EPI) so as to analyze two aspects of the personality (extraversion and neuroticism). Thirty-eight subjects who had undergone hormonal surgical reassignment were included in the study. Results: The results show that gender reassignment surgery improves the QoL for transsexuals in several different important areas: most are satisfied of their sexual reassignment (28/30), their social (21/30) and sexual QoL (25/30) are improved. However, there are differences between male-to-female (MtF) and female-to-male (FtM) transsexuals in terms of QoL: FtM have a better social, professional, friendly lifestyles than MtF. Finally, the results of this study did not evidence any influence by certain aspects of the personality, such as extraversion and neuroticism, on the QoL for reassigned subjects.

Pfäfflin, 1993

Pfäfflin, F. (1993). Regrets after sex reassignment surgery. Journal of Psychology & Human Sexuality , 5 (4), 69-85.

Using data draw from the follow-up literature covering the last 30 years, and the author’s clinical data on 295 men and women after SRS, an estimation of the number of patients who regretted the operations is made. Among female-to-male transsexuals after SRS, i.e., in men, no regrets were reported in the author’s sample, and in the literature they amount to less than 1%. Among male-to- female transsexuals after SRS, i.e., in women, regrets are reported in 1-1.5%. Poor differential diagnosis, failure to carry out the real-life- test, and poor surgical results seem to be the main reasons behind the regrets reported in the literature. According to three cases observed by the author in addition to personality traits the lack of proper care in treating the patients played a major role.

Pimenoff and Pfäfflin, 2011

Pimenoff, V., & Pfäfflin, F. (2011). Transsexualism: Treatment outcome of compliant and noncompliant patients. International Journal Of Transgenderism , 13 (1), 37-44.

The objective of the study was a follow-up of the treatment outcome of Finnish transsexuals who sought sex reassignment during the period 1970–2002 and a comparison of the results and duration of treatment of compliant and noncompliant patients. Fifteen male-to-female transsexuals and 17 female-to-male transsexuals who had undergone hormone and surgical treatment and legal sex reassignment in Finland completed a questionnaire on psychosocial data and on their experience with the different phases of clinical assessment and treatment. The changes in their vocational functioning and social and psychic adjustment were used as outcome indicators. The results and duration of the treatment of compliant and noncompliant patients were compared. The patients benefited significantly from treatment. The noncompliant patients achieved equally good results as the compliant ones, and did so in a shorter time. A good treatment outcome could be achieved even when the patient had told the assessing psychiatrist a falsified story of his life and sought hormone therapy, genital surgery, or legal sex reassignment on his own initiative without a recommendation from the psychiatrist. Based on these findings, it is recommended that the doctor-patient relationship be reconsidered and founded on frank cooperation.

Rakic et al., 1996

Rakic, Z., Starcevic, V., Maric, J., & Kelin, K. (1996). The outcome of sex reassignment surgery in Belgrade: 32 patients of both sexes. Archives of Sexual Behavior , 25 (5), 515-525.

Several aspects of the quality of life after sex reassignment surgery in 32 transsexuals of both sexes (22 men, 10 women) were examined. The Belgrade Team for Gender Identity Disorders designed a standardized questionnaire for this purpose. The follow-up period after operation was from 6 months to 4 years, and four aspects of the quality of life were examined: attitude towards the patients’ own body, relationships with other people, sexual activity, and occupational functioning. In most transsexuals, the quality of life was improved after surgery inasmuch as these four aspects are concerned. Only a few transsexuals were not satisfied with their life after surgery.

Rehman et al., 1999

Rehman, J., Lazer, S., Benet, A. E., Schaefer, L. C., & Melman, A. (1999). The reported sex and surgery satisfactions of 28 postoperative male-to-female transsexual patients. Archives of Sexual Behavior , 28 (1), 71-89.

From 1980 to July 1997 sixty-one male-to-female gender transformation surgeries were performed at our university center by one author (A.M.). Data were collected from patients who had surgery up to 1994 (n = 47) to obtain a minimum follow-up of 3 years; 28 patients were contacted. A mail questionnaire was supplemented by personal interviews with 11 patients and telephone interviews with remaining patients to obtain and clarify additional information. Physical and functional results of surgery were judged to be good, with few patients requiring additional corrective surgery. General satisfaction was expressed over the quality of cosmetic (normal appearing genitalia) and functional (ability to perceive orgasm) results. Follow-up showed satisfied who believed they had normal appearing genitalia and the ability to experience orgasm. Most patients were able to return to their jobs and live a more satisfactory social and personal life. One significant outcome was the importance of proper preparation of patients for surgery and especially the need for additional postoperative psychotherapy. None of the patients regretted having had surgery. However, some were, to a degree, disappointed because of difficulties experienced post operatively in adjusting satisfactorily as women both in their relationships with men and in living their lives generally as women. Findings of this study make a strong case for making a change in the Harry Benjamin Standards of Care to include a period of postoperative psychotherapy.

Rotondi et al., 2011

Rotondi, N. K., Bauer, G. R., Scanlon, K., Kaay, M., Travers, R., & Travers, A. (2011). Prevalence of and risk and protective factors for depression in female-to-male transgender Ontarians: Trans PULSE Project. Canadian Journal Of Community Mental Health , 30 (2), 135-155.

Although depression is understudied in transgender and transsexual communities, high prevalences have been reported. This paper presents original research from the Trans PULSE Project, an Ontario-wide, community-based initiative that surveyed 433 participants using respondent-driven sampling. The purpose of this analysis was to determine the prevalence of, and risk and protective factors for, depression among female-to-male (FTM) Ontarians (n = 207). We estimate that 66.4% of FTMs have symptomatology consistent with depression. In multivariable analyses, sexual satisfaction was a strong protective factor. Conversely, experiencing transphobia and being at the stage of planning but not having begun a medical transition (hormones and/or surgery) adversely affected mental health in FTMs.

Ruppin and Pfäfflin, 2015

Ruppin, U., & Pfäfflin, F. (2015). Long-term follow-up of adults with gender identity disorder. Archives of Sexual Behavior , 44 (5), 1321-1329.

The aim of this study was to re-examine individuals with gender identity disorder after as long a period of time as possible. To meet the inclusion criterion, the legal recognition of participants’ gender change via a legal name change had to date back at least 10 years. The sample comprised 71 participants (35 MtF and 36 FtM). The follow-up period was 10–24 years with a mean of 13.8 years (SD = 2.78). Instruments included a combination of qualitative and quantitative methods: Clinical interviews were conducted with the participants, and they completed a follow-up questionnaire as well as several standardized questionnaires they had already filled in when they first made contact with the clinic. Positive and desired changes were determined by all of the instruments: Participants reported high degrees of well-being and a good social integration. Very few participants were unemployed, most of them had a steady relationship, and they were also satisfied with their relationships with family and friends. Their overall evaluation of the treatment process for sex reassignment and its effectiveness in reducing gender dysphoria was positive. Regarding the results of the standardized questionnaires, participants showed significantly fewer psychological problems and interpersonal difficulties as well as a strongly increased life satisfaction at follow-up than at the time of the initial consultation. Despite these positive results, the treatment of transsexualism is far from being perfect.

Smith et al., 2005

Smith, Y. L. S., Van Goozen, S. H. M., Kuiper, A. J., & Cohen-Kettenis, P. (2005). Sex reassignment: Outcomes and predictors of treatment for adolescent and adult transsexuals. Psychological Medicine, 35 (1), 89-99.

Background: We prospectively studied outcomes of sex reassignment, potential differences between subgroups of transsexuals, and predictors of treatment course and outcome. Method: Altogether 325 consecutive adolescent and adult applicants for sex reassignment participated: 222 started hormone treatment, 103 did not; 188 completed and 34 dropped out of treatment. Only data of the 162 adults were used to evaluate treatment. Results between subgroups were compared to determine post-operative differences. Adults and adolescents were included to study predictors of treatment course and outcome. Results were statistically analysed with logistic regression and multiple linear regression analyses. Results: After treatment the group was no longer gender dysphoric. The vast majority functioned quite well psychologically, socially and sexually. Two non-homosexual male-to-female transsexuals expressed regrets. Post-operatively, female-to-male and homosexual transsexuals functioned better in many respects than male-to-female and non-homosexual transsexuals. Eligibility for treatment was largely based upon gender dysphoria, psychological stability, and physical appearance. Male-to-female transsexuals with more psychopathology and cross-gender symptoms in childhood, yet less gender dysphoria at application, were more likely to drop out prematurely. Non-homosexual applicants with much psychopathology and body dissatisfaction reported the worst post-operative outcomes. Conclusions: The results substantiate previous conclusions that sex reassignment is effective. Still, clinicians need to be alert for non-homosexual male-to-females with unfavourable psychological functioning and physical appearance and inconsistent gender dysphoria reports, as these are risk factors for dropping out and poor post-operative results. If they are considered eligible, they may require additional therapeutic guidance during or even after treatment.

van de Grift et al., 2017

van de Grift, T. C., Elaut, E., Cerwenka, S. C., Cohen-Kettenis, P. T., Cuypere, G. D., Richter-Appelt, H., & Kreukels, B. P. (2017). Effects of medical interventions on gender dysphoria and body image. Psychosomatic Medicine , 79 (7), 815-823.

Objective: The aim of this study from the European Network for the Investigation of Gender Incongruence is to investigate the status of all individuals who had applied for gender confirming interventions from 2007 to 2009, irrespective of whether they received treatment. The current article describes the study protocol, the effect of medical treatment on gender dysphoria and body image, and the predictive value of (pre)treatment factors on posttreatment outcomes. Methods: Data were collected on medical interventions, transition status, gender dysphoria (Utrecht Gender Dysphoria Scale), and body image (Body Image Scale for transsexuals). In total, 201 people participated in the study (37% of the original cohort). Results: At follow-up, 29 participants (14%) did not receive medical interventions, 36 hormones only (18%), and 136 hormones and surgery (68%). Most transwomen had undergone genital surgery, and most transmen chest surgery. Overall, the levels of gender dysphoria and body dissatisfaction were significantly lower at follow-up compared with clinical entry. Satisfaction with therapy responsive and unresponsive body characteristics both improved. High dissatisfaction at admission and lower psychological functioning at follow-up were associated with persistent body dissatisfaction. Conclusions: Hormone-based interventions and surgery were followed by improvements in body satisfaction. The level of psychological symptoms and the degree of body satisfaction at baseline were significantly associated with body satisfaction at follow-up.

van de Grift, T. C., Elaut, E., Cerwenka, S. C., Cohen-Kettenis, P. T., & Kreukels, B. P. (2017). Surgical satisfaction, quality of life, and their association after gender-affirming surgery: A follow-up study. Journal of Sex & Marital Therapy , 44 (2), 138-148.

We assessed the outcomes of gender-affirming surgery (GAS, or sex-reassignment surgery) 4 to 6 years after first clinical contact, and the associations between postoperative (dis)satisfaction and quality of life (QoL). Our multicenter, cross-sectional follow-up study involved persons diagnosed with gender dysphoria (DSM-IV-TR) who applied for medical interventions from 2007 until 2009. Of 546 eligible persons, 201 (37%) responded, of whom 136 had undergone GAS (genital, chest, facial, vocal cord and/or thyroid cartilage surgery). Main outcome measures were procedure performed, self-reported complications, and satisfaction with surgical outcomes (standardized questionnaires), QoL (Satisfaction With Life Scale, Subjective Happiness Scale, Cantril Ladder), gender dysphoria (Utrecht Gender Dysphoria Scale), and psychological symptoms (Symptom Checklist-90). Postoperative satisfaction was 94% to 100%, depending on the type of surgery performed. Eight (6%) of the participants reported dissatisfaction and/or regret, which was associated with preoperative psychological symptoms or self-reported surgical complications (OR= 6.07). Satisfied respondents’ QoL scores were similar to reference values; dissatisfied or regretful respondents’ scores were lower. Therefore, dissatisfaction after GAS may be viewed as indicator of unfavorable psychological and QoL outcomes.

Vujovic et al., 2009

Vujovic, S., Popovic, S., Sbutega-Milosevic, G., Djordjevic, M., & Gooren, L. (2009). Transsexualism in Serbia: A twenty-year follow-up study. The Journal of Sexual Medicine , 6 (4), 1018-1023.

Introduction: Gender dysphoria occurs in all societies and cultures. The prevailing social context has a strong impact on its manifestations as well as on applications by individuals with the condition for sex reassignment treatment. Aim: To describe a transsexual population seeking sex reassignment treatment in Serbia, part of former Yugoslavia. Methods: Data, collated over a period of 20 years, from subjects applying for sex reassignment to the only center in Serbia, were analyzed retrospectively. Main Outcome Measures: Age at the time of application, demographic data, family background, sex ratio, the prevalence of polycystic ovarian syndrome (PCOS) among female-to-male (FTM) transsexuals, and readiness to undergo surgical sex reassignment were tabulated. Results: Applicants for sex reassignment in Serbia are relatively young. The sex ratio is close to 1:1. They often come from single-child families. More than 10% do not wish to undergo surgical sex reassignment. The prevalence of PCOS among FTM transsexuals was higher than in the general population but considerably lower than that reported in the literature from other populations. Of those who had undergone sex reassignment, none expressed regret for their decision. Conclusions: Although transsexualism is a universal phenomenon, the relatively young age of those applying for sex reassignment and the sex ratio of 1:1 distinguish the population in Serbia from others reported in the literature.

Weigert et al., 2013

Weigert, R., Frison, E., Sessiecq, Q., Al Mutairi, K., & Casoli, V. (2013). Patient satisfaction with breasts and psychosocial, sexual, and physical well-being after breast augmentation in male-to-female transsexuals. Plastic and Reconstructive Surgery, 132 (6), 1421-1429.

Background: Satisfaction with breasts, sexual well-being, psychosocial well-being, and physical well-being are essential outcome factors following breast augmentation surgery in male-to-female transsexual patients. The aim of this study was to measure change in patient satisfaction with breasts and sexual, physical, and psychosocial well-being after breast augmentation in male-to-female transsexual patients. Methods: All consecutive male-to-female transsexual patients who underwent breast augmentation between 2008 and 2012 were asked to complete the BREAST-Q Augmentation module questionnaire before surgery, at 4 months, and later after surgery. A prospective cohort study was designed and postoperative scores were compared with baseline scores. Satisfaction with breasts and sexual, physical, and psychosocial outcomes assessment was based on the BREAST-Q. Results: Thirty-five male-to-female transsexual patients completed the questionnaires. BREAST-Q subscale median scores (satisfaction with breasts, +59 points; sexual well-being, +34 points; and psychosocial well-being, +48 points) improved significantly (p < 0.05) at 4 months postoperatively and later. No significant change was observed in physical well-being. Conclusions: In this prospective, noncomparative, cohort study, the current results suggest that the gains in breast satisfaction, psychosocial well-being, and sexual well-being after male-to-female transsexual patients undergo breast augmentation are statistically significant and clinically meaningful to the patient at 4 months after surgery and in the long term.

Weyers et al., 2009

Weyers, S., Elaut, E., De Sutter, P., Gerris, J., T’Sjoen, G., et al. (2009). Long-term assessment of the physical, mental, and sexual health among transsexual women. The Journal of Sexual Medicine , 6 (3), 752-760.

Introduction: Transsexualism is the most extreme form of gender identity disorder and most transsexuals eventually pursue sex reassignment surgery (SRS). In transsexual women, this comprises removal of the male reproductive organs, creation of a neovagina and clitoris, and often implantation of breast prostheses. Studies have shown good sexual satisfaction after transition. However, long-term follow-up data on physical, mental and sexual functioning are lacking. Aim: To gather information on physical, mental, and sexual well-being, health-promoting behavior and satisfaction with gender-related body features of transsexual women who had undergone SRS. Methods: Fifty transsexual women who had undergone SRS >or=6 months earlier were recruited. Main Outcome Measures: Self-reported physical and mental health using the Dutch version of the Short-Form-36 (SF-36) Health Survey; sexual functioning using the Dutch version of the Female Sexual Function Index (FSFI). Satisfaction with gender-related bodily features as well as with perceived female appearance; importance of sex, relationship quality, necessity and advisability of gynecological exams, as well as health concerns and feelings of regret concerning transition were scored. Results: Compared with reference populations, transsexual women scored good on physical and mental level (SF-36). Gender-related bodily features were shown to be of high value. Appreciation of their appearance as perceived by others, as well as their own satisfaction with their self-image as women obtained a good score (8 and 9, respectively). However, sexual functioning as assessed through FSFI was suboptimal when compared with biological women, especially the sublevels concerning arousal, lubrication, and pain. Superior scores concerning sexual function were obtained in those transsexual women who were in a relationship and in heterosexuals. Conclusions: Transsexual women function well on a physical, emotional, psychological and social level. With respect to sexuality, they suffer from specific difficulties, especially concerning arousal, lubrication, and pain.

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Below are 4 studies that contain mixed or null findings on the effect of gender transition on transgender well-being. Click here to jump to the 17 studies that consist of literature reviews or guidelines that help advance knowledge about the effect of gender transition on transgender well-being . Click here to jump to the 51 studies that found that gender transition improves the well-being of transgender people .

Barrett, 1998.

Barrett J. (1998). Psychological and social function before and after phalloplasty. The International Journal of Transgenderism , 2 (1), 1-8.

There are no quantitative assessments of the benefits of phalloplasty in a female transsexual population. The study addresses this question, comparing transsexuals accepted for such surgery with transsexuals after such surgery has been performed. A population of 23 transsexuals accepted for phalloplasty was compared to a population of 40 who had undergone such surgery between six and one hundred and sixty months previously. The General Health Questionnaire (GHQ), Symptom Checklist 90 (SCL-90), Bem Sex Role Inventory and Social Role Performance Schedule (SRPS) were employed. Additionally, a questionnaire assessing satisfaction with cosmetic appearance, sexual function, relationship and urinary function was used, along with a semi-structured interview quantifying alcohol, cigarette and drug usage, and current sexual practice. There were significant differences between the populations. The post operative group showed higher depression ratings on the depression subscale of the GHQ. The masculine pre-operative Bem scores were neutral post-operatively as feminine sub-scores increased. There was improved satisfaction with genital appearance post-operatively, but satisfaction with relationships fell, although to a non-significant extent. Most other changes were in the expected direction but did not achieve significance. Transsexuals accepted for phalloplasty have very good psychological health. Tendency to further improvement is the case after phalloplasty. Depression is commoner, however, and quality of relationships declines somewhat, perhaps in consequence. Surgeons might advise partners as well as patients of realistic expectations from such surgery.

Lindqvist et al., 2017

Lindqvist, E. K., Sigurjonsson, H., Möllermark, C., Rinder, J., Farnebo, F., et al. (2017). Quality of life improves early after gender reassignment surgery in transgender women. European Journal of Plastic Surgery , 40 (3), 223-226.

Background: Few studies have examined the long-term quality of life (QoL) of individuals with gender dysphoria, or how it is affected by treatment. Our aim was to examine the QoL of transgender women undergoing gender reassignment surgery (GRS). Methods: We performed a prospective cohort study on 190 patients undergoing male-to-female GRS at Karolinska University Hospital between 2003 and 2015. We used the Swedish version of the Short Form-36 Health Survey (SF-36), which measures QoL across eight domains. The questionnaire was distributed to patients pre-operatively, as well as 1, 3, and 5 years post-operatively. The results were compared between the different measure points, as well as between the study group and the general population. Results: On most dimensions of the SF-36 questionnaire, transgender women reported a lower QoL than the general population. The scores of SF-36 showed a non-significant trend to be lower 5 years post-GRS compared to pre-operatively, a decline consistent with that of the general population. Self-perceived health compared to 1 year previously rose in the first post-operative year, after which it declined. Conclusions: To our knowledge, this is the largest prospective study to follow a group of transgender patients with regards to QoL over continuous temporal measure points. Our results show that transgender women generally have a lower QoL compared to the general population. GRS leads to an improvement in general well-being as a trend but over the long-term, QoL decreases slightly in line with that of the comparison group. Level of evidence: Level III, therapeutic study.

Simonsen et al., 2016

Simonsen, R. K., Giraldi, A., Kristensen, E., & Hald, G. M. (2016). Long-term follow-up of individuals undergoing sex reassignment surgery: Psychiatric morbidity and mortality. Nordic Journal Of Psychiatry , 70 (4), 241-247.

Background: There is a lack of long-term register-based follow-up studies of sex-reassigned individuals concerning mortality and psychiatric morbidity. Accordingly, the present study investigated both mortality and psychiatric morbidity using a sample of individuals with transsexualism which comprised 98% (n = 104) of all individuals in Denmark. Aims: (1) To investigate psychiatric morbidity before and after sex reassignment surgery (SRS) among Danish individuals who underwent SRS during the period of 1978–2010. (2) To investigate mortality among Danish individuals who underwent SRS during the period of 1978–2010.Method: Psychiatric morbidity and mortality were identified by data from the Danish Psychiatric Central Research Register and the Cause of Death Register through a retrospective register study of 104 sex-reassigned individuals. Results: Overall, 27.9% of the sample were registered with psychiatric morbidity before SRS and 22.1% after SRS (p = not significant). A total of 6.7% of the sample were registered with psychiatric morbidity both before and after SRS. Significantly more psychiatric diagnoses were found before SRS for those assigned as female at birth. Ten individuals were registered as deceased post-SRS with an average age of death of 53.5 years. Conclusions: No significant difference in psychiatric morbidity or mortality was found between male to female and female to male (FtM) save for the total number of psychiatric diagnoses where FtM held a significantly higher number of psychiatric diagnoses overall. Despite the over-representation of psychiatric diagnoses both pre- and post-SRS the study found that only a relatively limited number of individuals had received diagnoses both prior to and after SRS. This suggests that generally SRS may reduce psychological morbidity for some individuals while increasing it for others.

Udeze, 2008

Udeze, B., Abdelmawla, N., Khoosal, D., & Terry, T. (2008). Psychological functions in male-to-female transsexual people before and after surgery. Sexual & Relationship Therapy , 23 (2), 141-145.

Patients with gender dysphoria (GD) suffer from a constant feeling of psychological discomfort related to their anatomical sex. Gender reassignment surgery (GRS) attempts to release this discomfort. The aim of this study was to compare the functioning of a cohort or patients with GD before and after GRS. We hypothesized that there would be an improvement in the scores of the self-administered SCL-90R following gender reassignment surgery among male-to-female people with gender dysphoria. We studied 40 patients with a DSM-IV diagnosis of Gender Identity Disorder (GID) who attended Leicester Gender Identity Clinic. We compared their functioning as measured by Symptom Check List-90R (SCL-90R) which was administered to 40 randomly selected male-to-female patients before and within six months after GRS using the same sample as control pre-and post-surgery. There was no significant change in the different sub-scales of the SCL-90R scores in patients with male-to-female GID pre- and within six months post-surgery. The results of the study showed that GRS had no significant effect on functioning as measured by SCL-90R within six months of surgery. Our study has the advantage of reducing inter-subject variability by using the same patients as their own control. This study may be limited by the duration of reassessment post-surgery. Further studies with larger sample size and using other psychosocial scales are needed to elucidate on the effectiveness of surgical intervention on psychosocial parameters in patients with GD.

Below are 17 studies that consist of literature reviews or guidelines that help advance knowledge about the effect of gender transition on transgender well-being. Click here to jump to the 4 studies that contain mixed or null findings on the effect of gender transition on transgender well-being. Click here Click here to jump to the 51 studies that found that gender transition improves the well-being of transgender people .

American psychological, 2015.

Guidelines for psychological practice with transgender and gender nonconforming people. (2015). American Psychologist, 70 (9), 832-864.

In 2015, the American Psychological Association adopted Guidelines for Psychological Practice with Transgender and Gender Nonconforming Clients in order to describe affirmative psychological practice with transgender and gender nonconforming (TGNC) clients. There are 16 guidelines in this document that guide TGNC-affirmative psychological practice across the lifespan, from TGNC children to older adults. The Guidelines are organized into five clusters: (a) foundational knowledge and awareness; (b) stigma, discrimination, and barriers to care; (c) lifespan development; (d) assessment, therapy, and intervention; and (e) research, education, and training. In addition, the guidelines provide attention to TGNC people across a range of gender and racial/ethnic identities. The psychological practice guidelines also attend to issues of research and how psychologists may address the many social inequities TGNC people experience.

Bockting et al., 2016

Bockting, W., Coleman, E., Deutsch, M. B., Guillamon, A., Meyer, W., et al. (2016). Adult development and quality of life of transgender and gender nonconforming people. Current Opinion in Endocrinology & Diabetes and Obesity , 23 (2), 188–197.

Purpose of review: Research on the health of transgender and gender nonconforming people has been limited with most of the work focusing on transition-related care and HIV. The present review summarizes research to date on the overall development and quality of life of transgender and gender nonconforming adults, and makes recommendations for future research. Recent findings: Pervasive stigma and discrimination attached to gender nonconformity affect the health of transgender people across the lifespan, particularly when it comes to mental health and well-being. Despite the related challenges, transgender and gender nonconforming people may develop resilience over time. Social support and affirmation of gender identity play herein a critical role. Although there is a growing awareness of diversity in gender identity and expression among this population, a comprehensive understanding of biopsychosocial development beyond the gender binary and beyond transition is lacking. Summary: Greater visibility of transgender people in society has revealed the need to understand and promote their health and quality of life broadly, including but not limited to gender dysphoria and HIV. This means addressing their needs in context of their families and communities, sexual and reproductive health, and successful aging. Research is needed to better understand what factors are associated with resilience and how it can be effectively promoted.

Byne et al., 2012

Byne, W., Bradley, S.J., Coleman, E., et al. (2012). Report of the American Psychiatric Association task force on treatment of gender identity disorder. Archives of Sexual Behavior, 41 (4): 759–796.

Both the diagnosis and treatment of Gender Identity Disorder (GID) are controversial. Although linked, they are separate issues and the DSM does not evaluate treatments. The Board of Trustees (BOT) of the American Psychiatric Association (APA), therefore, formed a Task Force charged to perform a critical review of the literature on the treatment of GID at different ages, to assess the quality of evidence pertaining to treatment, and to prepare a report that included an opinion as to whether or not sufficient credible literature exists for development of treatment recommendations by the APA. The literature on treatment of gender dysphoria in individuals with disorders of sex development was also assessed. The completed report was accepted by the BOT on September 11, 2011. The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups. With subjective improvement as the primary outcome measure, current evidence was judged sufficient to support recommendations for adults in the form of an evidence-based APA Practice Guideline with gaps in the empirical data supplemented by clinical consensus. The report recommends that the APA take steps beyond drafting treatment recommendations. These include issuing position statements to clarify the APA’s position regarding the medical necessity of treatments for GID, the ethical bounds of treatments of gender variant minors, and the rights of persons of any age who are gender variant, transgender or transsexual.

Carroll, 1999

Carroll, R. A. (1999). Outcomes of treatment for gender dysphoria. Journal of Sex Education and Therapy , 24 (3), 128–136.

This paper reviews the empirical research on the psychosocial outcomes of treatment for gender dysphoria. Recent research has highlighted the heterogeneity of transgendered experiences. There are four possible outcomes for patients who present with the dilemma of gender dysphoria: an unresolved outcome, acceptance of one’s given gender, engaging in a cross-gender role on a part-time basis, and making a full-time transition to the other gender role. Clinical work, but not empirical research, suggests that some individuals with gender dysphoria may come to accept their given gender role through psychological treatment. Many individuals find that it is psychologically sufficient to express the transgendered part of themselves through such activities as cross-dressing or gender blending. The large body of research on the outcome of gender reassignment surgery indicates that, for the majority of those who undergo this process, the outcome is positive. Predictors of a good outcome include good pre-reassignment psychological adjustment, family support, at least 1 year of living in the desired role, consistent use of hormones, psychological treatment, and good surgical outcomes. The outcome literature provides strong support for adherence to the Standards of Care of the Harry Benjamin International Gender Dysphoria Association. Implications to be drawn from this research include an appreciation of the diversity of transgendered experience, the need for more research on non-reassignment resolutions to gender dysphoria, and the importance of assisting the transgendered individual to identify the resolution that best suits him or her.

Cohen-Kettenis and Gooren, 1999

Cohen-Kettenis, P. T., & Gooren, L. J. G. (1999). Transsexualism: A review of etiology, diagnosis and treatment. Journal of Psychosomatic Research , 46 (4), 315-333.

Transsexualism is considered to be the extreme end of the spectrum of gender identity disorders characterized by, among other things, a pursuit of sex reassignment surgery (SRS). The origins of transsexualism are still largely unclear. A first indication of anatomic brain differences between transsexuals and nontranssexuals has been found. Also, certain parental (rearing) factors seem to be associated with transsexualism. Some contradictory findings regarding etiology, psychopathology and success of SRS seem to be related to the fact that certain subtypes of transsexuals follow different developmental routes. The observations that psychotherapy is not helpful in altering a crystallized cross-gender identity and that certain transsexuals do not show severe psychopathology has led clinicians to adopt sex reassignment as a treatment option. In many countries, transsexuals are now treated according to the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, a professional organization in the field of transsexualism. Research on postoperative functioning of transsexuals does not allow for unequivocal conclusions, but there is little doubt that sex reassignment substantially alleviates the suffering of transsexuals. However, SRS is no panacea. Psychotherapy may be needed to help transsexuals in adapting to the new situation or in dealing with issues that could not be addressed before treatment.

Coleman et al., 2012

Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., et al. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism , 13 (4), 165-232.

The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People is a publication of the World Professional Association for Transgender Health (WPATH). The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments. The SOC are based on the best available science and expert professional consensus. Because most of the research and experience in this field comes from a North American and Western European perspective, adaptations of the SOC to other parts of the world are necessary. The SOC articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, this version of the SOC recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized. Some individuals who present for care will have made significant self-directed progress towards gender role changes or other resolutions regarding their gender identity or gender dysphoria. Other individuals will require more intensive services. Health professionals can use the SOC to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression.

Committee on Health Care for Underserved, 2011

Committee Opinion No. 512: Health Care for Transgender Individuals. (2011). Obstetrics & Gynecology , 118 (6), 1454–1458.

Transgender individuals face harassment, discrimination, and rejection within our society. Lack of awareness, knowledge, and sensitivity in health care communities eventually leads to inadequate access to, underutilization of, and disparities within the health care system for this population. Although the care for these patients is often managed by a specialty team, obstetrician–gynecologists should be prepared to assist or refer transgender individuals with routine treatment and screening as well as hormonal and surgical therapies. The American College of Obstetricians and Gynecologists opposes discrimination on the basis of gender identity and urges public and private health insurance plans to cover the treatment of gender identity disorder.

Costa and Colizzi, 2016

Costa, R., & Colizzi, M. (2016). The effect of cross-sex hormonal treatment on gender dysphoria individuals’ mental health: A systematic review. Neuropsychiatric Disease and Treatment , 12 , 1953-1966.

Cross-sex hormonal treatment represents a main aspect of gender dysphoria health care pathway. However, it is still debated whether this intervention translates into a better mental well-being for the individual and which mechanisms may underlie this association. Although sex reassignment surgery has been the subject of extensive investigation, few studies have specifically focused on hormonal treatment in recent years. Here, we systematically review all studies examining the effect of cross-sex hormonal treatment on mental health and well-being in gender dysphoria. Research tends to support the evidence that hormone therapy reduces symptoms of anxiety and dissociation, lowering perceived and social distress and improving quality of life and self-esteem in both male-to-female and female-to-male individuals. Instead, compared to female-to-male individuals, hormone-treated male-to-female individuals seem to benefit more in terms of a reduction in their body uneasiness and personality-related psychopathology and an amelioration of their emotional functioning. Less consistent findings support an association between hormonal treatment and other mental health-related dimensions. In particular, depression, global psychopathology, and psychosocial functioning difficulties appear to reduce only in some studies, while others do not suggest any improvement in these domains. Results from longitudinal studies support more consistently the association between hormonal treatment and improved mental health. On the contrary, a number of cross-sectional studies do not support this evidence. This review provides possible biological explanation vs psychological explanation (direct effect vs indirect effect) for the hormonal treatment-induced better mental well-being. In conclusion, this review indicates that gender dysphoria-related mental distress may benefit from hormonal treatment intervention, suggesting a transient reaction to the nonsatisfaction connected to the incongruent body image rather than a stable psychiatric comorbidity. In this perspective, timely hormonal treatment intervention represents a crucial issue in gender dysphoria individuals’ mental health-related outcome.

Dhejne et al., 2016

Dhejne, C., Van Vlerken, R., Heylens, G., & Arcelus, J. (2016). Mental health and gender dysphoria: A review of the literature. International Review Of Psychiatry , 28 (1), 44-57.

Studies investigating the prevalence of psychiatric disorders among trans individuals have identified elevated rates of psychopathology. Research has also provided conflicting psychiatric outcomes following gender-confirming medical interventions. This review identifies 38 cross-sectional and longitudinal studies describing prevalence rates of psychiatric disorders and psychiatric outcomes, pre- and post-gender-confirming medical interventions, for people with gender dysphoria. It indicates that, although the levels of psychopathology and psychiatric disorders in trans people attending services at the time of assessment are higher than in the cis population, they do improve following gender-confirming medical intervention, in many cases reaching normative values. The main Axis I psychiatric disorders were found to be depression and anxiety disorder. Other major psychiatric disorders, such as schizophrenia and bipolar disorder, were rare and were no more prevalent than in the general population. There was conflicting evidence regarding gender differences: some studies found higher psychopathology in trans women, while others found no differences between gender groups. Although many studies were methodologically weak, and included people at different stages of transition within the same cohort of patients, overall this review indicates that trans people attending transgender health-care services appear to have a higher risk of psychiatric morbidity (that improves following treatment), and thus confirms the vulnerability of this population.

Gijs and Brewaeys, 2007

Gijs, L., & Brewaeys, A. (2007). Surgical treatment of gender dysphoria in adults and adolescents: Recent developments, effectiveness, and challenges. Annual Review of Sex Research , 18 (1), 178-224.

In 1990 Green and Fleming concluded that sex reassignment surgery (SRS) is an effective treatment for transsexuality because it reduced gender dysphoria drastically. Since 1990, many new outcome studies have been published, raising the question as to whether the conclusion of Green and Fleming still holds. After describing terminological and conceptual developments related to the treatment of gender identity disorder (GID), follow-up studies, including both adults and adolescents, of the outcomes of SRS are reviewed. Special attention is paid to the effects of SRS on gender dysphoria, sexuality, and regret. Despite methodological shortcomings of many of the studies, we conclude that SRS is an effective treatment for transsexualism and the only treatment that has been evaluated empirically with large clinical case series.

Gooren, 2011

Gooren, L. J. (2011). Care of transsexual persons. New England Journal of Medicine , 364 (13), 1251–1257.

This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations. A healthy and successful 40-year-old man finds it increasingly difficult to live as a male. In childhood he preferred playing with girls and recalls feeling that he should have been one. Over time he has come to regard himself more and more as a female personality inhabiting a male body. After much agonizing, he has concluded that only sex reassignment can offer the peace of mind he craves. What would you advise? A healthy and successful 40-year-old man finds it increasingly difficult to live as a male. In childhood he preferred playing with girls and recalls feeling that he should have been one. Over time he has come to regard himself more and more as a female personality inhabiting a male body. After much agonizing, he has concluded that only sex reassignment can offer the peace of mind he craves. What would you advise?

Hembree et al., 2009

Hembree, W. C., Cohen-Kettenis, P., Delemarre-van de Waal, H. A., Gooren, L. J., Meyer, W., et al. (2009). Endocrine treatment of transsexual persons: An endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 94 (9), 3132–3154.

Objective: The aim was to formulate practice guidelines for endocrine treatment of transsexual persons. Evidence: This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and the quality of evidence, which was low or very low. Consensus Process: Committees and members of The Endocrine Society, European Society of Endocrinology, European Society for Paediatric Endocrinology, Lawson Wilkins Pediatric Endocrine Society, and World Professional Association for Transgender Health commented on preliminary drafts of these guidelines. Conclusions: Transsexual persons seeking to develop the physical characteristics of the desired gender require a safe, effective hormone regimen that will 1) suppress endogenous hormone secretion determined by the person’s genetic/biologic sex and 2) maintain sex hormone levels within the normal range for the person’s desired gender. A mental health professional (MHP) must recommend endocrine treatment and participate in ongoing care throughout the endocrine transition and decision for surgical sex reassignment. The endocrinologist must confirm the diagnostic criteria the MHP used to make these recommendations. Because a diagnosis of transsexualism in a prepubertal child cannot be made with certainty, we do not recommend endocrine treatment of prepubertal children. We recommend treating transsexual adolescents (Tanner stage 2) by suppressing puberty with GnRH analogues until age 16 years old, after which cross-sex hormones may be given. We suggest suppressing endogenous sex hormones, maintaining physiologic levels of gender-appropriate sex hormones and monitoring for known risks in adult transsexual persons. Endocrine treatment of transsexual persons should include suppression of endogenous sex hormones, physiologic levels of gender-appropriate sex hormones, and suppression of puberty in adolescents (Tanner stage 2).

Michel et al., 2002

Michel, A., Ansseau, M., Legros, J., Pitchot, W., & Mormont, C. (2002). The transsexual: What about the future? European Psychiatry , 17 (6), 353-362.

Since the 1950s, sexual surgical reassignments have been frequently carried out. As this surgical therapeutic procedure is controversial, it seems important to explore the actual consequences of such an intervention and objectively evaluate its relevance. In this context, we have carried out a review of the literature. After looking at the methodological limitations of follow-up studies, the psychological, sexual, social, and professional futures of the individuals subject to a transsexual operation are presented. Finally, prognostic aspects are considered. In the literature, follow-up studies tend to show that surgical transformations have positive consequences for the subjects. In the majority of cases, transsexuals are very satisfied with their intervention and any difficulties experienced are often temporary and disappear within a year after the surgical transformation. Studies show that there is less than 1% of regrets, and a little more than 1% of suicides among operated subjects. The empirical research does not confirm the opinion that suicide is strongly associated with surgical transformation.

Murad et al., 2010

Murad, M. H., Elamin, M. B., Garcia, M. Z., Mullan, R. J., Murad, A., Erwin, P. J., & Montori, V. M. (2010). Hormonal therapy and sex reassignment: A systematic review and meta-analysis of quality of life and psychosocial outcomes. Clinical Endocrinology , 72 (2), 214-231.

Objective: To assess the prognosis of individuals with gender identity disorder (GID) receiving hormonal therapy as a part of sex reassignment in terms of quality of life and other self‐reported psychosocial outcomes. Methods: We searched electronic databases, bibliography of included studies and expert files. All study designs were included with no language restrictions. Reviewers working independently and in pairs selected studies using predetermined inclusion and exclusion criteria, extracted outcome and quality data. We used a random‐effects meta‐analysis to pool proportions and estimate the 95% confidence intervals (CIs). We estimated the proportion of between‐study heterogeneity not attributable to chance using the I2 statistic. Results: We identified 28 eligible studies. These studies enrolled 1833 participants with GID (1093 male‐to‐female, 801 female‐to‐male) who underwent sex reassignment that included hormonal therapies. All the studies were observational and most lacked controls. Pooling across studies shows that after sex reassignment, 80% of individuals with GID reported significant improvement in gender dysphoria (95% CI = 68–89%; 8 studies; I2 = 82%); 78% reported significant improvement in psychological symptoms (95% CI = 56–94%; 7 studies; I2 = 86%); 80% reported significant improvement in quality of life (95% CI = 72–88%; 16 studies; I2 = 78%); and 72% reported significant improvement in sexual function (95% CI = 60–81%; 15 studies; I2 = 78%). Conclusions: Very low quality evidence suggests that sex reassignment that includes hormonal interventions in individuals with GID likely improves gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life.

Reisner et al., 2016

Reisner, S. L., Poteat, T., Keatley, J., Cabral, M., Mothopeng, T., et al. (2016). Global health burden and needs of transgender populations: A review. The Lancet , 388 (10042), 412-436.

Transgender people are a diverse population affected by a range of negative health indicators across high-income, middle-income, and low-income settings. Studies consistently document a high prevalence of adverse health outcomes in this population, including HIV and other sexually transmitted infections, mental health distress, and substance use and abuse. However, many other health areas remain understudied, population-based representative samples and longitudinal studies are few, and routine surveillance efforts for transgender population health are scarce. The absence of survey items with which to identify transgender respondents in general surveys often restricts the availability of data with which to estimate the magnitude of health inequities and characterise the population-level health of transgender people globally. Despite the limitations, there are sufficient data highlighting the unique biological, behavioural, social, and structural contextual factors surrounding health risks and resiliencies for transgender people. To mitigate these risks and foster resilience, a comprehensive approach is needed that includes gender affirmation as a public health framework, improved health systems and access to health care informed by high quality data, and effective partnerships with local transgender communities to ensure responsiveness of and cultural specificity in programming. Consideration of transgender health underscores the need to explicitly consider sex and gender pathways in epidemiological research and public health surveillance more broadly.

Schmidt and Levine, 2015

Schmidt, L., & Levine, R. (2015). Psychological Outcomes and Reproductive Issues Among Gender Dysphoric Individuals. Endocrinology and Metabolism Clinics of North America , 44 (4), 773-785.

Gender dysphoria is a condition in which a person experiences discrepancy between the natal anatomic sex and the gender he or she identifies with, resulting in internal distress and a desire to live as the preferred gender. There is increasing demand for treatment, which includes suppression of puberty, cross-sex hormone therapy, and sex reassignment surgery. This article reviews longitudinal outcome data evaluating psychological well-being and quality of life among transgender individuals who have undergone cross-sex hormone treatment or sex reassignment surgery. Proposed methodologies for diagnosis and initiation of treatment are discussed, and the effects of cross-sex hormones and sex reassignment surgery on future reproductive potential.

White Hughto and Reisner, 2016

White Hughto, J. M., & Reisner, S. L. (2016). A systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals. Transgender Health , 1 (1), 21–31.

Objectives: To review evidence from prospective cohort studies of the relationship between hormone therapy and changes in psychological functioning and quality of life in transgender individuals accessing hormone therapy over time. Data Sources: MEDLINE, PsycINFO, and PubMed were searched for relevant studies from inception to November 2014. Reference lists of included studies were hand searched. Results: Three uncontrolled prospective cohort studies, enrolling 247 transgender adults (180 male-to-female [MTF], 67 female-to-male [FTM]) initiating hormone therapy for the treatment of gender identity disorder (prior diagnostic term for gender dysphoria), were identified. The studies measured exposure to hormone therapy and subsequent changes in mental health (e.g., depression, anxiety) and quality of life outcomes at follow-up. Two studies showed a significant improvement in psychological functioning at 3–6 months and 12 months compared with baseline after initiating hormone therapy. The third study showed improvements in quality of life outcomes 12 months after initiating hormone therapy for FTM and MTF participants; however, only MTF participants showed a statistically significant increase in general quality of life after initiating hormone therapy. Conclusions: Hormone therapy interventions to improve the mental health and quality of life in transgender people with gender dysphoria have not been evaluated in controlled trials. Low quality evidence suggests that hormone therapy may lead to improvements in psychological functioning. Prospective controlled trials are needed to investigate the effects of hormone therapy on the mental health of transgender people.

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Transgender Healthcare Inequity: How Bias Kills

In an effort to remain accountable to communities who have been negatively impacted by past and present medical injustices, the staff at Himmelfarb Library is committed to the work of maintaining an anti-discriminatory practice. We will uplift and highlight diverse stories throughout the year, and not shy away from difficult conversations necessary for health sciences education. To help fulfill this mission, today's blog post highlights transgender healthcare equity.

Author notes 

The topics presented in this article may be difficult and/or retraumatizing for some readers. Subject matter includes medical neglect, transphobic harassment, usage of slurs, medical misdiagnosis, death of a Black transgender women by medical neglect, and cancer. 

While some of the sources cited in this article are from over a decade ago and may use outdated terminology and may misgender the individuals discussed in them, this article was written by a transgender member of Himmelfarb staff, who has used appropriate language in the article itself.

August 7th, 1995. Washington, DC. 

A 24 year old woman named Tyra Hunter was critically wounded in a car accident when another driver ran a stop sign (Bowles, 1995). Once first responders came on the scene and assessed the situation, instead of treating her properly, they mocked and degraded her (Remembering Our Dead, 2019). When she was finally brought to the emergency room at DC General Hospital, she was given a paralytic and slowly bled out (Fox, 1998). The delay in treatment and degrading comments took place because she was a black transgender woman.

Tyra Hunter’s case is, perhaps, one of the more extreme instances of medical transphobia and healthcare inequity. That said, Tyra Hunter is one of many transgender people who have been victimized by anti-transgender prejudice – both personal and systemic – in healthcare. 

From avoidance of medical care due to fear, to biased diagnoses from prejudiced professionals, to even the blatant transphobia that first responders directed at Tyra Hunter, transgender people – particularly for Black transgender women – frequently lack access to quality healthcare. In this post, we will review the most common ways prejudice and cultural incompetency impact transgender patients, and we will consider ways medical professionals can provide equitable healthcare to transgender individuals.

Medical transphobia can take many forms, and not all of them are as blatant as what Tyra Hunter experienced on the day of her death in 1995. Even microaggressions, when experienced over long periods of time, can cause transgender patients to avoid or delay seeking treatment. A study by Seelman et al. in the journal Transgender Health found that among transgender participants, “those reporting a noninclusive PCP or who delayed needed medical care because of fear of discrimination were less likely to have had a routine checkup in the past 2 years” (Seelman et al., 2017, p. 25). This is supported by a study by Jaffee et al., which found that “1 in 3 transgender respondents delayed needed medical care for an illness or injury due to discrimination” (Jaffee et al., 2016, p. 1012), and that “the odds of delaying needed care was approximately 4 times greater for those who reported having to teach their provider about transgender people” (Jaffee et al., 2016, p. 1012).

This fear of medical discrimination is by no means irrational. A study by Rodriguez et al. analyzing data from the National Transgender Discrimination Survey which included over 6000 participants, found that “more than one-third of transgender participants reporting having experienced discrimination in health-care settings” (Rodriguez et al., 2017, p. 980), wherein discrimination was defined as, “physical abuse, verbal harassment, and/or denied equal treatment” (Rodriguez et al., 2017, p. 975). Of note here is that this number parallels Jaffee et al.’s reported 1 in 3 transgender respondents delaying treatment.

Transgender patients’ lack of trust is also attributed to “Transgender Broken Arm Syndrome,” which occurs when healthcare providers attribute unrelated medical issues to a patient’s transgender identity or transition-related care. The colloquial term comes from the scenario where a transgender patient might go into the doctor for a broken arm, but the healthcare provider questions to the patient about their gender instead. Jennifer Kelley describes this kind of scenario with a patient named Cam in the article, Stigma and Human Rights: Transgender Discrimination and Its Influence on Patient Health . Cam wanted to see the doctor about a chronic issue unrelated to her transness, and perhaps discuss hormone replacement therapy, but the provider instead questioned her about her identity, gave her a pamphlet on HIV, and told her to find a specialist (Kelley, 2021). 

Another example of a transgender patient who was not able to access appropriate quality healthcare occured when Jay Kallio, a transgender man in his 50s living in New York, was discovered to have an aggressive form of breast cancer (Buxton, 2015). After receiving a mammogram and a biopsy, Kallio did not hear from his physician for many weeks. When he finally heard about his diagnosis, it was from the medical professional who performed the biopsy, who was shocked to hear that Kallio’s physician, a surgeon at a major New York hospital, had not informed him of the swiftly-worsening cancer. Kallio struggled to get in contact with this physician, and when he did, the surgeon began the conversation by stating that he wanted to send Kallio to a psychiatrist for his identity. Eventually, Kallio was thankfully able to transfer his case to another surgeon, and even beat the cancer in 2008, though he later succumbed to lung cancer in 2016. (Jay Kallio, n.d.) Ultimately, Kallio’s case is one that serves as a reminder of the very real potential consequences for medical transphobia.

There are, however, some of the most wretched instances of transphobia that involve harassment and blatant cruelty, such as what happened to Tyra Hunter. Another such case is that of Robert Eads, a transgender man who was taken to the emergency room in Georgia in 1996 after passing out. When he was diagnosed with ovarian cancer, he was refused treatment by more than a dozen medical practitioners. By the time he was accepted by the hospital of the Medical College of Georgia in 1997, the cancer had metastasized, and no treatment would have been able to save his life (Ravishankar, 2013). He died in 1999, and his story is told in the 2001 documentary, Southern Comfort , named after a popular transgender gathering that he spoke at after his prognosis (“Robert Eads”, 2007). His case is more similar to that of Jay Kallio than Tyra Hunter’s, but Eads’ slow and painful death was the result of medical transphobia in action.

Even the late transgender activist and author of the well-revered Stone Butch Blues , Leslie Feinberg (who used the neopronouns ze/hir), has discussed the transphobia ze faced after seeking treatment. In zir 2001 work, “Trans Health Crisis: For Us It’s Life or Death”, ze detailed how hospital staff gathered around zir, calling Feinberg “it” and “martian”. Feinberg chose to leave the hospital in question without being treated, and thankfully the illness ze had was not life-threatening, as it had been for Tyra Hunter and Robert Eads (Feinberg, 2001).

Knowing what we do about medical transphobia, how can healthcare professionals enact change within the healthcare system, ensure that transgender patients are treated equitably and ethically, and rebuild trust with the transgender community? 

Leslie Feinberg urges in zir aforementioned work that decisions related to transgender patients involve transgender and gender variant people of all kinds. Ze made recommendations large and small, some of which have been implemented already. One of the simplest, which has been picked up by quite a few healthcare professionals, is to “refer to patients by their first and last names, not Mr. or Ms., sir or ma'am.” Another is a call for institutional standards (Feinberg, 2001), such as the Standards of Care developed by the World Professional Association for Transgender Health (WPATH). This comprehensive document acts as a guideline for health care professionals “to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment.” (Standards of Care, 2012, p. 1)

Medical education has also been shown to have significant gaps in coverage of transgender healthcare. Fung et al. performed a qualitative review of Toronto medical residents’ knowledge and confidence in transgender care in 2016. The results indicated that residents had limited exposure to formal training in transgender medicine, as well as few mentors within their specializations who had enough knowledge to confidently educate or advise on such topics (Fung et al., 2020). If you’d like to learn more about the gaps in transgender health education, Korpaisarn et al.’s Gaps in transgender medical education among healthcare providers reviews a number of studies on the subject and follows with a section on effective interventions, including the use of WPATH’s Global Education Initiative (GEI), which offers training and certification courses on transgender healthcare (Kopaisarn et al., 2018).

Healthcare professionals should stay up to date on legislative matters. Our previous article for Transgender Day of Visibility discussed this at length and included a number of resources for education and for action. If you would like to learn more about the legal side of transgender health, that piece would be a good starting point. Likewise, if you would like to learn more about some terminology related to transgender individuals in a healthcare setting or about how to build rapport with transgender patients or otherwise equitably treat transgender patients, Klein et al.’s Caring for Transgender and Gender-Diverse Persons: What Clinicians Should Know , is another useful resource.

Unfortunately, transphobia may persist in society and healthcare. It is unfortunately not enough to educate ourselves alone on matters of inequity and bias; the best way to support transgender patients is to speak out against transphobia when you see it. There will be times when speaking out is difficult, but when those moments happen, please remember that if even a single person had taken action, Tyra Hunter may have survived.

Bowles, S. (1995, December 10) A Death Robbed of Dignity Mobilizes a Community, Washington Post . https://www.washingtonpost.com/archive/local/1995/12/10/a-death-robbed-of-dignity-mobilizes-a-community/2ca40566-9d67-47a2-80f2-e5756b2753a6/ 

Buxton, R. (2015, June 15) This Trans Man's Breast Cancer Nightmare Exemplifies The Problem With Transgender Health Care, HuffPost . https://www.huffpost.com/entry/transgender-health-care_n_7587506

Feinberg, L. (2001)  Trans health crisis: For us it's life or death, American Journal of Public Health , 91(6), p. 897-900. https://doi.org/10.2105/AJPH.91.6.897

Fox, S. D. (1998, December 12) Damages Awarded after Transsexual Woman's Death. Polare . Internet Archive . https://web.archive.org/web/20140324052938/http://www.gendercentre.org.au/resources/polare-archive/archived-articles/damages-awarded-after-transsexual-womans-death.htm

Fung, R., Gallibois, C., Coutin, A., & Wright, S. (2020) Learning by chance: Investigating gaps in transgender care education amongst family medicine, endocrinology, psychiatry and urology residents, Canadian Medical Education Journal , 11(4), p. e19-e28. https://doi.org/10.36834/cmej.53009

Jaffee, K. D., Shires, D. A., & Stroumsa, D. (2016) Discrimination and delayed health care among transgender women and men, Medical Care , 54(11), p. 1010-1016. https://doi.org/10.1097/MLR.0000000000000583

Jay Kallio. (n.d.) Compassion and Choices. https://compassionandchoices.org/stories/jay-kallio/

Kelley, J. (2021) Stigma and Human Rights: Transgender Discrimination and Its Influence on Patient Health, Professional Case Management . 26(6), p. 298-303. https://doi.org/10.1097/NCM.0000000000000506

Klein, D. A., Paradise, S. L., & Goodwin, E. T. (2018) Caring for Transgender and Gender-Diverse Persons: What Clinicians Should Know, American Family Physician , 98(11), p. 645-653.

Korpaisarn, S., Safer, J. D., & Tangpricha, V. (2020) Gaps in transgender medical education among healthcare providers: A major barrier to care for transgender persons, Reviews in endocrine & metabolic disorders , 19(3), p. e271-275. https://doi.org/10.1007/s11154-018-9452-5

Main Page. (n.d.) Global Education Institute. WPATH. https://www.wpath.org/gei

National Center for Transgender Equality. (2007, January 16) Robert Eads, National Center for Transgender Equality . https://transequality.org/blog/robert-eads

Ravishankar, M. (2013, January 18) The Story About Robert Eads, The Journal of Global Health . https://archive.ph/20130914005716/http://www.ghjournal.org/jgh-online/the-story-about-robert-eads/

Rodriguez, A., Agardh, A., & Asamoah, B. O. (2017) Self-Reported Discrimination in Health-Care Settings Based on Recognizability as Transgender: A Cross-Sectional Study Among Transgender U.S. Citizens, Archives of Sexual Behavior , 47(4), p. 973-985. https://doi.org/10.1007/s10508-017-1028-z

Seelman, K. L., Colón-Diaz, M. J. P., LeCroix, R. H., Xavier-Brier, M, & Kattari, L. (2017) Transgender Noninclusive Healthcare and Delaying Care Because of Fear: Connections to General Health and Mental Health Among Transgender Adults, Transgender Health , 2(1), p. 17-28. https://doi.org/10.1089/trgh.2016.0024

Transgender Day of Rememberance. (2019, February 17) Remembering Our Dead: Tyra Hunter, https://tdor.translivesmatter.info/reports/1995/08/08/tyra-hunter_washington-dc-usa_04a01786

World Professional Association for Transgender Health. (2012) Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 7th ed. https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_English.pdf

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Why Aren’t We Making More Progress Towards Gender Equity?

• Elisabeth Kelan

Research on how “gender fatigue” is holding us back.

Despite many of the advances we’ve made toward gender equality in the past few decades, progress has been slow. Research shows that one reason may be that many managers acknowledge that the bias exists in general but fail to recognize it in their daily workplace interactions. This “gender fatigue” means that people aren’t motivated to make change in their organizations. Through ethnographic studies and interviews across industries, the author identified several rationalizations managers use to deny gender inequality. First, they assume it happens elsewhere, at a competitor, for example, but not in their own organization. Second, they believe that gender inequality existed in the past but is no longer an issue. Third, they point to the initiatives to support women as evidence that inequality has been addressed. Last, when they do see incidents of discrimination, they reason that the situation had nothing to do with gender. Until we stop denying inequality exists in our own organizations, it will be impossible to make progress.

Organizations have worked towards achieving gender equality for decades. They’ve invested resources into developing women’s careers. They’ve implemented bias awareness training. Those at the top, including many CEOs, have made public commitments to make their workplaces more fair and equitable. And, still, despite all of this, progress towards gender equality has been limited. In fact, many managers struggle to recognize gender inequalities in daily workplace interactions.

• EK Elisabeth Kelan is a Professor of Leadership and Organisation and a Leverhulme Trust Major Research Fellow at Essex Business School at University of Essex in the United Kingdom.

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The Courage to Follow the Evidence on Transgender Care

By David Brooks

Opinion Columnist

Hilary Cass is the kind of hero the world needs today. She has entered one of the most toxic debates in our culture: how the medical community should respond to the growing numbers of young people who seek gender transition through medical treatments, including puberty blockers and hormone therapies. This month, after more than three years of research, Cass, a pediatrician, produced a report , commissioned by the National Health Service in England, that is remarkable for its empathy for people on all sides of this issue, for its humility in the face of complex social trends we don’t understand and for its intellectual integrity as we try to figure out which treatments actually work to serve those patients who are in distress. With incredible courage, she shows that careful scholarship can cut through debates that have been marked by vituperation and intimidation and possibly reset them on more rational grounds.

Cass, a past president of Britain’s Royal College of Pediatrics and Child Health, is clear about the mission of her report: “This review is not about defining what it means to be trans, nor is it about undermining the validity of trans identities, challenging the right of people to express themselves or rolling back on people’s rights to health care. It is about what the health care approach should be, and how best to help the growing number of children and young people who are looking for support from the N.H.S. in relation to their gender identity.”

This issue begins with a mystery. For reasons that are not clear, the number of adolescents who have sought to medically change their sex has been skyrocketing in recent years, though the overall number remains very small. For reasons that are also not clear, adolescents who were assigned female at birth are driving this trend, whereas before the late 2000s, it was mostly adolescents who were assigned male at birth who sought these treatments.

Doctors and researchers have proposed various theories to try to explain these trends. One is that greater social acceptance of trans people has enabled people to seek these therapies. Another is that teenagers are being influenced by the popularity of searching and experimenting around identity. A third is that the rise of teen mental health issues may be contributing to gender dysphoria. In her report, Cass is skeptical of broad generalizations in the absence of clear evidence; these are individual children and adolescents who take their own routes to who they are.

Some activists and medical practitioners on the left have come to see the surge in requests for medical transitioning as a piece of the new civil rights issue of our time — offering recognition to people of all gender identities. Transition through medical interventions was embraced by providers in the United States and Europe after a pair of small Dutch studies showed that such treatment improved patients’ well-being. But a 2022 Reuters investigation found that some American clinics were quite aggressive with treatment: None of the 18 U.S. clinics that Reuters looked at performed long assessments on their patients, and some prescribed puberty blockers on the first visit.

Unfortunately, some researchers who questioned the Dutch approach were viciously attacked. This year, Sallie Baxendale, a professor of clinical neuropsychology at the University College London, published a review of studies looking at the impact of puberty blockers on brain development and concluded that “critical questions” about the therapy remain unanswered. She was immediately attacked. She recently told The Guardian, “I’ve been accused of being an anti-trans activist, and that now comes up on Google and is never going to go away.”

As Cass writes in her report, “The toxicity of the debate is exceptional.” She continues, “There are few other areas of health care where professionals are so afraid to openly discuss their views, where people are vilified on social media and where name-calling echoes the worst bullying behavior.”

Cass focused on Britain, but her description of the intellectual and political climate is just as applicable to the U.S., where brutality on the left has been matched by brutality on the right, with crude legislation that doesn’t acknowledge the well-being of the young people in question. In 24 states Republicans have passed laws banning these therapies, sometimes threatening doctors with prison time if they prescribe the treatment they think is best for their patients.

The battle lines on this issue are an extreme case, but they are not unfamiliar. On issue after issue, zealous minorities bully and intimidate the reasonable majority. Often, those who see nuance decide it’s best to just keep their heads down. The rage-filled minority rules.

Cass showed enormous courage in walking into this maelstrom. She did it in the face of practitioners who refused to cooperate and thus denied her information that could have helped inform her report. As an editorial in The BMJ puts it, “Despite encouragement from N.H.S. England,” the “necessary cooperation” was not forthcoming. “Professionals withholding data from a national inquiry seems hard to imagine, but it is what happened.”

Cass’s report does not contain even a hint of rancor, just a generous open-mindedness and empathy for all involved. Time and again in her report, she returns to the young people and the parents directly involved, on all sides of the issue. She clearly spent a lot of time meeting with them. She writes, “One of the great pleasures of the review has been getting to meet and talk to so many interesting people.”

The report’s greatest strength is its epistemic humility. Cass is continually asking, “What do we really know?” She is carefully examining the various studies — which are high quality, which are not. She is down in the academic weeds.

She notes that the quality of the research in this field is poor. The current treatments are “built on shaky foundations,” she writes in The BMJ. Practitioners have raced ahead with therapies when we don’t know what the effects will be. As Cass tells The BMJ, “I can’t think of another area of pediatric care where we give young people a potentially irreversible treatment and have no idea what happens to them in adulthood.”

She writes in her report, “The option to provide masculinizing/feminizing hormones from age 16 is available, but the review would recommend extreme caution.” She does not issue a blanket, one-size-fits-all recommendation, but her core conclusion is this: “For most young people, a medical pathway will not be the best way to manage their gender-related distress.” She realizes that this conclusion will not please many of the young people she has come to know, but this is where the evidence has taken her.

You can agree or disagree with this or that part of the report, and maybe the evidence will look different in 10 years, but I ask you to examine the integrity with which Cass did her work in such a treacherous environment.

In 1877 a British philosopher and mathematician named William Kingdon Clifford published an essay called “ The Ethics of Belief .” In it he argued that if a shipowner ignored evidence that his craft had problems and sent the ship to sea having convinced himself it was safe, then of course we would blame him if the ship went down and all aboard were lost. To have a belief is to bear responsibility, and one thus has a moral responsibility to dig arduously into the evidence, avoid ideological thinking and take into account self-serving biases. “It is wrong always, everywhere, and for anyone, to believe anything upon insufficient evidence,” Clifford wrote. A belief, he continued, is a public possession. If too many people believe things without evidence, “the danger to society is not merely that it should believe wrong things, though that is great enough; but that it should become credulous, and lose the habit of testing things and inquiring into them; for then it must sink back into savagery.”

Since the Trump years, this habit of not consulting the evidence has become the underlying crisis in so many realms. People segregate into intellectually cohesive teams, which are always dumber than intellectually diverse teams. Issues are settled by intimidation, not evidence. Our natural human tendency is to be too confident in our knowledge, too quick to ignore contrary evidence. But these days it has become acceptable to luxuriate in those epistemic shortcomings, not to struggle against them. See, for example, the modern Republican Party.

Recently it’s been encouraging to see cases in which the evidence has won out. Many universities have acknowledged that the SAT is a better predictor of college success than high school grades and have reinstated it. Some corporations have come to understand that while diversity, equity and inclusion are essential goals, the current programs often empirically fail to serve those goals and need to be reformed. I’m hoping that Hilary Cass is modeling a kind of behavior that will be replicated across academia, in the other professions and across the body politic more generally and thus save us from spiraling into an epistemological doom loop.

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

Follow the New York Times Opinion section on Facebook , Instagram , TikTok , WhatsApp , X and Threads .

David Brooks has been a columnist with The Times since 2003. He is the author, most recently,  of “How to Know a Person: The Art of Seeing Others Deeply and Being Deeply Seen.” @ nytdavidbrooks

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Peer-reviewed

Research Article

Twenty years of gender equality research: A scoping review based on a new semantic indicator

Contributed equally to this work with: Paola Belingheri, Filippo Chiarello, Andrea Fronzetti Colladon, Paola Rovelli

Roles Conceptualization, Formal analysis, Funding acquisition, Visualization, Writing – original draft, Writing – review & editing

Affiliation Dipartimento di Ingegneria dell’Energia, dei Sistemi, del Territorio e delle Costruzioni, Università degli Studi di Pisa, Largo L. Lazzarino, Pisa, Italy

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Visualization, Writing – original draft, Writing – review & editing

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Software, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Department of Engineering, University of Perugia, Perugia, Italy, Department of Management, Kozminski University, Warsaw, Poland

Roles Conceptualization, Formal analysis, Funding acquisition, Writing – original draft, Writing – review & editing

Affiliation Faculty of Economics and Management, Centre for Family Business Management, Free University of Bozen-Bolzano, Bozen-Bolzano, Italy

• Paola Belingheri, 
• Filippo Chiarello, 
• Andrea Fronzetti Colladon, 
• Paola Rovelli

• Published: September 21, 2021
• https://doi.org/10.1371/journal.pone.0256474
• Reader Comments

9 Nov 2021: The PLOS ONE Staff (2021) Correction: Twenty years of gender equality research: A scoping review based on a new semantic indicator. PLOS ONE 16(11): e0259930. https://doi.org/10.1371/journal.pone.0259930 View correction

Gender equality is a major problem that places women at a disadvantage thereby stymieing economic growth and societal advancement. In the last two decades, extensive research has been conducted on gender related issues, studying both their antecedents and consequences. However, existing literature reviews fail to provide a comprehensive and clear picture of what has been studied so far, which could guide scholars in their future research. Our paper offers a scoping review of a large portion of the research that has been published over the last 22 years, on gender equality and related issues, with a specific focus on business and economics studies. Combining innovative methods drawn from both network analysis and text mining, we provide a synthesis of 15,465 scientific articles. We identify 27 main research topics, we measure their relevance from a semantic point of view and the relationships among them, highlighting the importance of each topic in the overall gender discourse. We find that prominent research topics mostly relate to women in the workforce–e.g., concerning compensation, role, education, decision-making and career progression. However, some of them are losing momentum, and some other research trends–for example related to female entrepreneurship, leadership and participation in the board of directors–are on the rise. Besides introducing a novel methodology to review broad literature streams, our paper offers a map of the main gender-research trends and presents the most popular and the emerging themes, as well as their intersections, outlining important avenues for future research.

Citation: Belingheri P, Chiarello F, Fronzetti Colladon A, Rovelli P (2021) Twenty years of gender equality research: A scoping review based on a new semantic indicator. PLoS ONE 16(9): e0256474. https://doi.org/10.1371/journal.pone.0256474

Editor: Elisa Ughetto, Politecnico di Torino, ITALY

Received: June 25, 2021; Accepted: August 6, 2021; Published: September 21, 2021

Copyright: © 2021 Belingheri et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its supporting information files. The only exception is the text of the abstracts (over 15,000) that we have downloaded from Scopus. These abstracts can be retrieved from Scopus, but we do not have permission to redistribute them.

Funding: P.B and F.C.: Grant of the Department of Energy, Systems, Territory and Construction of the University of Pisa (DESTEC) for the project “Measuring Gender Bias with Semantic Analysis: The Development of an Assessment Tool and its Application in the European Space Industry. P.B., F.C., A.F.C., P.R.: Grant of the Italian Association of Management Engineering (AiIG), “Misure di sostegno ai soci giovani AiIG” 2020, for the project “Gender Equality Through Data Intelligence (GEDI)”. F.C.: EU project ASSETs+ Project (Alliance for Strategic Skills addressing Emerging Technologies in Defence) EAC/A03/2018 - Erasmus+ programme, Sector Skills Alliances, Lot 3: Sector Skills Alliance for implementing a new strategic approach (Blueprint) to sectoral cooperation on skills G.A. NUMBER: 612678-EPP-1-2019-1-IT-EPPKA2-SSA-B.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The persistent gender inequalities that currently exist across the developed and developing world are receiving increasing attention from economists, policymakers, and the general public [e.g., 1 – 3 ]. Economic studies have indicated that women’s education and entry into the workforce contributes to social and economic well-being [e.g., 4 , 5 ], while their exclusion from the labor market and from managerial positions has an impact on overall labor productivity and income per capita [ 6 , 7 ]. The United Nations selected gender equality, with an emphasis on female education, as part of the Millennium Development Goals [ 8 ], and gender equality at-large as one of the 17 Sustainable Development Goals (SDGs) to be achieved by 2030 [ 9 ]. These latter objectives involve not only developing nations, but rather all countries, to achieve economic, social and environmental well-being.

As is the case with many SDGs, gender equality is still far from being achieved and persists across education, access to opportunities, or presence in decision-making positions [ 7 , 10 , 11 ]. As we enter the last decade for the SDGs’ implementation, and while we are battling a global health pandemic, effective and efficient action becomes paramount to reach this ambitious goal.

Scholars have dedicated a massive effort towards understanding gender equality, its determinants, its consequences for women and society, and the appropriate actions and policies to advance women’s equality. Many topics have been covered, ranging from women’s education and human capital [ 12 , 13 ] and their role in society [e.g., 14 , 15 ], to their appointment in firms’ top ranked positions [e.g., 16 , 17 ] and performance implications [e.g., 18 , 19 ]. Despite some attempts, extant literature reviews provide a narrow view on these issues, restricted to specific topics–e.g., female students’ presence in STEM fields [ 20 ], educational gender inequality [ 5 ], the gender pay gap [ 21 ], the glass ceiling effect [ 22 ], leadership [ 23 ], entrepreneurship [ 24 ], women’s presence on the board of directors [ 25 , 26 ], diversity management [ 27 ], gender stereotypes in advertisement [ 28 ], or specific professions [ 29 ]. A comprehensive view on gender-related research, taking stock of key findings and under-studied topics is thus lacking.

Extant literature has also highlighted that gender issues, and their economic and social ramifications, are complex topics that involve a large number of possible antecedents and outcomes [ 7 ]. Indeed, gender equality actions are most effective when implemented in unison with other SDGs (e.g., with SDG 8, see [ 30 ]) in a synergetic perspective [ 10 ]. Many bodies of literature (e.g., business, economics, development studies, sociology and psychology) approach the problem of achieving gender equality from different perspectives–often addressing specific and narrow aspects. This sometimes leads to a lack of clarity about how different issues, circumstances, and solutions may be related in precipitating or mitigating gender inequality or its effects. As the number of papers grows at an increasing pace, this issue is exacerbated and there is a need to step back and survey the body of gender equality literature as a whole. There is also a need to examine synergies between different topics and approaches, as well as gaps in our understanding of how different problems and solutions work together. Considering the important topic of women’s economic and social empowerment, this paper aims to fill this gap by answering the following research question: what are the most relevant findings in the literature on gender equality and how do they relate to each other ?

To do so, we conduct a scoping review [ 31 ], providing a synthesis of 15,465 articles dealing with gender equity related issues published in the last twenty-two years, covering both the periods of the MDGs and the SDGs (i.e., 2000 to mid 2021) in all the journals indexed in the Academic Journal Guide’s 2018 ranking of business and economics journals. Given the huge amount of research conducted on the topic, we adopt an innovative methodology, which relies on social network analysis and text mining. These techniques are increasingly adopted when surveying large bodies of text. Recently, they were applied to perform analysis of online gender communication differences [ 32 ] and gender behaviors in online technology communities [ 33 ], to identify and classify sexual harassment instances in academia [ 34 ], and to evaluate the gender inclusivity of disaster management policies [ 35 ].

Applied to the title, abstracts and keywords of the articles in our sample, this methodology allows us to identify a set of 27 recurrent topics within which we automatically classify the papers. Introducing additional novelty, by means of the Semantic Brand Score (SBS) indicator [ 36 ] and the SBS BI app [ 37 ], we assess the importance of each topic in the overall gender equality discourse and its relationships with the other topics, as well as trends over time, with a more accurate description than that offered by traditional literature reviews relying solely on the number of papers presented in each topic.

This methodology, applied to gender equality research spanning the past twenty-two years, enables two key contributions. First, we extract the main message that each document is conveying and how this is connected to other themes in literature, providing a rich picture of the topics that are at the center of the discourse, as well as of the emerging topics. Second, by examining the semantic relationship between topics and how tightly their discourses are linked, we can identify the key relationships and connections between different topics. This semi-automatic methodology is also highly reproducible with minimum effort.

This literature review is organized as follows. In the next section, we present how we selected relevant papers and how we analyzed them through text mining and social network analysis. We then illustrate the importance of 27 selected research topics, measured by means of the SBS indicator. In the results section, we present an overview of the literature based on the SBS results–followed by an in-depth narrative analysis of the top 10 topics (i.e., those with the highest SBS) and their connections. Subsequently, we highlight a series of under-studied connections between the topics where there is potential for future research. Through this analysis, we build a map of the main gender-research trends in the last twenty-two years–presenting the most popular themes. We conclude by highlighting key areas on which research should focused in the future.

Our aim is to map a broad topic, gender equality research, that has been approached through a host of different angles and through different disciplines. Scoping reviews are the most appropriate as they provide the freedom to map different themes and identify literature gaps, thereby guiding the recommendation of new research agendas [ 38 ].

Several practical approaches have been proposed to identify and assess the underlying topics of a specific field using big data [ 39 – 41 ], but many of them fail without proper paper retrieval and text preprocessing. This is specifically true for a research field such as the gender-related one, which comprises the work of scholars from different backgrounds. In this section, we illustrate a novel approach for the analysis of scientific (gender-related) papers that relies on methods and tools of social network analysis and text mining. Our procedure has four main steps: (1) data collection, (2) text preprocessing, (3) keywords extraction and classification, and (4) evaluation of semantic importance and image.

Data collection

In this study, we analyze 22 years of literature on gender-related research. Following established practice for scoping reviews [ 42 ], our data collection consisted of two main steps, which we summarize here below.

Firstly, we retrieved from the Scopus database all the articles written in English that contained the term “gender” in their title, abstract or keywords and were published in a journal listed in the Academic Journal Guide 2018 ranking of the Chartered Association of Business Schools (CABS) ( https://charteredabs.org/wp-content/uploads/2018/03/AJG2018-Methodology.pdf ), considering the time period from Jan 2000 to May 2021. We used this information considering that abstracts, titles and keywords represent the most informative part of a paper, while using the full-text would increase the signal-to-noise ratio for information extraction. Indeed, these textual elements already demonstrated to be reliable sources of information for the task of domain lexicon extraction [ 43 , 44 ]. We chose Scopus as source of literature because of its popularity, its update rate, and because it offers an API to ease the querying process. Indeed, while it does not allow to retrieve the full text of scientific articles, the Scopus API offers access to titles, abstracts, citation information and metadata for all its indexed scholarly journals. Moreover, we decided to focus on the journals listed in the AJG 2018 ranking because we were interested in reviewing business and economics related gender studies only. The AJG is indeed widely used by universities and business schools as a reference point for journal and research rigor and quality. This first step, executed in June 2021, returned more than 55,000 papers.

In the second step–because a look at the papers showed very sparse results, many of which were not in line with the topic of this literature review (e.g., papers dealing with health care or medical issues, where the word gender indicates the gender of the patients)–we applied further inclusion criteria to make the sample more focused on the topic of this literature review (i.e., women’s gender equality issues). Specifically, we only retained those papers mentioning, in their title and/or abstract, both gender-related keywords (e.g., daughter, female, mother) and keywords referring to bias and equality issues (e.g., equality, bias, diversity, inclusion). After text pre-processing (see next section), keywords were first identified from a frequency-weighted list of words found in the titles, abstracts and keywords in the initial list of papers, extracted through text mining (following the same approach as [ 43 ]). They were selected by two of the co-authors independently, following respectively a bottom up and a top-down approach. The bottom-up approach consisted of examining the words found in the frequency-weighted list and classifying those related to gender and equality. The top-down approach consisted in searching in the word list for notable gender and equality-related words. Table 1 reports the sets of keywords we considered, together with some examples of words that were used to search for their presence in the dataset (a full list is provided in the S1 Text ). At end of this second step, we obtained a final sample of 15,465 relevant papers.

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https://doi.org/10.1371/journal.pone.0256474.t001

Text processing and keyword extraction

Text preprocessing aims at structuring text into a form that can be analyzed by statistical models. In the present section, we describe the preprocessing steps we applied to paper titles and abstracts, which, as explained below, partially follow a standard text preprocessing pipeline [ 45 ]. These activities have been performed using the R package udpipe [ 46 ].

The first step is n-gram extraction (i.e., a sequence of words from a given text sample) to identify which n-grams are important in the analysis, since domain-specific lexicons are often composed by bi-grams and tri-grams [ 47 ]. Multi-word extraction is usually implemented with statistics and linguistic rules, thus using the statistical properties of n-grams or machine learning approaches [ 48 ]. However, for the present paper, we used Scopus metadata in order to have a more effective and efficient n-grams collection approach [ 49 ]. We used the keywords of each paper in order to tag n-grams with their associated keywords automatically. Using this greedy approach, it was possible to collect all the keywords listed by the authors of the papers. From this list, we extracted only keywords composed by two, three and four words, we removed all the acronyms and rare keywords (i.e., appearing in less than 1% of papers), and we clustered keywords showing a high orthographic similarity–measured using a Levenshtein distance [ 50 ] lower than 2, considering these groups of keywords as representing same concepts, but expressed with different spelling. After tagging the n-grams in the abstracts, we followed a common data preparation pipeline that consists of the following steps: (i) tokenization, that splits the text into tokens (i.e., single words and previously tagged multi-words); (ii) removal of stop-words (i.e. those words that add little meaning to the text, usually being very common and short functional words–such as “and”, “or”, or “of”); (iii) parts-of-speech tagging, that is providing information concerning the morphological role of a word and its morphosyntactic context (e.g., if the token is a determiner, the next token is a noun or an adjective with very high confidence, [ 51 ]); and (iv) lemmatization, which consists in substituting each word with its dictionary form (or lemma). The output of the latter step allows grouping together the inflected forms of a word. For example, the verbs “am”, “are”, and “is” have the shared lemma “be”, or the nouns “cat” and “cats” both share the lemma “cat”. We preferred lemmatization over stemming [ 52 ] in order to obtain more interpretable results.

In addition, we identified a further set of keywords (with respect to those listed in the “keywords” field) by applying a series of automatic words unification and removal steps, as suggested in past research [ 53 , 54 ]. We removed: sparse terms (i.e., occurring in less than 0.1% of all documents), common terms (i.e., occurring in more than 10% of all documents) and retained only nouns and adjectives. It is relevant to notice that no document was lost due to these steps. We then used the TF-IDF function [ 55 ] to produce a new list of keywords. We additionally tested other approaches for the identification and clustering of keywords–such as TextRank [ 56 ] or Latent Dirichlet Allocation [ 57 ]–without obtaining more informative results.

Classification of research topics

To guide the literature analysis, two experts met regularly to examine the sample of collected papers and to identify the main topics and trends in gender research. Initially, they conducted brainstorming sessions on the topics they expected to find, due to their knowledge of the literature. This led to an initial list of topics. Subsequently, the experts worked independently, also supported by the keywords in paper titles and abstracts extracted with the procedure described above.

Considering all this information, each expert identified and clustered relevant keywords into topics. At the end of the process, the two assignments were compared and exhibited a 92% agreement. Another meeting was held to discuss discordant cases and reach a consensus. This resulted in a list of 27 topics, briefly introduced in Table 2 and subsequently detailed in the following sections.

https://doi.org/10.1371/journal.pone.0256474.t002

Evaluation of semantic importance

Working on the lemmatized corpus of the 15,465 papers included in our sample, we proceeded with the evaluation of semantic importance trends for each topic and with the analysis of their connections and prevalent textual associations. To this aim, we used the Semantic Brand Score indicator [ 36 ], calculated through the SBS BI webapp [ 37 ] that also produced a brand image report for each topic. For this study we relied on the computing resources of the ENEA/CRESCO infrastructure [ 58 ].

The Semantic Brand Score (SBS) is a measure of semantic importance that combines methods of social network analysis and text mining. It is usually applied for the analysis of (big) textual data to evaluate the importance of one or more brands, names, words, or sets of keywords [ 36 ]. Indeed, the concept of “brand” is intended in a flexible way and goes beyond products or commercial brands. In this study, we evaluate the SBS time-trends of the keywords defining the research topics discussed in the previous section. Semantic importance comprises the three dimensions of topic prevalence, diversity and connectivity. Prevalence measures how frequently a research topic is used in the discourse. The more a topic is mentioned by scientific articles, the more the research community will be aware of it, with possible increase of future studies; this construct is partly related to that of brand awareness [ 59 ]. This effect is even stronger, considering that we are analyzing the title, abstract and keywords of the papers, i.e. the parts that have the highest visibility. A very important characteristic of the SBS is that it considers the relationships among words in a text. Topic importance is not just a matter of how frequently a topic is mentioned, but also of the associations a topic has in the text. Specifically, texts are transformed into networks of co-occurring words, and relationships are studied through social network analysis [ 60 ]. This step is necessary to calculate the other two dimensions of our semantic importance indicator. Accordingly, a social network of words is generated for each time period considered in the analysis–i.e., a graph made of n nodes (words) and E edges weighted by co-occurrence frequency, with W being the set of edge weights. The keywords representing each topic were clustered into single nodes.

The construct of diversity relates to that of brand image [ 59 ], in the sense that it considers the richness and distinctiveness of textual (topic) associations. Considering the above-mentioned networks, we calculated diversity using the distinctiveness centrality metric–as in the formula presented by Fronzetti Colladon and Naldi [ 61 ].

Lastly, connectivity was measured as the weighted betweenness centrality [ 62 , 63 ] of each research topic node. We used the formula presented by Wasserman and Faust [ 60 ]. The dimension of connectivity represents the “brokerage power” of each research topic–i.e., how much it can serve as a bridge to connect other terms (and ultimately topics) in the discourse [ 36 ].

The SBS is the final composite indicator obtained by summing the standardized scores of prevalence, diversity and connectivity. Standardization was carried out considering all the words in the corpus, for each specific timeframe.

This methodology, applied to a large and heterogeneous body of text, enables to automatically identify two important sets of information that add value to the literature review. Firstly, the relevance of each topic in literature is measured through a composite indicator of semantic importance, rather than simply looking at word frequencies. This provides a much richer picture of the topics that are at the center of the discourse, as well as of the topics that are emerging in the literature. Secondly, it enables to examine the extent of the semantic relationship between topics, looking at how tightly their discourses are linked. In a field such as gender equality, where many topics are closely linked to each other and present overlaps in issues and solutions, this methodology offers a novel perspective with respect to traditional literature reviews. In addition, it ensures reproducibility over time and the possibility to semi-automatically update the analysis, as new papers become available.

Overview of main topics

In terms of descriptive textual statistics, our corpus is made of 15,465 text documents, consisting of a total of 2,685,893 lemmatized tokens (words) and 32,279 types. As a result, the type-token ratio is 1.2%. The number of hapaxes is 12,141, with a hapax-token ratio of 37.61%.

Fig 1 shows the list of 27 topics by decreasing SBS. The most researched topic is compensation , exceeding all others in prevalence, diversity, and connectivity. This means it is not only mentioned more often than other topics, but it is also connected to a greater number of other topics and is central to the discourse on gender equality. The next four topics are, in order of SBS, role , education , decision-making , and career progression . These topics, except for education , all concern women in the workforce. Between these first five topics and the following ones there is a clear drop in SBS scores. In particular, the topics that follow have a lower connectivity than the first five. They are hiring , performance , behavior , organization , and human capital . Again, except for behavior and human capital , the other three topics are purely related to women in the workforce. After another drop-off, the following topics deal prevalently with women in society. This trend highlights that research on gender in business journals has so far mainly paid attention to the conditions that women experience in business contexts, while also devoting some attention to women in society.

https://doi.org/10.1371/journal.pone.0256474.g001

Fig 2 shows the SBS time series of the top 10 topics. While there has been a general increase in the number of Scopus-indexed publications in the last decade, we notice that some SBS trends remain steady, or even decrease. In particular, we observe that the main topic of the last twenty-two years, compensation , is losing momentum. Since 2016, it has been surpassed by decision-making , education and role , which may indicate that literature is increasingly attempting to identify root causes of compensation inequalities. Moreover, in the last two years, the topics of hiring , performance , and organization are experiencing the largest importance increase.

https://doi.org/10.1371/journal.pone.0256474.g002

Fig 3 shows the SBS time trends of the remaining 17 topics (i.e., those not in the top 10). As we can see from the graph, there are some that maintain a steady trend–such as reputation , management , networks and governance , which also seem to have little importance. More relevant topics with average stationary trends (except for the last two years) are culture , family , and parenting . The feminine topic is among the most important here, and one of those that exhibit the larger variations over time (similarly to leadership ). On the other hand, the are some topics that, even if not among the most important, show increasing SBS trends; therefore, they could be considered as emerging topics and could become popular in the near future. These are entrepreneurship , leadership , board of directors , and sustainability . These emerging topics are also interesting to anticipate future trends in gender equality research that are conducive to overall equality in society.

https://doi.org/10.1371/journal.pone.0256474.g003

In addition to the SBS score of the different topics, the network of terms they are associated to enables to gauge the extent to which their images (textual associations) overlap or differ ( Fig 4 ).

https://doi.org/10.1371/journal.pone.0256474.g004

There is a central cluster of topics with high similarity, which are all connected with women in the workforce. The cluster includes topics such as organization , decision-making , performance , hiring , human capital , education and compensation . In addition, the topic of well-being is found within this cluster, suggesting that women’s equality in the workforce is associated to well-being considerations. The emerging topics of entrepreneurship and leadership are also closely connected with each other, possibly implying that leadership is a much-researched quality in female entrepreneurship. Topics that are relatively more distant include personality , politics , feminine , empowerment , management , board of directors , reputation , governance , parenting , masculine and network .

The following sections describe the top 10 topics and their main associations in literature (see Table 3 ), while providing a brief overview of the emerging topics.

https://doi.org/10.1371/journal.pone.0256474.t003

Compensation.

The topic of compensation is related to the topics of role , hiring , education and career progression , however, also sees a very high association with the words gap and inequality . Indeed, a well-known debate in degrowth economics centers around whether and how to adequately compensate women for their childbearing, childrearing, caregiver and household work [e.g., 30 ].

Even in paid work, women continue being offered lower compensations than their male counterparts who have the same job or cover the same role [ 64 – 67 ]. This severe inequality has been widely studied by scholars over the last twenty-two years. Dealing with this topic, some specific roles have been addressed. Specifically, research highlighted differences in compensation between female and male CEOs [e.g., 68 ], top executives [e.g., 69 ], and boards’ directors [e.g., 70 ]. Scholars investigated the determinants of these gaps, such as the gender composition of the board [e.g., 71 – 73 ] or women’s individual characteristics [e.g., 71 , 74 ].

Among these individual characteristics, education plays a relevant role [ 75 ]. Education is indeed presented as the solution for women, not only to achieve top executive roles, but also to reduce wage inequality [e.g., 76 , 77 ]. Past research has highlighted education influences on gender wage gaps, specifically referring to gender differences in skills [e.g., 78 ], college majors [e.g., 79 ], and college selectivity [e.g., 80 ].

Finally, the wage gap issue is strictly interrelated with hiring –e.g., looking at whether being a mother affects hiring and compensation [e.g., 65 , 81 ] or relating compensation to unemployment [e.g., 82 ]–and career progression –for instance looking at meritocracy [ 83 , 84 ] or the characteristics of the boss for whom women work [e.g., 85 ].

The roles covered by women have been deeply investigated. Scholars have focused on the role of women in their families and the society as a whole [e.g., 14 , 15 ], and, more widely, in business contexts [e.g., 18 , 81 ]. Indeed, despite still lagging behind their male counterparts [e.g., 86 , 87 ], in the last decade there has been an increase in top ranked positions achieved by women [e.g., 88 , 89 ]. Following this phenomenon, scholars have posed greater attention towards the presence of women in the board of directors [e.g., 16 , 18 , 90 , 91 ], given the increasing pressure to appoint female directors that firms, especially listed ones, have experienced. Other scholars have focused on the presence of women covering the role of CEO [e.g., 17 , 92 ] or being part of the top management team [e.g., 93 ]. Irrespectively of the level of analysis, all these studies tried to uncover the antecedents of women’s presence among top managers [e.g., 92 , 94 ] and the consequences of having a them involved in the firm’s decision-making –e.g., on performance [e.g., 19 , 95 , 96 ], risk [e.g., 97 , 98 ], and corporate social responsibility [e.g., 99 , 100 ].

Besides studying the difficulties and discriminations faced by women in getting a job [ 81 , 101 ], and, more specifically in the hiring , appointment, or career progression to these apical roles [e.g., 70 , 83 ], the majority of research of women’s roles dealt with compensation issues. Specifically, scholars highlight the pay-gap that still exists between women and men, both in general [e.g., 64 , 65 ], as well as referring to boards’ directors [e.g., 70 , 102 ], CEOs and executives [e.g., 69 , 103 , 104 ].

Finally, other scholars focused on the behavior of women when dealing with business. In this sense, particular attention has been paid to leadership and entrepreneurial behaviors. The former quite overlaps with dealing with the roles mentioned above, but also includes aspects such as leaders being stereotyped as masculine [e.g., 105 ], the need for greater exposure to female leaders to reduce biases [e.g., 106 ], or female leaders acting as queen bees [e.g., 107 ]. Regarding entrepreneurship , scholars mainly investigated women’s entrepreneurial entry [e.g., 108 , 109 ], differences between female and male entrepreneurs in the evaluations and funding received from investors [e.g., 110 , 111 ], and their performance gap [e.g., 112 , 113 ].

Education has long been recognized as key to social advancement and economic stability [ 114 ], for job progression and also a barrier to gender equality, especially in STEM-related fields. Research on education and gender equality is mostly linked with the topics of compensation , human capital , career progression , hiring , parenting and decision-making .

Education contributes to a higher human capital [ 115 ] and constitutes an investment on the part of women towards their future. In this context, literature points to the gender gap in educational attainment, and the consequences for women from a social, economic, personal and professional standpoint. Women are found to have less access to formal education and information, especially in emerging countries, which in turn may cause them to lose social and economic opportunities [e.g., 12 , 116 – 119 ]. Education in local and rural communities is also paramount to communicate the benefits of female empowerment , contributing to overall societal well-being [e.g., 120 ].

Once women access education, the image they have of the world and their place in society (i.e., habitus) affects their education performance [ 13 ] and is passed on to their children. These situations reinforce gender stereotypes, which become self-fulfilling prophecies that may negatively affect female students’ performance by lowering their confidence and heightening their anxiety [ 121 , 122 ]. Besides formal education, also the information that women are exposed to on a daily basis contributes to their human capital . Digital inequalities, for instance, stems from men spending more time online and acquiring higher digital skills than women [ 123 ].

Education is also a factor that should boost employability of candidates and thus hiring , career progression and compensation , however the relationship between these factors is not straightforward [ 115 ]. First, educational choices ( decision-making ) are influenced by variables such as self-efficacy and the presence of barriers, irrespectively of the career opportunities they offer, especially in STEM [ 124 ]. This brings additional difficulties to women’s enrollment and persistence in scientific and technical fields of study due to stereotypes and biases [ 125 , 126 ]. Moreover, access to education does not automatically translate into job opportunities for women and minority groups [ 127 , 128 ] or into female access to managerial positions [ 129 ].

Finally, parenting is reported as an antecedent of education [e.g., 130 ], with much of the literature focusing on the role of parents’ education on the opportunities afforded to children to enroll in education [ 131 – 134 ] and the role of parenting in their offspring’s perception of study fields and attitudes towards learning [ 135 – 138 ]. Parental education is also a predictor of the other related topics, namely human capital and compensation [ 139 ].

Decision-making.

This literature mainly points to the fact that women are thought to make decisions differently than men. Women have indeed different priorities, such as they care more about people’s well-being, working with people or helping others, rather than maximizing their personal (or their firm’s) gain [ 140 ]. In other words, women typically present more communal than agentic behaviors, which are instead more frequent among men [ 141 ]. These different attitude, behavior and preferences in turn affect the decisions they make [e.g., 142 ] and the decision-making of the firm in which they work [e.g., 143 ].

At the individual level, gender affects, for instance, career aspirations [e.g., 144 ] and choices [e.g., 142 , 145 ], or the decision of creating a venture [e.g., 108 , 109 , 146 ]. Moreover, in everyday life, women and men make different decisions regarding partners [e.g., 147 ], childcare [e.g., 148 ], education [e.g., 149 ], attention to the environment [e.g., 150 ] and politics [e.g., 151 ].

At the firm level, scholars highlighted, for example, how the presence of women in the board affects corporate decisions [e.g., 152 , 153 ], that female CEOs are more conservative in accounting decisions [e.g., 154 ], or that female CFOs tend to make more conservative decisions regarding the firm’s financial reporting [e.g., 155 ]. Nevertheless, firm level research also investigated decisions that, influenced by gender bias, affect women, such as those pertaining hiring [e.g., 156 , 157 ], compensation [e.g., 73 , 158 ], or the empowerment of women once appointed [ 159 ].

Career progression.

Once women have entered the workforce, the key aspect to achieve gender equality becomes career progression , including efforts toward overcoming the glass ceiling. Indeed, according to the SBS analysis, career progression is highly related to words such as work, social issues and equality. The topic with which it has the highest semantic overlap is role , followed by decision-making , hiring , education , compensation , leadership , human capital , and family .

Career progression implies an advancement in the hierarchical ladder of the firm, assigning managerial roles to women. Coherently, much of the literature has focused on identifying rationales for a greater female participation in the top management team and board of directors [e.g., 95 ] as well as the best criteria to ensure that the decision-makers promote the most valuable employees irrespectively of their individual characteristics, such as gender [e.g., 84 ]. The link between career progression , role and compensation is often provided in practice by performance appraisal exercises, frequently rooted in a culture of meritocracy that guides bonuses, salary increases and promotions. However, performance appraisals can actually mask gender-biased decisions where women are held to higher standards than their male colleagues [e.g., 83 , 84 , 95 , 160 , 161 ]. Women often have less opportunities to gain leadership experience and are less visible than their male colleagues, which constitute barriers to career advancement [e.g., 162 ]. Therefore, transparency and accountability, together with procedures that discourage discretionary choices, are paramount to achieve a fair career progression [e.g., 84 ], together with the relaxation of strict job boundaries in favor of cross-functional and self-directed tasks [e.g., 163 ].

In addition, a series of stereotypes about the type of leadership characteristics that are required for top management positions, which fit better with typical male and agentic attributes, are another key barrier to career advancement for women [e.g., 92 , 160 ].

Hiring is the entrance gateway for women into the workforce. Therefore, it is related to other workforce topics such as compensation , role , career progression , decision-making , human capital , performance , organization and education .

A first stream of literature focuses on the process leading up to candidates’ job applications, demonstrating that bias exists before positions are even opened, and it is perpetuated both by men and women through networking and gatekeeping practices [e.g., 164 , 165 ].

The hiring process itself is also subject to biases [ 166 ], for example gender-congruity bias that leads to men being preferred candidates in male-dominated sectors [e.g., 167 ], women being hired in positions with higher risk of failure [e.g., 168 ] and limited transparency and accountability afforded by written processes and procedures [e.g., 164 ] that all contribute to ascriptive inequality. In addition, providing incentives for evaluators to hire women may actually work to this end; however, this is not the case when supporting female candidates endangers higher-ranking male ones [ 169 ].

Another interesting perspective, instead, looks at top management teams’ composition and the effects on hiring practices, indicating that firms with more women in top management are less likely to lay off staff [e.g., 152 ].

Performance.

Several scholars posed their attention towards women’s performance, its consequences [e.g., 170 , 171 ] and the implications of having women in decision-making positions [e.g., 18 , 19 ].

At the individual level, research focused on differences in educational and academic performance between women and men, especially referring to the gender gap in STEM fields [e.g., 171 ]. The presence of stereotype threats–that is the expectation that the members of a social group (e.g., women) “must deal with the possibility of being judged or treated stereotypically, or of doing something that would confirm the stereotype” [ 172 ]–affects women’s interested in STEM [e.g., 173 ], as well as their cognitive ability tests, penalizing them [e.g., 174 ]. A stronger gender identification enhances this gap [e.g., 175 ], whereas mentoring and role models can be used as solutions to this problem [e.g., 121 ]. Despite the negative effect of stereotype threats on girls’ performance [ 176 ], female and male students perform equally in mathematics and related subjects [e.g., 177 ]. Moreover, while individuals’ performance at school and university generally affects their achievements and the field in which they end up working, evidence reveals that performance in math or other scientific subjects does not explain why fewer women enter STEM working fields; rather this gap depends on other aspects, such as culture, past working experiences, or self-efficacy [e.g., 170 ]. Finally, scholars have highlighted the penalization that women face for their positive performance, for instance when they succeed in traditionally male areas [e.g., 178 ]. This penalization is explained by the violation of gender-stereotypic prescriptions [e.g., 179 , 180 ], that is having women well performing in agentic areas, which are typical associated to men. Performance penalization can thus be overcome by clearly conveying communal characteristics and behaviors [ 178 ].

Evidence has been provided on how the involvement of women in boards of directors and decision-making positions affects firms’ performance. Nevertheless, results are mixed, with some studies showing positive effects on financial [ 19 , 181 , 182 ] and corporate social performance [ 99 , 182 , 183 ]. Other studies maintain a negative association [e.g., 18 ], and other again mixed [e.g., 184 ] or non-significant association [e.g., 185 ]. Also with respect to the presence of a female CEO, mixed results emerged so far, with some researches demonstrating a positive effect on firm’s performance [e.g., 96 , 186 ], while other obtaining only a limited evidence of this relationship [e.g., 103 ] or a negative one [e.g., 187 ].

Finally, some studies have investigated whether and how women’s performance affects their hiring [e.g., 101 ] and career progression [e.g., 83 , 160 ]. For instance, academic performance leads to different returns in hiring for women and men. Specifically, high-achieving men are called back significantly more often than high-achieving women, which are penalized when they have a major in mathematics; this result depends on employers’ gendered standards for applicants [e.g., 101 ]. Once appointed, performance ratings are more strongly related to promotions for women than men, and promoted women typically show higher past performance ratings than those of promoted men. This suggesting that women are subject to stricter standards for promotion [e.g., 160 ].

Behavioral aspects related to gender follow two main streams of literature. The first examines female personality and behavior in the workplace, and their alignment with cultural expectations or stereotypes [e.g., 188 ] as well as their impacts on equality. There is a common bias that depicts women as less agentic than males. Certain characteristics, such as those more congruent with male behaviors–e.g., self-promotion [e.g., 189 ], negotiation skills [e.g., 190 ] and general agentic behavior [e.g., 191 ]–, are less accepted in women. However, characteristics such as individualism in women have been found to promote greater gender equality in society [ 192 ]. In addition, behaviors such as display of emotions [e.g., 193 ], which are stereotypically female, work against women’s acceptance in the workplace, requiring women to carefully moderate their behavior to avoid exclusion. A counter-intuitive result is that women and minorities, which are more marginalized in the workplace, tend to be better problem-solvers in innovation competitions due to their different knowledge bases [ 194 ].

The other side of the coin is examined in a parallel literature stream on behavior towards women in the workplace. As a result of biases, prejudices and stereotypes, women may experience adverse behavior from their colleagues, such as incivility and harassment, which undermine their well-being [e.g., 195 , 196 ]. Biases that go beyond gender, such as for overweight people, are also more strongly applied to women [ 197 ].

Organization.

The role of women and gender bias in organizations has been studied from different perspectives, which mirror those presented in detail in the following sections. Specifically, most research highlighted the stereotypical view of leaders [e.g., 105 ] and the roles played by women within firms, for instance referring to presence in the board of directors [e.g., 18 , 90 , 91 ], appointment as CEOs [e.g., 16 ], or top executives [e.g., 93 ].

Scholars have investigated antecedents and consequences of the presence of women in these apical roles. On the one side they looked at hiring and career progression [e.g., 83 , 92 , 160 , 168 , 198 ], finding women typically disadvantaged with respect to their male counterparts. On the other side, they studied women’s leadership styles and influence on the firm’s decision-making [e.g., 152 , 154 , 155 , 199 ], with implications for performance [e.g., 18 , 19 , 96 ].

Human capital.

Human capital is a transverse topic that touches upon many different aspects of female gender equality. As such, it has the most associations with other topics, starting with education as mentioned above, with career-related topics such as role , decision-making , hiring , career progression , performance , compensation , leadership and organization . Another topic with which there is a close connection is behavior . In general, human capital is approached both from the education standpoint but also from the perspective of social capital.

The behavioral aspect in human capital comprises research related to gender differences for example in cultural and religious beliefs that influence women’s attitudes and perceptions towards STEM subjects [ 142 , 200 – 202 ], towards employment [ 203 ] or towards environmental issues [ 150 , 204 ]. These cultural differences also emerge in the context of globalization which may accelerate gender equality in the workforce [ 205 , 206 ]. Gender differences also appear in behaviors such as motivation [ 207 ], and in negotiation [ 190 ], and have repercussions on women’s decision-making related to their careers. The so-called gender equality paradox sees women in countries with lower gender equality more likely to pursue studies and careers in STEM fields, whereas the gap in STEM enrollment widens as countries achieve greater equality in society [ 171 ].

Career progression is modeled by literature as a choice-process where personal preferences, culture and decision-making affect the chosen path and the outcomes. Some literature highlights how women tend to self-select into different professions than men, often due to stereotypes rather than actual ability to perform in these professions [ 142 , 144 ]. These stereotypes also affect the perceptions of female performance or the amount of human capital required to equal male performance [ 110 , 193 , 208 ], particularly for mothers [ 81 ]. It is therefore often assumed that women are better suited to less visible and less leadership -oriented roles [ 209 ]. Women also express differing preferences towards work-family balance, which affect whether and how they pursue human capital gains [ 210 ], and ultimately their career progression and salary .

On the other hand, men are often unaware of gendered processes and behaviors that they carry forward in their interactions and decision-making [ 211 , 212 ]. Therefore, initiatives aimed at increasing managers’ human capital –by raising awareness of gender disparities in their organizations and engaging them in diversity promotion–are essential steps to counter gender bias and segregation [ 213 ].

Emerging topics: Leadership and entrepreneurship

Among the emerging topics, the most pervasive one is women reaching leadership positions in the workforce and in society. This is still a rare occurrence for two main types of factors, on the one hand, bias and discrimination make it harder for women to access leadership positions [e.g., 214 – 216 ], on the other hand, the competitive nature and high pressure associated with leadership positions, coupled with the lack of women currently represented, reduce women’s desire to achieve them [e.g., 209 , 217 ]. Women are more effective leaders when they have access to education, resources and a diverse environment with representation [e.g., 218 , 219 ].

One sector where there is potential for women to carve out a leadership role is entrepreneurship . Although at the start of the millennium the discourse on entrepreneurship was found to be “discriminatory, gender-biased, ethnocentrically determined and ideologically controlled” [ 220 ], an increasing body of literature is studying how to stimulate female entrepreneurship as an alternative pathway to wealth, leadership and empowerment [e.g., 221 ]. Many barriers exist for women to access entrepreneurship, including the institutional and legal environment, social and cultural factors, access to knowledge and resources, and individual behavior [e.g., 222 , 223 ]. Education has been found to raise women’s entrepreneurial intentions [e.g., 224 ], although this effect is smaller than for men [e.g., 109 ]. In addition, increasing self-efficacy and risk-taking behavior constitute important success factors [e.g., 225 ].

Finally, the topic of sustainability is worth mentioning, as it is the primary objective of the SDGs and is closely associated with societal well-being. As society grapples with the effects of climate change and increasing depletion of natural resources, a narrative has emerged on women and their greater link to the environment [ 226 ]. Studies in developed countries have found some support for women leaders’ attention to sustainability issues in firms [e.g., 227 – 229 ], and smaller resource consumption by women [ 230 ]. At the same time, women will likely be more affected by the consequences of climate change [e.g., 230 ] but often lack the decision-making power to influence local decision-making on resource management and environmental policies [e.g., 231 ].

Research gaps and conclusions

Research on gender equality has advanced rapidly in the past decades, with a steady increase in publications, both in mainstream topics related to women in education and the workforce, and in emerging topics. Through a novel approach combining methods of text mining and social network analysis, we examined a comprehensive body of literature comprising 15,465 papers published between 2000 and mid 2021 on topics related to gender equality. We identified a set of 27 topics addressed by the literature and examined their connections.

At the highest level of abstraction, it is worth noting that papers abound on the identification of issues related to gender inequalities and imbalances in the workforce and in society. Literature has thoroughly examined the (unconscious) biases, barriers, stereotypes, and discriminatory behaviors that women are facing as a result of their gender. Instead, there are much fewer papers that discuss or demonstrate effective solutions to overcome gender bias [e.g., 121 , 143 , 145 , 163 , 194 , 213 , 232 ]. This is partly due to the relative ease in studying the status quo, as opposed to studying changes in the status quo. However, we observed a shift in the more recent years towards solution seeking in this domain, which we strongly encourage future researchers to focus on. In the future, we may focus on collecting and mapping pro-active contributions to gender studies, using additional Natural Language Processing techniques, able to measure the sentiment of scientific papers [ 43 ].

All of the mainstream topics identified in our literature review are closely related, and there is a wealth of insights looking at the intersection between issues such as education and career progression or human capital and role . However, emerging topics are worthy of being furtherly explored. It would be interesting to see more work on the topic of female entrepreneurship , exploring aspects such as education , personality , governance , management and leadership . For instance, how can education support female entrepreneurship? How can self-efficacy and risk-taking behaviors be taught or enhanced? What are the differences in managerial and governance styles of female entrepreneurs? Which personality traits are associated with successful entrepreneurs? Which traits are preferred by venture capitalists and funding bodies?

The emerging topic of sustainability also deserves further attention, as our society struggles with climate change and its consequences. It would be interesting to see more research on the intersection between sustainability and entrepreneurship , looking at how female entrepreneurs are tackling sustainability issues, examining both their business models and their company governance . In addition, scholars are suggested to dig deeper into the relationship between family values and behaviors.

Moreover, it would be relevant to understand how women’s networks (social capital), or the composition and structure of social networks involving both women and men, enable them to increase their remuneration and reach top corporate positions, participate in key decision-making bodies, and have a voice in communities. Furthermore, the achievement of gender equality might significantly change firm networks and ecosystems, with important implications for their performance and survival.

Similarly, research at the nexus of (corporate) governance , career progression , compensation and female empowerment could yield useful insights–for example discussing how enterprises, institutions and countries are managed and the impact for women and other minorities. Are there specific governance structures that favor diversity and inclusion?

Lastly, we foresee an emerging stream of research pertaining how the spread of the COVID-19 pandemic challenged women, especially in the workforce, by making gender biases more evident.

For our analysis, we considered a set of 15,465 articles downloaded from the Scopus database (which is the largest abstract and citation database of peer-reviewed literature). As we were interested in reviewing business and economics related gender studies, we only considered those papers published in journals listed in the Academic Journal Guide (AJG) 2018 ranking of the Chartered Association of Business Schools (CABS). All the journals listed in this ranking are also indexed by Scopus. Therefore, looking at a single database (i.e., Scopus) should not be considered a limitation of our study. However, future research could consider different databases and inclusion criteria.

With our literature review, we offer researchers a comprehensive map of major gender-related research trends over the past twenty-two years. This can serve as a lens to look to the future, contributing to the achievement of SDG5. Researchers may use our study as a starting point to identify key themes addressed in the literature. In addition, our methodological approach–based on the use of the Semantic Brand Score and its webapp–could support scholars interested in reviewing other areas of research.

Supporting information

S1 text. keywords used for paper selection..

https://doi.org/10.1371/journal.pone.0256474.s001

Acknowledgments

The computing resources and the related technical support used for this work have been provided by CRESCO/ENEAGRID High Performance Computing infrastructure and its staff. CRESCO/ENEAGRID High Performance Computing infrastructure is funded by ENEA, the Italian National Agency for New Technologies, Energy and Sustainable Economic Development and by Italian and European research programmes (see http://www.cresco.enea.it/english for information).

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CONCEPTUAL ANALYSIS article

Better together: a model for women and lgbtq equality in the workplace.

• Faculty of Psychology, Work and Organizational Psychology, Philipps University of Marburg, Marburg, Germany

Much has been achieved in terms of human rights for women and people of the lesbian, gay, bisexual, transsexual, and queer (LGBTQ) community. However, human resources management (HRM) initiatives for gender equality in the workplace focus almost exclusively on white, heterosexual, cisgender women, leaving the problems of other gender, and social minorities out of the analysis. This article develops an integrative model of gender equality in the workplace for HRM academics and practitioners. First, it analyzes relevant antecedents and consequences of gender-based discrimination and harassment (GBDH) in the workplace. Second, it incorporates the feminist, queer, and intersectional perspectives in the analysis. Third, it integrates literature findings about women and the LGBTQ at work, making the case for an inclusive HRM. The authors underscore the importance of industry-university collaboration and offer a starters' toolkit that includes suggestions for diagnosis, intervention, and applied research on GBDH. Finally, avenues for future research are identified to explore gendered practices that hinder the career development of women and the LGBTQ in the workplace.

Introduction

Gender has diversified itself. More than four decades have passed since Bem (1974) published her groundbreaking article on psychological androgyny. With her work, she challenged the binary conception of gender in the western academia, calling for the disposal of gender as a stable trait consistent of discrete categories ( Mehta and Keener, 2017 ). Nowadays, people from the LGBTQ community find safe spaces to express their gender in most developed countries (see ILGA-Europe, 2017 ). Also, women-rights movements have impulsed changes for the emancipation and integration of women at every social level, enabling them to achieve things barely imaginable before (see Hooks, 2000 ).

However, there is still a lot to do to improve the situation of women and people from the LGBTQ community ( International Labour Office, 2016 ; ILGA-Europe, 2017 ). Some actions to increase gender inclusion in organizations actually conceal inequality against women, and many problems faced by the LGBTQ originate within frameworks that anti-discrimination policy reinforce (see Benschop and Doorewaard, 1998 , 2012 ; Verloo, 2006 ). For example, the gender equality, gender management, and gender mainstreaming approaches overlook most problems faced by people from the LGBTQ community and from women of color, framing their target stakeholders as white, cisgender, and heterosexual (see Tomic, 2011 ; Hanappi-Egger, 2013 ; Klein, 2016 ). These problems seem to originate in the neoliberalization of former radical movements when adopted by the mainstream (see Cho et al., 2013 ). This translates into actions addressing sexism and heterosexism that overlook other forms of discrimination (e.g., racism, ableism), resisting an intersectional approach that would question white, able-bodied, and other forms of privilege (see Crenshaw, 1991 ; Cho et al., 2013 ; Liasidou, 2013 ; van Amsterdam, 2013 ).

The purpose of this paper is to support the claim that gender equality shall be done within a queer, feminist, and intersectional framework. This argument is developed by integrating available evidence on the antecedents and consequences of GBDH against women and people from the LGBTQ community in the workplace. The authors believe that GBDH against these groups has its origin in the different manifestations of sexism in organizations. A model with the antecedents and consequences of GBDH in the workplace is proposed. It considers an inclusive definition of gender and integrates the queer-feminist approach to HRM ( Gedro and Mizzi, 2014 ) with the intersectional perspective ( Crenshaw, 1991 ; McCall, 2005 ; Verloo, 2006 ). In this way, it provides a framework for HRM scholars and practitioners working to counteract sexism, heterosexism, and other forms of discrimination in organizations.

GBDH in the Workplace

GBDH is the umbrella term we propose to refer to the different manifestations of sexism and heterosexism in the workplace. The roots of GBDH are beyond the forms that discriminatory acts and behaviors take, being rather “about the power relations that are brought into play in the act of harassing” ( Connell, 2006 , p. 838). This requires acknowledging that gender harassment is a technology of sexism, that “perpetuates, enforces, and polices a set of gender roles that seek to feminize women and masculinize men” ( Franke, 1997 , p. 696). Harassment against the LGBTQ is rooted in a heterosexist ideology that establishes heterosexuality as the superior, valid, and natural form of expressing sexuality (see Wright and Wegner, 2012 ; Rabelo and Cortina, 2014 ). Furthermore, women and the LGBTQ are oppressed by the institutionalized sexism that underscores the supremacy of hegemonic masculinity (male, white, heterosexual, strong, objective, rational) over femininity (female, non-white, non-heterosexual, weak, emotional, irrational; Wright, 2013 ; Denissen and Saguy, 2014 ; Dougherty and Goldstein Hode, 2016 ). In addition, GBDH overlaps with other frameworks (e.g., racism, ableism, anti-fat discrimination) that concurrently work to maintain white, able-bodied, and thin privilege, impeding changes in the broader social structure (see Yoder, 1991 ; Yoder and Aniakudo, 1997 ; Buchanan and Ormerod, 2002 ; Acker, 2006 ; Liasidou, 2013 ; van Amsterdam, 2013 ). The next paragraphs offer a definition of some of the most studied forms of GBDH in the workplace.

Sexual Harassment

Sexual harassment was first defined in its different dimensions as gender harassment, unwanted sexual attention, and sexual coercion ( Gelfand et al., 1995 ). Later, Leskinen and Cortina (2013) focused on the gender-harassment subcomponent of sexual harassment and developed a broadened taxonomy of the term. This was motivated by the fact that legal practices gave little importance to gender-harassment forms of sexual harassment, despite of the negative impact they have on the targets' well-being ( Leskinen et al., 2011 ). Gender harassment consists of rejection or “put down” forms of sexual harassment such as sexist remarks, sexually crude/offensive behavior, infantilization, work/family policing, and gender policing ( Leskinen and Cortina, 2013 ). The concepts of sexual harassment and gender harassment were initially developed to refer to the experiences of women in the workplace, but there is also evidence of sexual and gender harassment against LGBTQ individuals ( Lombardi et al., 2002 ; Silverschanz et al., 2008 ; Denissen and Saguy, 2014 ). In addition, studies have shown how gender harassment and heterosexist harassment are complementary and frequently simultaneous phenomena accounting for mistreatment against members of the LGBTQ community ( Rabelo and Cortina, 2014 ).

Gender Microaggressions

Gender microaggressions account for GBDH against women and people from the LGBTQ community that presents itself in ways that are subtle and troublesome to notice ( Basford et al., 2014 ; Galupo and Resnick, 2016 ). Following the taxonomy on racial microaggressions developed by Sue et al. (2007) , the construct was adapted to account for gender-based forms of discrimination ( Basford et al., 2014 ). Gender microaggressions consist of microassaults, microinsults, and microinvalidations, and although they may appear to be innocent, they exert considerably negative effects in the targets' well-being ( Sue et al., 2007 ; Basford et al., 2014 ; Galupo and Resnick, 2016 ). As an example of microassault imagine an individual commenting their colleague that their way of dressing looks unprofessional (because it is not “masculine enough,” “too” feminine, or not according to traditional gender-binary standards). A microinsult is for example when the supervisor asks the subordinate about who helped them with their work (which was “too good” to be developed by the subordinate alone). An example of microinvalidation would be if in a corporate meeting the CEO dismisses information related to women or the LGBTQ in the company regarding it as unimportant, reinforcing the message that women and LGBTQ issues are inexistent or irrelevant (for more examples see Basford et al., 2014 ; Galupo and Resnick, 2016 ). Because gender is not explicitly addressed in microaggressions, it can be especially difficult for the victims to address the offense as such and act upon them (see Galupo and Resnick, 2016 ). Hence, they are not only emotionally distressing, but also tend to be highly ubiquitous, belonging to the daily expressions of a determined context ( Nadal et al., 2011 , 2014 ; Gartner and Sterzing, 2016 ).

Disguised Forms of GBDH

It is also the case that some forms of workplace mistreatment constitute disguised forms of GBDH. Rospenda et al. (2008) found in their US study that women presented higher rates of generalized workplace abuse (i.e., workplace bullying or mobbing). In the UK, a representative study detected that a high proportion of lesbian, gay, and bisexual respondents have faced workplace bullying ( Hoel et al., 2017 ). Specifically, the results indicated that while the bullying rate for heterosexuals over a six-months period was of 6.4%, this number was tripled for bisexuals (19.2%), and more than doubled for lesbians (16.9%) and gay (13.7%) individuals ( Hoel et al., 2017 ). Moreover, 90% of the transgender sample in a US study reported experiencing “harassment, mistreatment or discrimination on the job” ( Grant et al., 2011 , p. 3). These findings suggest that many of the individuals facing workplace harassment that appears to be gender neutral are actually targets of GBDH. Hence, they experience “ disguised gender-based harassment and discrimination” ( Rospenda et al., 2009 , p. 837) that should not be addressed as a gender-neutral issue.

Intersectional, Queer, and Feminist Approaches in Organizations

In this section, a short introduction to the feminist, queer, and intersectional approaches is given, as they are applied to the analyses throughout this article.

Feminist Approaches

In the beginning there was feminism.

In the words of bell hooks, “[f]eminism is a movement to end sexism, sexist exploitation, and oppression” ( Hooks, 2000 , viii). However, feminism can be a movement, a methodology, or a theoretical approach, and it is probably better to talk about feminisms than considering it a unitary concept. In this paper, different feminist approaches (see Bendl, 2000 ) are applied to the analysis. Gender as a variable takes gender as a politically neutral, uncontested variable; the feminist standpoint focuses on women as a group; and the feminist poststructuralist approach searches to deconstruct hegemonic discourses that perpetuate inequality (for the complete definitions see Bendl, 2000 ).

Gender Subtext

The gender subtext refers to an approach to the managerial discourse that brings attention to how official speeches of inclusion work to conceal inequalities ( Benschop and Doorewaard, 1998 ). Its methodology -subtext analysis- brings discourse analysis and feminist deconstruction together to scrutiny the managerial discourse and practices in organizations ( Benschop and Doorewaard, 1998 ; Bendl, 2000 ; Bendl, 2008 ; Benschop and Doorewaard, 2012 ).

Integration and Applications of Feminist Approaches and the Gender Subtext

The gender subtext serves to understand the role that organizational factors play in the occurrence of GBDH. Gender as a variable serves to underscore how the hegemonic definition of gender excludes and otherizes the LGBTQ from HRM approaches to gender equality. The feminist standpoint is applied in this paper as a framework in which two groups—women and the LGBTQ—are recognized in their heterogeneity, and still brought together to search for synergies to counteract sexism as a common source of institutionalized oppression (see Oliver, 1992 ; Franke, 1997 ). Finally, the feminist-poststructuralist approach enables conceiving gender as deconstructed and reconstructed, and to apply the subtext analysis to the organizational discourse (see Benschop and Doorewaard, 1998 ; Monro, 2005 ).

Queer Approach

Queer theory and politics.

The origins of the queer movement can be traced to the late eighties, when lesbians, gays, bisexuals, and the transgender took distance from the LGBT community as a sign of disconformity with the depoliticization of its agenda ( Woltersdorff, 2003 ). However, the “Queer” label was later incorporated in the broader movement ( Woltersdorff, 2003 ). In terms of queer theory, the most recognized scholar is Judith Butler, whose work Gender Trouble (1990) was revolutionary because it made visible the oppressive character of the categories used to signify gender, and insisted in its performative nature (see Butler, 1990 ; Woltersdorff, 2003 ).

Queer Standpoint, the LGBTQ, and HRM

In the presented model, queer theory brings attention to the exclusion of the LGBTQ community from the organizational and HRM speech. This exclusion is observed in the policies and politics supported by the HRM literature and practitioners, as well as in the way the LGBTQ are otherized by their discursive practices (e.g., validating only a binary vision of gender, Carrotte et al., 2016 ). Although the categories that the queer theory criticizes are applied in this model, its constructed nature is acknowledged (see Monro, 2005 ). In this way, McCall's (2005) argument in favor of the strategic use of categories for the intersectional analysis of oppression is supported. This analysis is conducted adopting a queer-feminist perspective ( Marinucci, 2016 ) and the intersectional approach.

Integration of Intersectionality With the Queer and Feminist Approaches

Origin and approaches.

The concept of intersectionality was initially introduced to frame the problem of double exclusion and discrimination that black women face in the United States ( Crenshaw, 1989 , 1991 ). Crenshaw (1991) analyzed how making visible the specific violence faced by black women conflicted with the political agendas of the feminist and anti-racist movements. This situation left those women devoid of a framework to direct political attention and resources toward ending with the violence they were (and still are) subjected to ( Crenshaw, 1991 ). Intersectionality theory has evolved since then, and different approaches exist within it ( McCall, 2005 ). These approaches range from fully deconstructivist (total rejection of categories), to intracategorical (focused on the differences within groups), to intercategorical (exploring the experiences of groups in the intersections), and are compatible with queer-feminist approaches (see Parker, 2002 ; McCall, 2005 ; Chapman and Gedro, 2009 ; Hill, 2009 ).

The intracategorical approach acknowledges the heterogeneity that exist within repressed groups (see Bendl, 2000 ; McCall, 2005 ). Within this framework (also called intracategorical complexity, see McCall, 2005 ), the intersectional analysis emerges, calling for attention to historically marginalized groups, [as in Crenshaw (1989 , 1991 )]. The deconstructivist view helps to de-essentialize categories as gender, race, and ableness, making visible the power dynamics they contribute to maintain (see Acker, 2006 ). The intercategorical approach takes constructed social categories and analyzes the power dynamics occurring between groups ( McCall, 2005 ).

Integration: Queer-Feminist Intersectional Synergy

Applying these complementary approaches helps to analyze how women and people from the LGBTQ community are defined (e.g., deconstructivist approach), essentialized (e.g., deconstructivist and intracategorical approaches), and oppressed by social actors (e.g., intercategorical approach) and institutionalized sexism (e.g., Oliver, 1992 ; Franke, 1997 ). It also allows the analysis of the oppression reinforced by members of the dominant group (intercategorical approach), as well as by minority members that enjoy other forms of privilege (e.g., white privilege), and endorse hegemonic values (deconstructivist and intracategorical approaches). In addition, the analyses within the inter- and intra-categorical framework allow approaching the problems faced by individuals in the intersections between sexism, heterosexism, cissexism, and monosexism (e.g., transgender women, lesbians, bisexuals), as well as considering the way classism, racism, ableism, and ethnocentrism shape their experiences (e.g., disabled women, transgender men of color).

Support for an Integrative HRM Model of GBDH in the Workplace

This section describes an integrative model of GBDH in the workplace ( Figure 1 ). First, the effects of GBDH on the health and occupational well-being of targeted individuals are illustrated (P1 and P2). Afterwards, the model deals with the direct and moderation effects of organizational climate, culture, policy, and politics (OCCPP) on GBDH in the workplace. OCCPP acts as a “switch” that enables or disables the other paths to GBDH. OCCPP's effects on GBDH are described as: a direct effect on GBDH (P3), the moderation of the relationship between gender diversity and GBDH (P3a), the moderation of the relationship between individual characteristics and GBDH (P3b), and the moderation (P3c) of the moderation effect of gender diversity on the relationship between individual's characteristics and GBDH (P4). In other words, when OCCPP produce environments that are adverse for gender minorities, gender diversity and gender characteristics become relevant to explain GBDH. When OCCPP generate respectful and integrative environments, gender diversity, and gender characteristics are no longer relevant predictors of harassment.

Figure 1 . Integrative model of GBDH in the workplace. Continuous paths represent direct relationships. Dashed paths represent fully moderated relationships. The double-ended arrow signals the relationship between gender diversity and OCCPP, which follows a circular causation logic.

Consequences of GBDH in the Workplace

Gbdh and individuals' health.

Evidence suggests that exposure to sexist discrimination and harassment in the workplace negatively affects women's well-being ( Yoder and McDonald, 2016 ; Manuel et al., 2017 ), and that different forms of sexual harassment can constitute trauma and lead to posttraumatic stress disorder ( Avina and O'Donohue, 2002 ). In their meta-analysis ( N = 89.382), Chan et al. (2008) found a negative relationship between workplace sexual harassment, psychological health, and physical health conditions. Regarding the LGBTQ at work, Flanders (2015) found a positive relationship between negative identity events, microaggressions, and feelings of stress and anxiety among a sample of bisexual individuals in the US. This is consistent with Galupo and Resnick's (2016) results about the negative effects of microaggressions for the well-being of lesbian, bisexual, and gay workers. In another study, Seelman et al. (2017) found that microaggressions and other forms of gender discrimination relate to lowered self-esteem and increased stress and anxiety in LGBTQ individuals, with the most negative effects reported by the transgender. In a study among gay, lesbian, and bisexual emerging adults in the US, exposure to the phrase “that's so gay” related to feelings of isolation and physical health symptoms as headaches, poor appetite, and eating problems ( Woodford et al., 2012 ). In the literature on gender discrimination, Khan et al. (2017) found that harassment relates to depression risk factors among the LGBTQ. Finally, according to Chan et al. (2008) meta-analysis, targets of workplace sexual harassment suffer its detrimental job-related, psychological, and physical consequences regardless of their gender.

Proposition P1: GBDH negatively affects women and LGBTQ individuals' health in the workplace .

GBDH and Occupational Well-Being

Occupational well-being refers to the relationship between job characteristics and individuals' well-being ( Warr, 1990 ). It is defined “as a positive evaluation of various aspects of one's job, including affective, motivational, behavioral, cognitive, and psychosomatic dimensions” ( Horn et al., 2004 , p. 366). It has a positive relationship with general well-being ( Warr, 1990 ) and work-related outcomes like task performance ( Devonish, 2013 ; Taris and Schaufeli, 2015 ).

There is robust evidence on the negative effects of GBDH on indicators of occupational well-being, such as overall job satisfaction, engagement, commitment, performance, job withdrawal, and job-related stress ( Stedham and Mitchell, 1998 ; Lapierre et al., 2005 ; Chan et al., 2008 ; Cogin and Fish, 2009 ; Sojo et al., 2016 ). Its negative effects have been reported among women ( Fitzgerald et al., 1997 ), gay and heterosexual men ( Stockdale et al., 1999 ), lesbians ( Denissen and Saguy, 2014 ), and transgender individuals ( Lombardi et al., 2002 ), to name some.

Proposition P2: GBDH negatively affects the occupational well-being of women and people from the LGBTQ community in the workplace .

Antecedents of GBDH in the Workplace

Direct effect of occpp on gbdh.

In the next lines, the direct effects of OCCPP on GBDH against women and people from the LGBTQ community are explored, supporting the next proposition of this model.

Proposition P3: OCCPP affect the incidence of GBDH against women and the LGBTQ .

Organizational Culture and GBDH

Organizational culture refers to the shared norms, values, and assumptions that are relatively stable and greatly affect the functioning of organizations ( Schein, 1996 ). The most plausible link between organizational culture and GBDH seems to be the endorsement of sexist beliefs and attitudes. This is supported by evidence that sexism endorsement encourages GBDH attitudes and behavior (see Pryor et al., 1993 ; Fitzgerald et al., 1997 ; Stockdale et al., 1999 ; Stoll et al., 2016 ). The literature on sexism has mainly adopted a binary conception of gender (see Carrotte et al., 2016 ). However, the last decade more research has focused on heterosexism and anti-LGBTQ attitudes, uncovering their negative effects in the lives of LGBTQ individuals.

Sexism Against Women

Scholars focusing on sexism against women have categorized it in different ways. Old-fashioned sexism refers to the explicit endorsement of traditional beliefs about women's inferiority ( Morrison et al., 1999 ). Modern and neo sexism define the denial of gender inequality in society and resentment against measures that support women as a group ( Campbell et al., 1997 ; Morrison et al., 1999 ). Gender-blind sexism refers to the denial of the existence of sexism against women ( Stoll et al., 2016 ). Benevolent sexism defines the endorsement of an idealized vision of women that is used to reinforce their submission ( Glick et al., 2000 ). Finally, ambivalent sexism is the term for the endorsement of both hostile and “benevolent” sexist attitudes ( Glick and Fiske, 1997 , 2001 , 2011 ).

Sexism Against the LGBTQ

Sexism directed against the LGBTQ takes different forms, that can be also held by members of the LGBTQ community, as the evidence about biphobia and transphobia points out (see Vernallis, 1999 ; Weiss, 2011 ). Heterosexism is the endorsement of beliefs stating that heterosexuality is the normal and desirable manifestation of sexuality, while framing other sexual orientations as deviant, inferior, or flawed (see Habarth, 2013 ; Rabelo and Cortina, 2014 ). Monosexism and biphobia refer to negative beliefs toward people that are not monosexual , namely, whose sexual orientation is not defined by the attraction to people from only one gender (see Vernallis, 1999 ). Cissexism (also transphobia ) refers to “an ideology that denigrates and subordinates trans* people because their sex and gender identities exist outside the gender binary. Transgender people are thus positioned as less authentic and inferior to cisgender people” ( Yavorsky, 2016 , p. 950). Hence, transgender individuals experience concurrently sexism, heterosexism, and cissexism/transphobia in their workplaces (see Yavorsky, 2016 ).

Organizational Climate and GBDH

Organizational climate reflects the “social perceptions of the appropriateness of particular behaviors and attitudes [in an organization]” ( Sliter et al., 2014 ). There is evidence linking organizational climate with workplace harassment ( Bowling and Beehr, 2006 ), sexual harassment ( Fitzgerald et al., 1997 , p. 578), and gender microaggressions ( Galupo and Resnick, 2016 ).

Diversity climate is “the extent to which employees perceive their organization to be supportive of underrepresented groups, both in terms of policy implementation and social integration” ( Sliter et al., 2014 ). Hence, a gender-diversity climate reflects the employees' perceptions of their workplace as welcoming and positively appreciating gender differences ( Jansen et al., 2015 ). It has been associated with an increased perception of inclusion by members of an organization, buffering the negative effects of gender dissimilarity (i.e., gender diversity) between individuals in a group ( Jansen et al., 2015 ). Sliter et al. (2014) found a negative relationship between diversity climate perceptions and conflict at work. Also, it has been suggested that it plays a crucial role for workers' active support of diversity initiatives, which is determinant for their successful implementation ( Avery, 2011 ). A similar construct, climate for inclusion has also shown to be a positive factor in gender-diverse groups, protecting against the negative effects of group conflict over unit-level satisfaction ( Nishii, 2013 ).

Heterosexist climate refers to an organizational climate in which heterosexist attitudes and behaviors are accepted and reinforced, propitiating GBDH against the LGBTQ (see Rabelo and Cortina, 2014 ; Galupo and Resnick, 2016 ). For example, Burn et al. (2005) conducted a study using hypothethical scenarios to test the effects of indirect heterosexism on lesbians, gays, and bisexuals. The participants of their study reported that hearing heterosexist comments would be experienced as an offense, affecting their decision to share information about their sexual orientation ( Burn et al., 2005 ). In addition, it has been found that LGBTQ-friendly climates (hence, low in heterosexism), can have a positive impact on the individual and organizational level ( Eliason et al., 2011 ). Examples of positive outcomes are reduced discrimination, better health, increased job satisfaction, job commitment ( Badgett et al., 2013 ), perceived organizational support ( Pichler et al., 2017 ), and feelings of validation for lesbians that become mothers ( Hennekam and Ladge, 2017 ).

Workplace Policy and GBDH

Workplace policy plays an important role in the incidence of GBDH. Finally, evidence shows that policy affects the extent to which the work environment presents itself as LGBTQ-friendly, influencing the experience of LGBTQ individuals at work ( Riger, 1991 ; Eliason et al., 2011 ; Döring, 2013 ; Dougherty and Goldstein Hode, 2016 ; Galupo and Resnick, 2016 ; Gruber, 2016 ). Eliason et al. (2011) found that inclusive language, domestic partner benefits, child-care solutions, and hiring policies are relevant for the constitution of a gender-inclusive work environment for the LGBTQ. Calafell (2014) wrote about how the absence of policy addressing discrimination against people with simultaneous minority identities (e.g., queer Latina) contributes to cover harassment against them. Galupo and Resnick (2016) found that weak policy contributes to the incidence of microaggressions against people from the LGBTQ community. Some of the situations they found include refusal of policy reinforcement, leak of confidential information, and refusal to acknowledge the gender identity of a worker ( Galupo and Resnick, 2016 ). Moreover, existent policy may serve to reinforce inequalities if its discourse is based on power binaries (e.g., rational/masculine vs. emotional/feminine) that discredit, oppress, and marginalize minority groups ( Riger, 1991 ; Dougherty and Goldstein Hode, 2016 ). For example, Peterson and Albrecht (1999) analyzed maternity-policy and found how discourse is shaped to protect organizational interest at the cost of the precarization of women's conditions in organizations. Finally, it is very important to address the mishandling of processes and backlash after GBDH complaints are filed, since they keep targets of harassment from seeking help within their organizations (see Vijayasiri, 2008 ).

Organizational Politics and GBDH

Organizations are political entities ( Mayes and Allen, 1977 ). In the workplace, power, conceived as access to information and resources, is negotiated through political networks embedded in communication practices ( Mayes and Allen, 1977 ; Mumby, 2001 ; Dougherty and Goldstein Hode, 2016 ). These communication practices operate within power dynamics in which the majority group sets the terms of the discussion and frames what is thematized ( Mumby, 1987 , 2001 ). Since gender affects the nature of these power relations, the effects of politics in gender issues and of gender issues in politics must be considered.

Full Moderation of OCCPP of the Relationship Between Gender Diversity and GBDH

Gender diversity refers to heterogeneity regarding gender characteristics of individuals in an organization. Broadly, an organization in which most workers are cisgender, male, and heterosexual would be low in gender diversity, and one in which individuals are evenly distributed in terms of their gender identity, sexual orientation, and gender expression, would be high on gender diversity. In this section, the moderation effect of OCCPP on the relationship between gender diversity and GBDH is discussed to support the next proposition of the model.

Proposition P3a: The relationship between gender diversity and GBDH is fully moderated by OCCPP. When OCCPP propitiate a hostile environment for gender minorities, low gender diversity will lead to high GBDH. When OCCPP propitiate a context of respect and integration of gender minorities, low gender diversity will not lead to higher GBDH .

Male-Dominated Workplace

In male-dominated organizations, a hypermasculine culture is predominant, male workers represent a numerical majority, and most positions of power are occupied by men (e.g., Carrington et al., 2010 ). These organizations present an increased frequency and intensity of GBDH against women, men who do not do gender in a hypermasculine form, and individuals from the LGBTQ community ( Stockdale et al., 1999 ; Street et al., 2007 ; Chan, 2013 ; Wright, 2013 ). Women in a male-dominated workplace may be confronted with misogyny at work ( Denissen and Saguy, 2014 ), becoming targets of more intense and frequent GBDH as they depart from the policed gender-rule that demands them to behave feminine, submissive, and heterosexual ( Berdahl, 2007 ). Women refusing sexual objectification in these contexts may become targets of serious forms of mistreatment, with the case that certain women “—including lesbians and those who present as butch, large, or black—may be less able to access emphasized femininity as a resource and thus [become] more subject to open hostility” ( Denissen and Saguy, 2014 , p. 383). In other words, the more they depart from the sexist and heteronormative standard, the worse is the mistreatment they will face. At the same time, the strategies some women apply to avoid hostility have a high cost for their identity and validation at work, as pointed by Denissen and Saguy (2014 , p. 383),

the presence of lesbians threatens heteronormativity and men's sexual subordination of women […] [b]y sexually objectifying tradeswomen, tradesmen, in effect, attempt to neutralize this threat. While tradeswomen, in turn, are sometimes able to deploy femininity to manage men's conduct and gain some measure of acceptance as women, it often comes at the cost of their perceived professional competence and sexual autonomy and—in the case of lesbians—sexual identity.

However, GBDH is not only directed to women in hypermasculine contexts, as suggested by Denissen and Saguy (2014) , who observed that “tradesmen unapologetically use homophobic slurs to repudiate both homosexuality and femininity (in men)” ( Denissen and Saguy, 2014 , p. 388). Hence, men working in a male-dominated context are also expected to perform hegemonic masculinity, being punished when they do not comply. This leaves men who do not present dominant traits, that are feminine, or that are not heterosexual, at risk of becoming targets of GBDH ( Franke, 1997 ; Stockdale et al., 1999 ; Carrington et al., (2010) .

Female-Dominated Workplace

Female-dominated workplaces are those where women represent a numeric majority. It has been suggested that in these contexts (e.g., nursing) women with care responsibilities can find more tools to balance work-family schedules ( Caroly, 2011 ), and face less harassment ( Konrad et al., 2010 ). However, evidence about heterosexism and harassment against people from the LGBTQ community uncovers heteronormativity in female-dominated workplaces (e.g., among nurses, see Eliason et al., 2011 ). For example, an experiment about discrimination of gays and lesbians in recruitment processes showed that while gay males were discriminated in male-dominated occupations, lesbians were discriminated in female-dominated ones ( Ahmed et al., 2013 ).

Representation of the LGBTQ in the Workplace

At the moment this paper is being written, the authors have not found research that specifically targets LGBTQ-dominated organizations. There is evidence suggesting that having more lesbian, gay, and non-binary coworkers contributes to the development of LGBTQ-friendly workplaces ( Eliason et al., 2011 ). In addition, evidence supports the positive effects of having LGBTQ leaders that advocate for the respect and integration of LGBTQ individuals in organizations ( Moore, 2017 ).

Gender Diversity, Tokenism, Glass Escalator, and GBDH

When gender-minority individuals are pioneers entering a gender-homogeneous workplace, they face a heightened probability of experiencing tokenism ( Maranto and Griffin, 2011 ). Tokenism refers to the performance pressures, social isolation, and role encapsulation that individuals from social minorities face in organizations in which they are underrepresented numerically ( Yoder, 1991 ). Gardiner and Tiggemann (1999) conducted a study comparing the effects of male- and female-dominated work environments on individuals' well-being and tokenism experiences. They found that women, in comparison to men, experience the highest levels of tokenism and discrimination in male-dominated sectors, and that they endure more pressure than men, even in female -dominated contexts ( Gardiner and Tiggemann, 1999 ). There is also an increasing number of reports on the experiences of tokenism by the LGBTQ ( LaSala et al., 2008 ; Colvin, 2015 ) and research on how to hinder the negative consequences of tokenism against them in organizations ( Davis, 2017 ; Nourafshan, 2018 ). The fact that men in female- dominated work settings report less levels of pressure than women in male dominated workplaces is compatible with Yoder's (1991) conception of tokenism as the oppression of social-minority members who are simultaneously a numerical minority. Because white men are a social majority, they do not experience the negative effects of tokenism when they are underrepresented numerically. Actually, evidence on the glass escalator effect shows that white men experience advantages when they enter female-dominated fields ( Williams, 1992 , 2013 , 2015 ; Woodhams et al., 2015 ). However, tokenism might be also present in female-dominated settings, as can be inferred from studies on LGBTQ experiences in women-dominated professions ( Eliason et al., 2011 ; Ahmed et al., 2013 ). Moreover, research in the US suggests that female CEOs tend to advance policies related to domestic-partner benefits and discrimination against women, but not necessarily advocate for a wider range of LGBTQ-inclusion policies ( Cook and Glass, 2016 ).

Gender Diversity, Contradictions, and the Role of OCCPP

The evidence on the effects of gender diversity in organizations is not free of contradictions. It has been found that the integration of male coworkers in female-dominated workplaces increases conflict between women ( Haile, 2012 ), and that as the proportion of male doctors in workgroups increases, the same happens with sexual harassment against female doctors ( Konrad et al., 2010 ). If taken together, it makes sense to consider an interaction of OCCPP and gender diversity to explain GBDH. In other words, it seems that gender diversity alone is not enough to end GBDH in the workplace, but can interact in a positive way with organizational factors to diminish conflict and GBDH (see Nishii, 2013 ). White, middle class, cisgender, heterosexual men would most likely not be targeted for GBDH in female-dominated contexts, since they are not a social minority, rather benefiting from their underrepresentation (see Williams, 1992 ). Finally, it is expected that gender diversity and OCCPP present a circular causation (see double-ended arrow in Figure 1 ), so that a higher representation of a particular minority group will traduce into OCCPP that promote inclusion for that group. At the same time, an organization whose OCCPP invites to respect and integrate gender minorities will attract more women and LGBTQ individuals (see Bajdo and Dickson, 2001 ; Moore, 2017 ).

OCCPP Full Moderation of the Relationship Between Individuals' Characteristics and GBDH

Individuals' gender characteristics intersect with race, class, ethnicity, and disability configuring complex identities and dynamics that affect individuals' experience of inequality in organizations (see Oliver, 1992 ; Acker, 2006 ; Verloo, 2006 ; Cunningham, 2008 ; Ericksen and Schultheiss, 2009 ; Cho et al., 2013 ; Donovan et al., 2013 ; Liasidou, 2013 ; Wright, 2013 ; Calafell, 2014 ; Moodley and Graham, 2015 ; Senyonga, 2017 ). In other words, it is difficult to isolate causes for exclusion, since they derive from complex power dynamics that shape individuals' experience. It was mentioned above that women and the LGBTQ tend to be more targeted for GBDH than white heterosexual men. However, it is in sexist organizational contexts that gender characteristics are made salient to propitiate GBDH.

Proposition P3b: The link between individuals' gender characteristics and GBDH in the workplace is fully moderated by OCCPP. This means that in a context of sexist OCCPP, individuals with gender-minority status will experience more GBDH. In contexts in which OCCPP propitiate respect and integration of gender minorities, GBDH will be low .

In other words, if the organizational context is tolerant of GBDH, harassment will occur based on individuals' sex, gender identity, sexual orientation, gender expression, or an intersection of those ( Crenshaw, 1991 ; Pryor et al., 1993 ; Franke, 1997 ; Stockdale et al., 1999 ; Galupo and Resnick, 2016 ). Some examples of how gender characteristics are used as grounds for GBDH are described in the following lines.

Sex assigned at birth refers to the gender category assigned to individuals according to their physical characteristics at birth ( ILGA-Europe, 2016 ). At the moment, the intersex category for those whose physical characteristics do not match the binary conception of gender at birth is not officially recognized in many countries ( ILGA-Europe, 2016 ).

Gender identity is the “deeply felt internal and individual experience of gender, which may or may not correspond with the sex assigned at birth” ( International Commission of Jurists, 2009 , p. 6). Despite the claims to adopt inclusive conceptions of gender, organizations continue to direct their gender-equality programs to white cisgender women, excluding the transgender and genderqueer (see Carrotte et al., 2016 ; Galupo and Resnick, 2016 ).

Gender expression is the way people handle their physical or external appearance so that it reflects their gender identity ( European Union Agency for Fundamental Rights, 2014 ). In highly sexist organizations, gender policing and harassment is directed against less gender-conforming individuals (e.g., Stockdale et al., 1999 ; Wright, 2013 ).

Sexual orientation refers to the “person's capacity for profound affection, emotional and sexual attraction to, and intimate and sexual relations with, individuals of a different gender or the same gender or more than one gender” ( ILGA-Europe, 2016 , p. 180). It is often the case that family policy in organizations consider only workers whose families are conformed by heterosexual couples and their children (e.g., Galupo and Resnick, 2016 ). This excludes those who are in same-sex or non-monosexual partnerships and families, sending the message that they are “different,” abnormal, or unnatural (see Galupo and Resnick, 2016 ). There is evidence that gender-exclusive language (using he and his instead of gender-inclusive forms) negatively affects the sense of belongingness, identification, and motivation of women in work settings ( Stout and Dasgupta, 2011 ). In the same way, the exclusion of people with non-binary or non-heterosexual gender characteristics in the organizational discourse makes them experience feelings of exclusion and otherization ( Carrotte et al., 2016 ).

Double Moderation of OCCPP: Its Effects on the Moderation of Gender Diversity of the Relationship Between Individuals' Characteristics and GBDH

Considering the literature on tokenism, gender characteristics (e.g., transgender) are expected to be a relevant predictor of GBDH if there is a reduced number of people with those characteristics in the organization (i.e., low gender diversity). Also, it is expected that this relationship will only take place in those situations in which the OCCPP propitiate a discriminatory and harassing environment for gender minorities.

Proposition P3c and P4: When OCCPP propitiate a discriminatory and harassing environment for gender minorities, women and the LGBTQ will experience more GBDH in a context low in gender diversity. If the OCCPP configure an environment that is inclusive and respectful of gender minorities, a low gender diversity will not lead to GBDH against women and the LGBTQ in that organization .

Recommendations for Academics and Practitioners

Need for industry-university collaborations: from the lab to the field.

Research that emerges from industry-university collaboration (IUC) is needed to better understand and counteract GBDH. Porter and Birdi (2018) identified twenty-two factors for a successful IUC. Some of these factors are: capacity of the stakeholders to enact change, a clear and shared vision, trust between the actors, and effective communication ( Porter and Birdi, 2018 ). Rajalo and Vadi (2017) developed a model of IUC, according to which success is more likely when preconditions from the involved partners (i.e., academics and practitioners) match. These preconditions are explained in terms of absorptive capacity (ability to process and incorporate new information), and motivation to collaborate ( Rajalo and Vadi, 2017 ). In other words, those involved in IUC need top management support, economic resources, a shared vision of gender equality, trust in each other, effective communication channels, and high motivation to collaborate. It is not a simple endeavor, but it is a necessary and possible one (see Porter and Birdi, 2018 ).

In collaborations, scholars and practitioners have the opportunity to work together in the design, development, implementation, and follow-up of HRM strategies. This must be done ensuring that projects are appropriate for each organization, and that the raised information is suitable for research purposes. Evidence on IUC spillover points out that firms and academics benefit from these collaborations (see Jensen et al., 2010 ). In the case of HRM, scholars can gain access to samples that are difficult to reach and economic resources to finance their research, while practitioners benefit from the academic expertise (see Jensen et al., 2010 ). In the context of gender equality, this can be useful to develop and implement evidence-based procedures to counteract GBDH (see Briner and Rousseau, 2011 ). To build the networks necessary for such collaborative alliances, public and private initiative must be taken (see Lee, 2018 ). Congresses and events that approach gender issues in organizations and aim to build bridges between the industry and the academia can offer opportunities for collaboration to occur. Finally, practitioners must gain awareness of gender issues in the workplace, and organizational-feminist scholars should write and reach for the practitioner audience as well.

A Small Help to Begin With: The Gender-Equality Starters' Toolkit

We know that for practitioners and researchers that are not familiarized with the poststructuralist, intersectional, queer-feminist theories, our recommendations may sound quite cryptic. For this reason, we developed a very simplified starters' toolkit ( Table 1 ). In its “HRM diagnose” section, we suggest ways to develop a first diagnose of the organization in relation to gender issues. The “HRM interventions” section refers to actions that can be taken in case further intervention is needed. In the “applied-research” section, we provide applied-research ideas to better understand GBDH and develop evidence-based tools for HRM. Finally, in the “references and resources” section we include references that support and complement the suggestions provided. Each row of the toolkit refers to one of the components of our model (health and occupational well-being were grouped together). As mentioned, the aim of this toolkit is to provide material for a first approach to GBDH in organizations, and inspire those interested in conducting applied research on GBDH in the workplace.

Table 1 . Recommendations for HRM practitioners and applied researchers: a starters' toolkit.

A Change of Perspective: Looking at the Organization with Queer-Feminist Lens

Change organizational politics, change the organization.

Organizational politics result from the interplay of discursive practices and power negotiations, and refer to who and how is determining the terms of these negotiations ( Mumby, 1987 , 2001 ). To understand organizational politics, the hegemonic discourse has to be analyzed utilizing deconstructive lens that uncover the operating power dynamics (e.g., Benschop and Doorewaard, 1998 ; Dougherty and Goldstein Hode, 2016 ). In other words, when deconstructing the organizational discourse, the researcher or practitioner analyzes both the content and structural elements of the particular text (see Peterson and Albrecht, 1999 ; Buzzanell and Liu, 2005 ). Organizational-text examples are: the sexual harassment policy of the organization, brochures from the last organizational-change campaign, the transcript of interviews on gender issues, the chart of values of the firm. The analysis of this material allows to observe the way gender issues are approached and defined (or not approached nor defined), to develop a first diagnose and lines of action (for an example see Dougherty and Goldstein Hode, 2016 ). Some questions that may help in the analysis are:

How is gender defined? (Whose gender is [not] validated?),

What actions or behaviors are constitutive of GBDH in this organization? (What forms of aggression and discrimination are hence allowed?),

What are the procedures if action is to be taken? (What is left out of procedure leaving space for leaks or inadequacies?), and

What is the organizational history in relation to GBDH claims? (Who has enjoyed impunity? Whose claims are [not] listened to?).

For example, the researcher or practitioner may realize that the sexual-harassment policy of a particular organization refers to cisgender individuals only. Moreover, it may be that this policy defines GBDH as harassment of men against women, excluding same-sex sexual harassment (see Stockdale et al., 1999 ). Furthermore, it may become evident that this policy is framed in a discourse of binary logics that serve to blame the victims and victimize harassers (see Dougherty and Goldstein Hode, 2016 ). Finally, after a follow-up of archived organization's processes, it may come out that harassers have historically enjoyed impunity (see Calafell, 2014 ). This initial analysis might be useful to develop a plan for change. Continuing with the example, this policy may be redefined so that it adopts an integrative conception of gender. In addition, it can be adapted to include cases of same-sex sexual harassment. It can be also reframed using a discourse that allows fairness for all parties involved. Finally, cases from the past may be analyzed to avoid committing old mistakes in the future, and if some of these cases are recent, rectification may be considered.

Reading Between the Lines: Disguised Forms of GBDH

Bullying and mobbing as disguised gbdh.

We argue that at least some workplace mistreatment that appears as “gender neutral” is actually gendered. Available evidence points to a higher frequency of bullying/mobbing against women and the LGBTQ in the workplace ( Rospenda et al., 2008 , 2009 ; Grant et al., 2011 ; Hoel et al., 2017 ). Hence, once data on workplace mistreatment is raised, it is advisable to evaluate gender disparities (e.g., statistically comparing means) that may point to cases of disguised GBDH. The importance of addressing disguised GBDH (i.e., “sexist” mobbing and bullying) lies on solving the problem (i.e., mistreatment) at its roots. According to our model, if sexist OCCPP are intervened and changed, their consequences (i.e., overt and disguised forms of GBDH) should disappear.

Disguised GBDH at the Task Level

We also believe that disguised GBDH might take place through task allocation processes. In other words, it may be that the processes of task allocation are such that they keep gender minorities away from career-development opportunities. Evidence signaling that women receive less challenging tasks that are relevant for career development suggests that the process of task allocation is not gender neutral ( de Pater et al., 2009 ). There is also research on the effects of illegitimate tasks that suggests that their assignation to individuals in organizations may be gendered ( Omansky et al., 2016 ). Illegitimate tasks are perceived as unreasonable and/or unnecessary by the person that undertakes them, and constitute a task-level stressor ( Semmer et al., 2010 , 2015 ). It was found that illegitimate tasks exert a stronger negative effect on perceptions of effort-reward imbalance (ERI) among male than female professionals ( Omansky et al., 2016 ). One explanation is that women are socialized to undertake these tasks, which is why they feel less disrupted by them ( Omansky et al., 2016 ). However, if this causes women to undertake more illegitimate tasks than men, that might bring negative consequences for their occupational development and well-being. Available evidence shows no gender differences in the reports of illegitimate tasks between women and men (see Semmer et al., 2010 , 2015 ; Omansky et al., 2016 ). However, it is unclear if this is because women do not perceive the tasks they undertake to be illegitimate, or if there is no difference de facto . To our knowledge, there is no evidence on illegitimate tasks assigned to LGBTQ individuals. We think that the findings on task-allocation and illegitimate-tasks call for more research in this subject, especially regarding the role of illegitimate tasks and task-allocation processes for the career development of women and the LGBTQ.

Lavender Over the Glass Ceiling

It is important to evaluate if, when, and what kind of leadership positions are available for gender minorities in organizations. This includes spotting cases when a single person or a small group is tokenized and expected to compensate for a lack of diversity of the whole organization (see Benschop and Doorewaard, 1998 ). The glass ceiling in the case of women and lavender ceiling in the case of LGBTQ individuals refer to the burdens faced by these groups to reach leadership positions as a consequence of sexism in organizations ( Hill, 2009 ; Ezzedeen et al., 2015 ). There is also evidence that female executives are appointed to leadership positions when odds of failing are high ( Ryan and Haslam, 2005 ). Regarding the LGBTQ, it is necessary to raise more evidence on the factors that make it possible for them to break through the lavender ceiling ( Gedro, 2010 ).

Limitations of This Study and Future Research

Our model was developed based on the review of available literature. The fact that it is based on secondary sources leaves space for bias and calls for its empirical testing. The mediation path that links the antecedents and consequences of GBDH should be tested in longitudinal studies, and the moderations proposed can be better assessed utilizing experimental designs. In this paper we argued for an integrative conception of gender in the HRM approach to GBDH. Nevertheless, data on the experiences of the LGBTQ in the workplace are mostly based on small samples, especially for the transgender. In addition, although we discussed the constructed nature of categories and pointed to their limitations, we considered women and the LGBTQ as relatively stable concepts. The experience of women and the LGBTQ greatly differs when looking to the heterogeneity between and within these groups. We thematized intersectionality mostly referring to sex assigned at birth, gender identity, and sexual orientation, and thus acknowledge our difficulty to account for exclusion dynamics involving identities in the intersection of race, gender, ableness, body form, and class. More research that focuses on these groups (e.g., transgender people of color) is needed. Finally, we made conjectures on the role that task-allocation processes may play as disguised GBDH that needs to be tested empirically as well. We think that since overt expressions of GBDH are in the decline in western workplaces, it is necessary to reach for gendered practices that disadvantage women and the LGBTQ in organizations.

Conclusions

There is a potential for synergy when HRM considers the needs of women and people from the LGBTQ community together, especially to propitiate gender equality and counteract gender-based discrimination and harassment. To start, organizational resources can be employed to neutralize the mechanisms through which gender oppression acts against women and members from the LGBTQ community. In this way, actions for gender equality help create safe spaces for both groups. In addition, framing gender and sexuality in inclusive ways helps dismantle heterosexist, cissexist, and monosexist paradigms that contribute to create discriminatory and harassing workplaces. Finally, queer and feminist perspectives should be integrated with the intersectional approach to counteract discrimination against those in the intersection of multiple marginalized identities. Hence, the needs of people of all genders, people of color, disabled people, people with different body shapes, and people with different cultural backgrounds are made visible and addressed. This assists in developing truly inclusive and respectful workplace environments in which workers can feel safe to be themselves and unleash their full potential.

Author Contributions

All authors contributed to the definition of the subject and the development of the hypotheses and model presented. CG drafted the manuscript and KO provided close support and supervision during the writing process and conducted revisions at all stages of the manuscript development. All authors contributed to the manuscript revision and approved the submitted version.

The authors received no specific funding for this work. CG acknowledges a doctoral scholarship (research grant) from the German Academic Exchange Service (Deutscher Akademischer Austauschdienst, DAAD).

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: diversity, gender equality, gender management, heteronormativity, heterosexism, human resources, intersectionality, LGBTQ

Citation: García Johnson CP and Otto K (2019) Better Together: A Model for Women and LGBTQ Equality in the Workplace. Front. Psychol. 10:272. doi: 10.3389/fpsyg.2019.00272

Received: 21 February 2018; Accepted: 28 January 2019; Published: 20 February 2019.

Reviewed by:

Copyright © 2019 García Johnson and Otto. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Carolina Pía García Johnson, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Inequalities in lesbian, gay, bisexual, and transgender (LGBT) health and health care access and utilization in Wisconsin

Linn jennings.

a Department of Population Health Sciences, University of Wisconsin-Madison, Wisconsin Alumni Research Foundation, Madison, WI, USA

Chris Barcelos

b Department of Gender and Women's Studies, University of Wisconsin-Madison, Madison, WI, USA

Christine McWilliams

Kristen malecki.

There are known health disparities between lesbian, gay, bisexual and transgender (LGBT) people and non-LGBT people, but only in the past couple of decades have population-based health surveys in the United States included questions on sexual and gender identity. We aimed to better understand LGBT disparities in health, health care access and utilization, and quality of care. Data are from the Survey of the Health of Wisconsin (SHOW) from 2014 to 2016 ( n  = 1957). The analyses focused on comparing health care access and utilization, and quality of care between LGB and non-LGB people and transgender and cisgender people. 3.8% ( n  = 73) identified as lesbian, gay or bisexual, and 1.3% ( n  = 25) were transgender. LGB adults were 2.17 (95th CI: 1.07–4.4) times more likely to delay obtaining health care. Transgender adults were 2.76 (95th CI: 1.64–4.65) times more likely to report poor quality of care and 2.78 (95th CI: 1.10–7.10) unfair treatment when receiving medical care. The results show differences in health care access and utilization and quality of care, and they add to the growing body of literature that suggest that improved health care services for LGBT patients are needed to promote health equity for LGBT populations.

• • LGBT individuals were more likely to report having fair/poor health than non-LGBT.
• • LGB individuals were more likely to delay health care than non-LGB individuals.
• • Trans respondents were more likely to report poor quality of care than non-LGBT.

1. Introduction

Health care access and utilization and quality of care are continuing to improve in the United States, but these improvements are not consistent across states or populations ( Agency for Healthcare Research and Quality, 2016 ). Health promotion initiatives in the United States, such as the Center for Disease Control's (CDC) Healthy People initiatives, have focused on understanding how these other factors differ among various populations in order to improve population health outcomes ( Alencar Albuquerque et al., 2016 ). These initiatives specifically target the health outcomes of marginalized groups, a term used to both define and understand the political and social impact of excluding and denying groups of people access to rights and services that are guaranteed to the rest of a country or society. These groups are at a higher risk of having low socioeconomic status and poor health outcomes, which contribute to why health disparities persist between marginalized and non-marginalized populations ( Agency for Healthcare Research and Quality, 2016 ; Blosnich et al., 2014 ).

Despite known health disparities between marginalized and non-marginalized populations, until recently, LGBT populations were rarely recognized as marginalized populations requiring research focus in national health initiatives ( Boehmer, 2002 ). Until the 2000's there were few surveys that included questions about sexual orientation and gender identity ( Bradford et al., 2013 ). There are vast inconsistencies in the questions on sexual and gender identity, and few use the validated questions recommended by the William's Institute: ( Bradford et al., 2013 ) three questions to establish sexual orientation (self-identification of sexual orientation, sexual behavior, and sexual attraction) ( Braveman et al., 2010 ), and a validated two-step question approach to measuring gender identity for population-based surveys (sex-assigned at birth and gender identity) ( Centers for Disease Control and Prevention, 2017 ). This incommensurability prevents surveys from identifying LGBT people with high sensitivity and specificity ( Cohen, 2017 ), which limits our ability to estimate the size of these populations, understand the health disparities, and to address these disparities on an individual, health system, and policy level.

1.1. LGBT health disparities and why they exist

The BRFSS (Behavior Risk Factor Surveillance System) and NHIS (National Health Interview Survey) survey a nationally representative sample of the United States population, and they are widely used in developing health policies at all levels of government across the United States. Previous results from national population-based studies identified several factors contributing to LGBT health disparities, including discrimination and stigma ( Conron et al., 2010 ; Cornelius and Carrick, 2015 ); limited access to health insurance ( Cruz, 2014 ); poor quality of care provided due to both discrimination based on sexual orientation and gender identity ( Conron et al., 2010 ; Durso and Meyer, 2013 ); lack of provider knowledge about LGBT health care needs ( Gates, 2014 ); and insufficient research about the health of LGBT populations ( Gorman, 2016 ; Graham et al., 2011 ). LGBT disparities in physical and mental health, health behaviors, and overall health status are shown to be linked to minority stress associated with the stigma and discrimination from having a minority status ( Grant et al., 2010 ).

Despite increased awareness about LGBT health disparities and known causes of these disparities, which are established by several decades of research, limited regional and state-level population-based data about LGBT populations continues to act as a barrier to understanding LGBT health disparities in the United States ( Bradford et al., 2013 ; Gorman, 2016 ; Graham et al., 2011 ). Health experiences of the LGBT community can vary by state and municipality due to differences in anti-discrimination laws and policies ( Green et al., 2018 ; Hasenbush et al., 2014 ). Additional evidence based research at all levels is needed to inform policies aimed at understanding the impact of these systemic biases. One of the first steps to addressing these gaps is through research to better understand LGBT health disparities in health outcomes and health care access and utilization, which can then be used to inform policy and improve provider training.

1.2. Study aims

The Survey of the Health of Wisconsin (SHOW) program, a unique state-specific population-based research infrastructure, offers an important opportunity to study LGBT health care access and utilization. Unlike other population-based health surveys (like BRFSS and NHIS) that include few questions on health insurance status and health care utilization, SHOW includes extensive questions on health care access and utilization, which help provide insight into how LGBT population use health care services differently than non-LGB/cisgender populations.

This study had two primary aims: ( Agency for Healthcare Research and Quality, 2016 ) to describe the LGB and transgender demographics, socioeconomic status, and occupation, and to compare these measure between LGB to non-LGB adults and transgender to non-LGB/cisgender adults in Wisconsin, and ( Centers for Disease Control and Prevention, 2017 ) to analyze the differences between LGB adults and non-LGB adults and between transgender and non-LGB/cisgender adults in physical and mental health, discrimination in the medical setting, health care access and utilization, and quality of care.

SHOW is an annual household-based survey that collects health-related data on a representative population in Wisconsin. The sampling strategy for 2014–2016 used a three-stage cluster sampling approach to randomly select households, using a population-weighted proportion to size with replacement (PWPPSWR) sampling protocol. First, counties were sampled based on mortality rate, and then census blocks within counties were chosen based on poverty, and third, households were randomly sampled within census blocks. The three-year sample included Milwaukee and Dane counties (the two most populated counties in the state); ten counties in total were sampled.

Since 2014, SHOW asks questions on sexual orientation and gender identity ( Table 1 ). These questions were chosen based on questions recommended by the Williams Institute and Fenway Health, but SHOW uses questions that are more similar to those used by BRFSS rather than the most recent best practice questions recommended by the Williams Institute ( Braveman et al., 2010 ; Cohen, 2017 ).

Survey of the Health of Wisconsin questions on sexual orientation and gender identity were asked during the duration of the study data (2014–2016). Questions were chosen based on the questions recommended by the Williams Institute and Fenway Health.

The SHOW data from 2014 to 2016 includes 1957 respondents who are age 18 and older. Of the survey respondents, 51 (2.6%) respondents did not answer the gender identity question, and 55 (2.8%) respondents did not answer the sexual orientation question. Of those who did not answer questions on sexual or gender identity, 41 (2.1%) respondents did not answer either of those questions.

2.1. Definitions

LGB included adults who identified as lesbian, gay or bisexual, and it included cisgender and transgender respondents. Cisgender is a term used for a person who identifies as their sex assigned at birth. Transgender is a term used for a person whose gender identity differs from their sex assigned at birth. Transgender included adults who identified as transgender or transsexual (intersex was removed from the comparison due to having a small n), and this measure included individuals who identified as LGB and non-LGB. The comparison group used for LGB and transgender was non-LGB/cisgender, which included adults who identified as heterosexual and were not transgender, transsexual or intersex. Occasionally LGBT was used to refer to both the LGB and transgender respondents.

2.2. Measures

Demographic variables included gender (for LGB and non-LGB only), age, race, occupation, income, education, and insurance status. Gender was excluded from the transgender analyses because it was unclear from the questions whether the transgender respondents answered the question about gender as sex-assigned at birth or as current gender identity. Occupation status was determined based on occupation status in the past week, income was assessed using the individual's income midpoint, and insurance status is measured by whether the respondent is currently insured.

Mental and physical health was assessed using the three measures: lifetime chronic illnesses, PHQ-2 depression screener score, Depression Anxiety Stress Scales (DASS) 21 short form scale. PHQ-2 is used as an assessment measure of depressive disorder, and it is not a diagnosis of depression. Scores range from 0 to 6, and scores of 3 and above have the highest sensitivities and specificities for identifying individuals with depressive disorders ( Igartua et al., 2009 ). DASS scores are considered a good a measure of the constructs of depression, anxiety and stress and an overall measure of emotional distress ( Ingham et al., 2018 ). We used the DASS21 z-score of 2.0 (moderate stress, anxiety, and depression) as our cut-point ( Ingham et al., 2018 ).

Health behaviors assessed were cigarette smoking and drinking habits. Cigarette smoking was divided into two categories: current smoker and former and/or never smoker. Drinking habits were divided into two categories: Heavy drinker (>14 drinks per week for men or more than drinks per week for women) and light drinker (less than these two cut-off values).

The analysis also includes measures of health care access and utilization, quality of care and discrimination: self-report of frequency of use of primary care, whether the respondent usually sees the same physician, use of preventative care services, satisfaction and quality of care received by providers, lifetime discrimination and discrimination experienced when receiving medical care.

2.3. Statistical analysis

Multiple logistic regression and multiple linear regression analyses were used to assess the relationship between LGB and non-LGB/cisgender respondents and transgender and non-LGB/cisgender respondents in Wisconsin. The analyses for LGB, transgender, and non-LGB/cisgender respondents were adjusted for age, gender (only LGB and non-LGB/cisgender respondents), race, income, and education, which were chosen based on previous survey data analyses of these populations ( Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, 2011 ). All statistical analysis was performed using SAS version 9.4 (SAS Institute Inc., Cary, North Carolina, USA) and weighted to adjust for sampling design. Sampling weights are generated for each data point by SHOW, and they are used to make the sample representative of the target population by stratifying by county, census block group, poverty, sex and race/ethnicity. The cluster, strata, and primary sampling unit estimates were used in the models run in SAS to calculate state-level estimates.

3.1. Demographic and socioeconomic characteristics

Table 2 shows the demographic and socioeconomic characteristics of LGB adults ( n  = 73) compared to non-LGB/cisgender adults ( n  = 1830) and transgender adults ( n  = 25) compared to non-LGB/cisgender adults ( n  = 1830). Socioeconomic variables were adjusted for age and gender. The weighted prevalence of lesbian, gay or bisexual respondents was 3.8% (95% CI: 2.91–4.67), and the weighted prevalence of transgender respondents was 1.33% (95% CI: 0.7–1.95). There were several differences in demographics and socioeconomic status between LGB and non-LGB/cisgender adults; the mean age of LGB adults in the sample was younger than non-LGB/cisgender adults ( p  < 0.001), fewer were married or have partners compared to non-LGB/cisgender adults ( p  < 0.001), more lived below the 200% FPL (Federal Poverty Level) than non-LGB/cisgender adults ( p  = 0.023), and more were unemployed compared to non-LGB/cisgender adults ( p  = 0.058). The mean age of transgender adults ( n  = 25) was older than non-LGB/cisgender adults ( p  = 0.03), and no transgender adults in the sample were uninsured.

Demographic characteristics for LGB ( n  = 73), transgender ( n  = 25), and heterosexual/cisgender adults ( n  = 1830) in Wisconsin from 2014 to 2016. Education, income, employment, insurance and marital status p -values were adjusted for age and gender for the comparison of LGB and heterosexual/cisgender adults and adjusted for age for the comparison of transgender and heterosexual/cisgender adults.

3.2. Health status

Table 3 presents results about health status and health behaviors, and the indicators were adjusted for by age and gender. LGB adults reported fair or poor health more often than non-LGB/cisgender adults (OR:2.12, 95% CI: 0.95–4.73), were more likely to have a depression diagnosis based on PHQ-2 (OR:2.13, 95% CI:1.26–3.62), and more likely to have a moderate to severe depression score (OR: 2.59, 95% CI: 1.15–5.83) and anxiety score (OR:1.73, 95% CI:0.99–2.99). As shown in Fig. 1 , LGB adults also scored lower on the SF-12 aggregate summary measures of mental ( p  = 0.049) and physical health ( p  < 0.01). Transgender respondents reported fair or poor health (OR: 2.22, 95% CI: 1.34–3.7), having a moderate to severe anxiety score (OR: 2.26, 95% CI:0.85–6.03), and having a history of chronic illness (OR:1.99, 95% CI: 0.86–4.6) more often than non-LGB/cisgender adults.

Adjusted odds ratios for health indicators for LGB ( n  = 73) compared to non-LGB/cisgender ( n  = 1830) (adjusted for age and gender) and for transgender ( n  = 25) compared to non-LGB/cisgender ( n  = 1830) (adjusted for age) in Wisconsin from 2014 to 2016.

Aggregate scores on mental and physical health from the SF-12 for LGB compared to non-LGB/cisgender (adjusted for age and gender) and for transgender compared to non-LGB/cisgender (adjusted for age) in Wisconsin from 2014 to 2016.

* p  < 0.05.

3.3. Health care access and utilization

Table 4 shows the adjusted odds for indicators of health care access and utilization. LGB adults were more likely not to have the cost of preventative services covered by their insurance (OR:1.89, 95% CI:1.1–3.23), to delay obtaining needed health care (OR:2.17 95% CI:1.07–4.4), and to take less medicine than prescribed, (OR:2.14, 95% CI:0.82–5.6). Transgender adults were more likely to report receiving poor quality health care (OR: 2.76, 95% CI: 1.64–4.65) and to be unfairly treated when receiving medical care (OR: 2.78, 95% CI:1.1–7.1).

Adjusted odds of healthcare access and utilization for LGB ( n  = 73) compared to non-LGB/cisgender ( n  = 1830) (adjusted for age, gender, race, education, and income) and transgender ( n  = 25) compared to non-LGB/cisgender ( n  = 1830) (adjusted for age, race, education, and income) in Wisconsin from 2014 to 2016.

4. Discussion

4.1. discussion of results on lgb health and health care access and utilization.

Few population-based studies have published results on health care access and utilization for LGBT populations. The results of this study indicate that there are differences in how LGB and non-LGB/cisgender populations access and utilize health care services in Wisconsin, and this could be due to barriers to accessing appropriate health care, such as health care cost and coverage of preventative health services. For example, although LGB respondents were equally likely to have health insurance, they were less likely to have health insurance that covers the cost of preventative health care services and more likely to delay receiving health care compared to non-LGB/cisgender respondents.

4.2. Discussion of results on transgender health and health care access and utilization

Despite having a small sample with large confidence intervals, this study is among the first statewide population-based studies to document differences in health outcomes between transgender and cis respondents. Transgender respondents were over two times more likely to report poor or fair health status (95% CI: 1.34–3.7) and to have a chronic illness (95% CI:0.86–4.6), and almost three times more likely to receive poor quality health care (95% CI: 1.64–4.65) and to be unfairly treated when receiving health care (95% CI: 1.10–7.10). Although, the study sample was small and some of the confidence intervals are quite wide, these results are similar to those from the national 2015 Transgender Survey and the twenty-one state BRFSs, which both report a higher percentage of transgender people reporting poor or fair health compared to cisgender people ( James and Herman, 2017 ; Kroenke et al., 2003 ). Our results add to the growing literature on how transgender people are more at risk for poor health outcomes and for receiving poor quality of healthcare ( Kroenke et al., 2003 ; Lerner and Robles, 2017 ; Lombardi and Banik, 2016 ). Further, these barriers and risk factors suggest opportunities towards prevention and policies to reduce discrimination need to consider transgender adults as a particularly vulnerable population.

4.3. Implications

The results from this study in Wisconsin are important in that they support previous findings about LGBT health disparities from many regions around the United States ( Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, 2011 ; Lovibond and Lovibond, 1995 ). The mounting evidence from population-based survey data support the need for federal and state public health and anti-discrimination policies to address LGBT health disparities ( Graham et al., 2011 ). Discriminatory laws and stigma faced in medical care environments have discouraged LGBT people from revealing information about their sexual orientation and gender identity, making it difficult to sufficiently identify LGBT health disparities ( Mayer et al., 2008 ). These discriminatory laws not only pose barriers to studying LGBT health disparities but also stem from stigma and bias against LGBT people, and these biases remain present in national and state policies that limit access to health care services to LGBT people and do not adequately protect the rights of LGBT people ( Green et al., 2018 ; Meyer, 1995 ; Meyer and Wilson, 2009 ).

Even with a small number of respondents in this population-based study, there are significant findings that support the notion that health insurance access is another barrier to accessing high quality health care among LGBT adults in Wisconsin. LGB respondents were more likely not to have the cost of preventative services covered by their insurance, delayed getting care and to took less medicine than prescribed, and transgender respondents were more likely to receive poor quality of care and to experience unfair treatment when receive medical care. National and state policies contribute to limiting access to health insurance and coverage for health care services. Despite significant policy changes like the Affordable Care Act (ACA) and marriage equality ( Meyer, 1995 ), disparities in access and coverage of care continue to exist in the United States. Nondiscrimination protections for health insurance and employment do not exist in most states, which prevents LGBT people from accessing and utilizing health care services to the same extent as non-LGBT people ( Meyer, 1995 ). What's more, the Trump administration has continuously worked to dismantle LGBT health protections afforded under the Obama administration, such as rolling back anti-discrimination regulations under the ACA ( Motwani and Fatehchehr, 2017 ), discouraging the use of words such as “evidence-based” or “transgender” in CDC budget documents ( Movement Advancement Project, 2018 ), and proposing that federal agencies define sex as an immutable category based on birth genitalia or chromosomes ( National Center for Transgender Equality, 2017 ).

In addition to the systemic barriers discussed above, provider discrimination and poor provider training may also prevent LGBT people from accessing necessary and appropriate health care ( Conron et al., 2010 ; Lombardi and Banik, 2016 ; Patterson et al., 2017 ). Data from this study are in agreement with previous research in other regions of the United States documenting a higher risk for poor physical and mental health due to a combination of factors related to discrimination, stigma and internalized homophobia LGBT populations ( Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, 2011 ; Lovibond and Lovibond, 1995 ). All the while LGBT populations are less likely to access and utilize health care services due to cost, not being offered appropriate preventative health screenings, or being refused care or coverage for care ( Cornelius and Carrick, 2015 ; Patterson et al., 2017 ; Ranji and Beamesderfer, 2018 ). Further, fear of discrimination in the medical care setting not only prevents transgender people from accessing health care but also influences whether they disclose their gender identity to their provider, which is an additional barrier to receiving appropriate health care ( Mayer et al., 2008 ).

These gaps in health outcomes and health care quality demonstrate that it is not sufficient to simply improve access to affordable health care. To entirely close the gap, improved provider training on LGBT health and health disparities are necessary to extend health care and high quality, appropriate health care to all LGBT populations ( Gorman, 2016 ).

4.4. Limitations

The analysis was limited by the questions asked about sexual and gender identity in the SHOW questionnaire and by the size of the survey sample. As with other population-based studies, the SHOW questionnaire includes some questions on sexual orientation and gender identity, but these questions do not follow the validated, best practice recommendations of the Williams Institute ( Braveman et al., 2010 ; Centers for Disease Control and Prevention, 2017 ; Cohen, 2017 ; Sabin et al., 2015 ). By not including all three questions about the three dimensions of sexual orientation and the two-step approach to asking about gender identity, the SHOW questionnaire most likely underestimates the percentage of respondents who are LGBT ( Centers for Disease Control and Prevention, 2017 ; Saewyc et al., 2004 ). Further, there are inconsistencies in the SHOW questionnaire with regard to time when the respondent identified with a particular gender identity or sexual orientation. The question about gender identity asks about current or past gender identity, but the sexual orientation question does not have a reference to the time (current, past, or both). The recommended practice for population-based surveys is to ask for the respondent to answer how they describe their sexual orientation and gender identity without a reference to current or past identity ( Cohen, 2017 ).

A second limitation of the survey is that reproductive health screenings are only asked of those who report their gender as female and prostate screenings are only asked of individuals who report their gender as male. Using gender as an indicator of whether a participant is eligible to answer these questions, rather than an indicator based on sex assigned at birth, prevents the survey from capturing how these services are used by transgender respondents. These are essential measures given the known barriers that prevent transgender individuals from receive appropriate preventative health screenings ( Conron et al., 2010 ; Cornelius and Carrick, 2015 ; Mayer et al., 2008 ; The GenIUSS Group and Herman, 2014 ).

Third, there are limitations to using a randomly sampled cross-sectional survey. First, the LGBT populations make up only small proportion of the population, so the survey sample of LGBT respondents is too small to estimate state-level prevalence of various health behavior and health care access and utilization indicators for LGBT sub-populations. In future studies, it will be important to make use of other sampling techniques, such as convenience sampling, in order to increase the number of LGBT respondents in the survey sample ( The Williams Institute and Badgett, 2009 ). Second, the cross-sectional survey data can only estimate current health care access and utilization and health outcomes. Without longitudinal data, we are unable to use these data to understand how these factors might contribute to LGBT disparities in health outcomes.

5. Conclusions

The goal of the CDC's Healthy People 2020 is to improve health by eliminating health disparities and promoting health equity. The results of this study are important because they add to the growing literature on LGBT health disparities and barriers to accessing and utilizing health care services. However, as we approach 2020, it becomes clear that LGBT health disparities still exist in the United States, and great changes in policy and healthcare delivery are still needed to achieve health equity for LGBT populations. Given the current knowledge of these health disparities and of the barriers that prevent LGBT populations from accessing and utilizing health care resources, steps need to be taken at many levels to reach the goals set by Healthy People 2020.

One of the next steps we need to take to begin to reduce these health disparities is to conduct more research that focuses on how health care is provided to LGBT populations at the health care system and provider levels and on how to design and implement interventions to improve provider training in serving LGBT populations. To take this next step, we need to both standardize how we measure LGBT populations and improve how we conduct population-based health survey research. First, population-based surveys need to include the recommended best practice questions published by the Williams Institute to identify LGBT respondents and questions on patient experience with providers and the health care system to better understand the health care services needs of LGBT people. Including these questions is essential for researchers, providers and policy makers to better understand the barriers to receiving necessary and appropriate health care. Second, often LGBT population samples are small, even in state and national population-based studies, which limit our ability to study these populations. This could be addressed by over-sampling LGBT populations by targeting neighborhoods are areas with larger populations of LGBT people, which has been used in other population-based studies to capture a larger sample of LGBT people ( The Williams Institute and Badgett, 2009 ). These changes to population-based survey questions are necessary to assess the patient experience so that these data can be used to design health care systems and provider training programs that are centered on improving health care services and health outcomes for LGBT populations.

Conflict of interest

Acknowledgements.

The authors would like to thank the University of Wisconsin Survey Center, SHOW administrative, field, and scientific staff, as well as all the SHOW participants for their contributions to this study. We would also like to thank Jane McElroy for her work on the sexual orientation and gender identity questionnaire to the SHOW survey, Dr. Mari Palta for her assistance with data analysis, and Dr. Bobbi Wolfe for her support on the drafting of the manuscript.

Funding for the Survey of the Health of Wisconsin (SHOW) was provided by the Wisconsin Partnership Program PERC Award (233 PRJ 25DJ), the National Institutes of Health's Clinical and Translational Science Award (5UL RR025011) and the National Heart Lung and Blood Institute (1 RC2 HL101468).

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How our education system undermines gender equity

Subscribe to the brown center on education policy newsletter, and why culture change—not policy—may be the solution, joseph cimpian jc joseph cimpian associate professor of economics and education policy - new york university @joecimpian.

April 23, 2018

There are well-documented achievement and opportunity gaps by income and race/ethnicity. K-12 accountability policies often have a stated goal of reducing or eliminating those gaps, though with questionable effectiveness . Those same accountability policies require reporting academic proficiency by gender, but there are no explicit goals of reducing gender gaps and no “hard accountability” sanctions tied to gender-subgroup performance. We could ask, “Should gender be included more strongly in accountability policies?”

In this post, I’ll explain why I don’t think accountability policy interventions would produce real gender equity in the current system—a system that largely relies on existing state standardized tests of math and English language arts to gauge equity. I’ll argue that although much of the recent research on gender equity from kindergarten through postgraduate education uses math or STEM parity as a measure of equity, the overall picture related to gender equity is of an education system that devalues young women’s contributions and underestimates young women’s intellectual abilities more broadly.

In a sense, math and STEM outcomes simply afford insights into a deeper, more systemic problem. In order to improve access and equity across gender lines from kindergarten through the workforce, we need considerably more social-questioning and self-assessment of biases about women’s abilities.

As soon as girls enter school, they are underestimated

For over a decade now, I have studied gender achievement with my colleague Sarah Lubienski, a professor of math education at Indiana University-Bloomington. In a series of studies using data from both the 1998-99 and 2010-11 kindergarten cohorts of the nationally representative Early Childhood Longitudinal Study, we found that no average gender gap in math test scores existed when boys and girls entered kindergarten, but a gap of nearly 0.25 standard deviations developed in favor of the boys by around second or third grade.

For comparison purposes, the growth of the black-white math test score gap was virtually identical to the growth in the gender gap. Unlike levels and growth in race-based gaps, though, which have been largely attributed to a combination of differences in the schools attended by black and white students and to socio-economic differences, boys and girls for the most part attend the same schools and come from families of similar socio-economic status. This suggests that something may be occurring within schools that contributes to an advantage for boys in math.

Exploring deeper, we found that the beliefs that teachers have about student ability might contribute significantly to the gap. When faced with a boy and a girl of the same race and socio-economic status who performed equally well on math tests and whom the teacher rated equally well in behaving and engaging with school, the teacher rated the boy as more mathematically able —an alarming pattern that replicated in a separate data set collected over a decade later .

Another way of thinking of this is that in order for a girl to be rated as mathematically capable as her male classmate, she not only needed to perform as well as him on a psychometrically rigorous external test, but also be seen as working harder than him. Subsequent matching and instrumental variables analyses suggested that teachers’ underrating of girls from kindergarten through third grade accounts for about half of the gender achievement gap growth in math. In other words, if teachers didn’t think their female students were less capable, the gender gap in math might be substantially smaller.

An interaction that Sarah and I had with a teacher drove home the importance and real-world relevance of these results. About five years ago, while Sarah and I were faculty at the University of Illinois, we gathered a small group of elementary teachers together to help us think through these findings and how we could intervene on the notion that girls were innately less capable than boys. One of the teachers pulled a stack of papers out of her tote bag, and spreading them on the conference table, said, “Now, I don’t even understand why you’re looking at girls’ math achievement. These are my students’ standardized test scores, and there are absolutely no gender differences. See, the girls can do just as well as the boys if they work hard enough.” Then, without anyone reacting, it was as if a light bulb went on. She gasped and continued, “Oh my gosh, I just did exactly what you said teachers are doing,” which is attributing girls’ success in math to hard work while attributing boys’ success to innate ability. She concluded, “I see now why you’re studying this.”

Although this teacher did ultimately recognize her gender-based attribution, there are (at least) three important points worth noting. First, her default assumption was that girls needed to work harder in order to achieve comparably to boys in math, and this reflects an all-too-common pattern among elementary school teachers, across at least the past couple decades and in other cultural contexts . Second, it is not obvious how to get teachers to change that default assumption. Third, the evidence that she brought to the table was state standardized test scores, and these types of tests can reveal different (often null or smaller) gender achievement gaps than other measures.

On this last point, state standardized tests consistently show small or no differences between boys and girls in math achievement, which contrasts with somewhat larger gaps on NAEP and PISA , as well as with gaps at the top of the distribution on the ECLS , SAT Mathematics assessment, and the American Mathematics Competition . The reasons for these discrepancies are not entirely clear, but what is clear is that there is no reason to expect that “hardening” the role of gender in accountability policies that use existing state tests and current benchmarks will change the current state of gender gaps. Policymakers might consider implementing test measures similar to those where gaps have been noted and placing more emphasis on gains throughout the achievement distribution. However, I doubt that a more nuanced policy for assessing math gains would address the underlying problem of the year-after-year underestimation of girls’ abilities and various signals and beliefs that buttress boys’ confidence and devalue girls, all of which cumulatively contributes to any measured gaps.

More obstacles await women in higher education and beyond

Looking beyond K-12 education, there is mounting evidence at the college and postgraduate levels that cultural differences between academic disciplines may be driving women away from STEM fields, as well as away from some non-STEM fields (e.g., criminal justice, philosophy, and economics). In fact, although research and policy discussions often dichotomize academic fields and occupations as “STEM” and “non-STEM,” the emerging research on gender discrimination in higher education finds that the factors that drive women away from some fields cut across the STEM/non-STEM divide. Thus, while gender representation disparities between STEM and non-STEM fields may help draw attention to gender representation more broadly, reifying the STEM/non-STEM distinction and focusing on math may be counterproductive to understanding the underlying reasons for gender representation gaps across academic disciplines.

In a recent study , my colleagues and I examined how perceptions on college majors relate to who is entering those majors. We found that the dominant factor predicting the gender of college-major entrants is the degree of perceived discrimination against women. To reach this conclusion, we used two sources of data. First, we created and administered surveys to gather perceptions on how much math is required for a major, how much science is required, how creative a field is, how lucrative careers are in a field, how helpful the field is to society, and how difficult it is for a woman to succeed in the field. After creating factor scales on each of the six dimensions for each major, we mapped those ratings onto the second data source, the Education Longitudinal Study, which contains several prior achievement, demographic, and attitudinal measures on which we matched young men and women attending four-year colleges.

Among this nationally representative sample, we found that the degree to which a field was perceived to be math- or science-intensive had very little relation to student gender. However, fields that were perceived to discriminate against women were strongly predictive of the gender of the students in the field, whether or not we accounted for the other five traits of the college majors. In short, women are less likely to enter fields where they expect to encounter discrimination.

And what happens if a woman perseveres in obtaining a college degree in a field where she encounters discrimination and underestimation and wants to pursue a postgraduate degree in that field, and maybe eventually work in academia? The literature suggests additional obstacles await her. These obstacles may take the form of those in the field thinking she’s not brilliant like her male peers in graduate school, having her looks discussed on online job boards when she’s job-hunting, performing more service work if she becomes university faculty, and getting less credit for co-authored publications in some disciplines when she goes up for tenure.

Each of the examples here and throughout this post reflects a similar problem—education systems (and society) unjustifiably and systematically view women as less intellectually capable.

Societal changes are necessary

My argument that policy probably isn’t the solution is not intended to undercut the importance of affirmative action and grievance policies that have helped many individuals take appropriate legal recourse. Rather, I am arguing that those policies are certainly not enough, and that the typical K-12 policy mechanisms will likely have no real effect in improving equity for girls.

The obstacles that women face are largely societal and cultural. They act against women from the time they enter kindergarten—instilling in very young girls a belief they are less innately talented than their male peers—and persist into their work lives. Educational institutions—with undoubtedly many well-intentioned educators—are themselves complicit in reinforcing the hurdles. In order to dismantle these barriers, we likely need educators at all levels of education to examine their own biases and stereotypes.

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Speech: Looking forward to a future of gender equality

Closing remarks by under-secretary-general of the united nations and executive director of un women, sima bahous, at the annual session of the un women executive board, 22 june 2022..

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[As delivered.]

Distinguished delegates, I would like to thank the President of the Executive Board, H.E. Ambassador Fatima Rabab—my good friend, your good friend—for leading us through the annual session so effectively. And we look forward, like we said earlier in the opening, to continuing to work with her in her new capacity as our best ally for gender equality within the system. So, thank you.

I would also like to thank the Vice-Presidents, and all those who have contributed to the robust discussion of this session’s significant agenda. I appreciate very much the collaborative and constructive spirit in which we are able to approach all topics. Congratulations on the adoption of the robust decisions that will guide our work.

Your engagement, distinguished delegates, in setting these joint directions signals the deep value of the multilateral process and our ability to chart a unified path for the future of UN Women. I leave the meeting today with renewed energy for the months and the years ahead.

In that regard, I also thank the delegations for their wide-ranging and perceptive remarks over the past two days.

Among the long-standing supporters of UN Women within this Board, and within your ranks of delegates, allow me to recognize, in particular, Mr. Markus Reisle, who returns to Bern as Chief of Staff at the Swiss Agency for Development Cooperation. We have deeply appreciated your skilful support during negotiations and wish you well in your new role.

Excellencies, at this session we have presented the results of the 2018–2021 period and looked ahead to the areas of focus under the new Strategic Plan . I greatly valued your guidance and feedback on this.

I would like to reiterate my remarks on our institutional strengthening efforts to enhance the transparency, accountability, and fiduciary strength of the organization. I would also like to be clear that we have heard the valuable feedback from our Independent Audit and Evaluation Service and our Audit Advisory Committee. Allow me to assure you of my personal commitment that we will take action as promised.

In my opening statement , I undertook to establish a dedicated ethics function within UN Women.   Thank you for your positive response. This confirms to me that this is the right decision. I will take action to strengthen our capacity in this area. I will ensure the highest standards of conduct in our organization, including protection of whistle-blowers, and report regularly on this to the Board from 2023. The Board’s formal decision on this subject is also welcome.

I share the Board’s views on your crucial oversight role. We will reflect carefully with you on how to make this role more effective, in addition to other aspects of internal controls of our organizational effectiveness and efficiency, such as robust anti-fraud mechanisms and strengthened audit and evaluation functions.

You have placed your trust in us, and we are committed to continuing to deserve it. I am grateful for your positive comments in regard to our success in mobilizing non-core resources, growing our regular resources, and maintaining a 30 per cent core to non-core ratio. We will continue to diversify and broaden our donor base, strengthening our strategic partnerships with international financial institutions and the work around innovative financing such as gender bonds. We will also pursue the success of multi-stakeholder partnerships in support of gender equality and women’s empowerment, such as Generation Equality , noting at the same time our shared regard for national ownership to ensure sensitivity to local contexts.

Excellencies, it is that strong relationship between country objectives and programme implementation that we saw reflected in the results of the Strategic Plan 2018–2021 . Your acknowledgement of the work that has been done to put in place gender-responsive laws, policies, and strategies at country level is especially important in the context of recovery, amidst the current political and economic turmoil.

However, as we have noted, we are still too far from achieving our shared Sustainable Development Goals .

I am pleased that the COVID-19 Policy Tracker has been useful to highlight the gaps and identify priorities. Among those gaps, social protection and care work are important for the revival of women’s participation in the labour force, including in the digital sector.

We are grateful for your recognition of the significant role played by UN Women, including through the UN Trust Fund on Violence Against Women and Girls , in responding to the intensification of violence against women and girls. I noted the emphasis, in particular, on virtual spaces and in crisis settings such as in Afghanistan and Ukraine. We share the deep concern expressed by you about reaching the most vulnerable populations in these contexts, including those at the “crossroads” of multiple forms of discrimination.

Distinguished delegates, as we look ahead to the implementation of the new Strategic Plan in the increasingly challenging global context, we will continue to focus on core areas of our work. These include ensuring that women participate meaningfully in peace and security as well as in humanitarian and climate action . As some of you noted, our UN system coordination role is vital in this regard, to amplify the work to support women and girls and make progress towards the achievement of SDG 5 and Agenda 2030 more broadly. I took good note of the several requests for stronger engagement in areas such as climate change, education, and the use of digital technology—both in terms of emerging opportunities and threats.

We appreciated the recognition of UN Women as a “catalyst of systematic change within the UN system”. We take very seriously our role in driving UN reforms, ensuring gender mainstreaming and accountability for gender equality and women’s empowerment across the UN system and assure you all of our continued commitment to do so.

I thank the Board for their continued support to the work and the mandate of UN Women.

I also thank the Secretary of the Executive Board, Jean-Luc Bories, and the entire team of the Executive Board Secretariat . Once again, they have ensured that the proceedings of the Board are seamless and well-coordinated, leading to the positive outcome of this session, including the four decisions.

Also, I would like to extend my thanks and appreciation to my Deputies, Åsa and Anita, and all my team who worked hard towards the positive decisions we have seen today.

Distinguished delegates, to conclude, this has been my first annual session. I have found it informative but, more importantly, inspiring, and also very satisfying in terms of the clarity with which we have addressed key issues with a shared focus on action. And we will act.

I will continue to depend on you all to support us. I ask those who can, to maintain or even increase funding support. I ask all of you to be champions for gender equality, alongside us, within the UN, in all multilateral spaces, and in your own countries. And I very much look forward to our ongoing work together.

I thank you.

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How Anti-Trans Efforts Misuse and Distort Science

Three types of misinformation are being used against transgender people: oversimplifying scientific knowledge, fabricating and misinterpreting research and promoting false equivalences

By Corey S. Powell & OpenMind Magazine

Falsehoods and half-truths obscure the actual science around trans rights.

Jorg Greuel/Getty Images

In 2023 alone, more than 500 anti-trans bills were proposed or adopted in nearly every state in the United States, targeting everything from drag performances to gender-affirming medical care to school inclusion policies for trans people. Support for these measures has been enabled and propelled by scientific misinformation, which has proven to be a distressingly effective tool in outraging a public that might otherwise be broadly empathetic, or at least uncertain about where to stand. In the following Q&A, law professor Florence Ashley and scientist Simón(e) Sun describe to OpenMind co-editor Corey S. Powell how deceptions in science have been used to disenfranchise trans people and other marginalized groups. (This conversation has been edited for length and clarity.)

Anti-trans sentiment has existed for a long time, but it seems like we're at a moment of particularly intense attacks. Why is that?

Florence Ashley : It’s definitely been getting worse. A lot of people who have been out since the '70s and '80s are saying that this is an unprecedented level of public hate. Even if there's been progress around rights for a lot of people, there's a whole lot more hostility. I am located in Canada, where we're starting to have anti-trans bills that would have been mostly unheard of just five years ago. In the U.S., the fact that the courts are so stacked by Trump appointees at the federal level has been particularly daunting. We are seeing alliances between the anti-reproductive justice and anti-trans movements, which is really concerning.

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Trans culture is more visible today than it has been in the past. Does that help, or is increased visibility stirring up the anti-trans movement?

Florence Ashley : Visibility is very much a double-edged sword. There are good sides to visibility, of course. It helps people realize that they're trans. You have more access to trans narratives, which gives you more space to understand yourself, and that's very positive. But at the social and political level, it has been quite negative. We're seeing a lot more people who vehemently hate trans people, who are even willing to harm trans people. Whereas people who are favorable to trans people largely just leave us alone. And a lot of reforms that we were able to achieve with relative ease, in a less visible manner, are now being rolled back.

Listen to the Podcast

Simón(e) Sun and Florence Ashley on anti-trans myths

Both of you work within academia, which is regarded, from the outside, as largely progressive. From your inside perspective, has the academic community been helpful and supportive?

Simón(e) Sun : It’s easy to assume, broadly, that academics tend to lean left, or lean progressive, but it’s much more nuanced in terms of what specific issues you're talking about. Often scientists have a false view of themselves as existing outside of social or political issues. Especially in the basic sciences, a lot of scientists feel like they don't have to think about any kind of political question.

Many of the arguments against trans rights center on the idea that transness itself is not legitimate—that there are just two sexes, period. You describe this idea as “sex essentialism.” Can you explain that term, and talk about how it shapes the debate

Simón(e) Sun : Essentialism is the idea that you can take any phenomenon that is complex and distill it down to a particular set of traits. In the case of sex essentialism, the idea is that you can sufficiently describe sex by a few particular characteristics. In this debate, it used to be chromosomes, now it’s gametes (egg and sperm cells). The target is always moving, because if you want to make something binary, then you need to find the most binary characteristic. Today, sex essentialism boils all of sex down to the gametes that a person produces. Then you draw a line from gametes to all of these other characteristics—to sex roles, even to the personality of an entire individual. But biology is just not that simple. The sex essentialist perspective is completely wrong about the biology of how sex characteristics arise.

What is the error at the center of sex essentialism and this attempt at a simple, binary definition of sex?

Simón(e) Sun : The error is simply that the gametes are a determining factor of sex—that once you know what gametes a person produces, that’s their sex and nothing about it can change. But biology is a dynamic system where an organism starts in a particular state and grows through life and through development with multiple systems interacting. That is, more precisely, how sex works. Sex essentialism boils all that down to one, immutable characteristic to preclude transness as a biological phenomenon. If you start with a model of sex that is binary, you'll always produce a binary result. And if you insist that it is true, then it is the only answer that you get.

Florence Ashley : There's something to be said about the rhetorical tricks here. The people who use ideas about biological sex against trans people are first appealing to the idea of biology as a description of difference, but then they do a jump and use that conception of biology as a form of meaning. The thing is, we organize society around meaning, not difference. Biology at its core can't tell you what matters to human organizations. So there is a fallacy here of looking at the human difference at the biological level, oversimplifying it, and then saying, “That's what we should organize people around.” We should really be asking what we care about, and then look to see if biology has anything to say about it. If you go through that exercise, then you realize that biology really has very little, if not virtually nothing, to say about things like trans rights.

You use the term “epistemological violence” to describe how people can apply ostensibly neutral scientific ideas in harmful ways. Can you explain that concept

Florence Ashley : Epistemological violence occurs when a researcher or somebody else interprets empirical results in a way that devalues, pathologizes or harms a marginalized group, even though there are equally good or better explanations for the same data. Science is always “under-determined,” a technical term that basically means there are always multiple possible ways to interpret a set of data. That’s where a lot of misinformation and oversimplification comes from, in that gap that's left. The idea of epistemological violence is that it's wrong to interpret data in a way that punches down on marginalized people. We should try to interpret the data in a way that's compatible with their inclusion and well-being, if that's an equally good interpretation. We shouldn't be cherry-picking the data to support prejudice and biased points.

You have written about three broad misinformation techniques in the trans debates: oversimplifying scientific knowledge, fabricating and misinterpreting research and promoting false equivalences. Are these the same techniques that have been used in science-based arguments about race and other human traits?

Simón(e) Sun : Absolutely. Even in climate change. Perhaps the most salient example is race science. There’s an entire history of asking about the science of racial differences, and how can we describe them in a biological way. That kind of research has been used in the past, and still is to some extent today, to bolster racist arguments. It’s an oversimplification to say that one population exhibits a lower average IQ than another population. That’s just biology, but there’s also social environment, socioeconomic status and other factors that come into play.

Here's a huge question: How do you help the general public recognize legitimate information from BS?

Florence Ashley : We need to get out of the idea that correcting misinformation by itself will convince people. But once you’ve appealed to people's emotions, once you've appealed to people's values and desire to be on your side, then correcting misinformation can make their commitment to equality sustainable. And there’s another gap, which is people who don't really have an opinion. If you already don't have an opinion on the topic, then being exposed to actual, scientifically grounded information can be very helpful. That's often what we see in courts, where even judges who were appointed by Donald Trump will sometimes rule in favor of trans rights when they're presented with information and they don’t have much preconceptions. They realize, oh, there’s so much evidence in favor of trans rights, we’ve got to do something about that. That's possible because we are talking about people who didn't have strong political attachments yet.

OK, so how can we help the general public identify the falsehoods?

Florence Ashley : There's no foolproof way. There is so much noise and misinformation that it's just hard to know even the most basic of facts. And because the problem of epistemological violence, it's not only difficult to find what the science says in terms of data, it’s difficult to interpret it on your own. We need journalists to do a better job and probe some of the basics of what people are saying. They’re legitimating a lot of anti-trans voice without really questioning the basis of their opinions, notably around claims that youth are being fast-tracked through medical transition. There's the other implied claim that if we take things slower, it's going to prevent potential regrets . We just published a review article in Psychology of Sexual Orientation and Gender Diversity where we find that there's no empirical or theoretical basis for that claim. The New York Times has been a particularly bad offender in that regard. For individuals, try to get information from a trans person who actually knows these issues.

What about ordinary people who want to help but don't know where to start—what can they do?

Florence Ashley : Shut down misinformation and hate when you see it crop up around you. Oftentimes we don't like confrontation, so we just let misinformation go. We need people to start speaking up whenever it comes up. And be loud. We’re in an ecosystem where the anti-trans voices are trying to portray themselves as speaking for a silent majority. We need people to be loud enough to counter any impression of a silent majority. You can also help trans people materially. Give them a job, help them get housing, help them pay for transition-related medical care. Share your power with trans people, giving them opportunities to write, opportunities to share with audiences and opportunities to have a say in policy-making. And share your skills.

This Q&A is part of a series of OpenMind essays, podcasts and videos supported by a generous grant from the Pulitzer Center 's Truth Decay initiative.

This story originally appeared on OpenMind , a digital magazine tackling science controversies and deceptions.

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Why is the idea of ‘gender’ provoking backlash the world over?

Increasingly, authoritarians are likening ‘genderism’ to ‘communism’ and ‘totalitarianism’

I n June, the Hungarian parliament voted overwhelmingly to eliminate from public schools all teaching related to “homosexuality and gender change”, associating LGBTQI rights and education with pedophilia and totalitarian cultural politics. In late May, Danish MPs passed a resolution against “excessive activism” in academic research environments, including gender studies, race theory, postcolonial and immigration studies in their list of culprits. In December 2020, the supreme court in Romania struck down a law that would have forbidden the teaching of “gender identity theory” but the debate there rages on. Trans-free spaces in Poland have been declared by transphobes eager to purify Poland of corrosive cultural influences from the US and the UK. Turkey’s withdrawal from the Istanbul convention in March sent shudders through the EU, since one of its main objections was the inclusion of protections for women and children against violence, and this “problem” was linked to the foreign word, “gender”.

The attacks on so-called “gender ideology” have grown in recent years throughout the world, dominating public debate stoked by electronic networks and backed by extensive rightwing Catholic and evangelical organizations. Although not always in accord, these groups concur that the traditional family is under attack, that children in the classroom are being indoctrinated to become homosexuals, and that “gender” is a dangerous, if not diabolical, ideology threatening to destroy families, local cultures, civilization, and even “man” himself.

It is not easy to fully reconstruct the arguments used by the anti-gender ideology movement because they do not hold themselves to standards of consistency or coherence. They assemble and launch incendiary claims in order to defeat what they see as “gender ideology” or “gender studies” by any rhetorical means necessary. For instance, they object to “gender” because it putatively denies biological sex or because it undermines the natural or divine character of the heteronormative family. They fear that men will lose their dominant positions or become fatally diminished if we start thinking along gender lines. They believe that children are being told to change genders, are actively recruited by gay and trans people, or pressured to declare themselves as gay in educational settings where an open discourse about gender is caricatured as a form of indoctrination. And they worry that if something called “gender” is socially accepted, a flood of sexual perversities, including bestiality and pedophilia, will be unleashed upon the earth.

Although nationalist, transphobic, misogynist, and homophobic, the principal aim of the movement is to reverse progressive legislation won in the last decades by both LGBTQI and feminist movements. Indeed, in attacking “gender” they oppose reproductive freedom for women and the rights of single parents; they oppose protections for women against rape and domestic violence; and they deny the legal and social rights of trans people along with a full array of legal and institutional safeguards against gender discrimination, forced psychiatric internment, brutal physical harassment and killing. All this fervor ramped up during a pandemic time in which domestic abuse has soared and queer and trans kids have been deprived of their spaces for gathering in life-supporting communities.

It is easy enough to debunk and even ridicule many of the claims that are made against gender studies or gender identity, since they are based on thin caricatures, and often verge on the phantasmagoric. If it matters (and let’s hope it still does), there is no one concept of gender, and gender studies is a complex and internally diverse field that includes a wide range of scholars. It does not deny sex, but it does tend to ask about how sex is established, through what medical and legal frameworks, how that has changed through time, and what difference it makes to the social organization of our world to disconnect the sex assigned at birth from the life that follows, including matters of work and love.

We generally think of sex assignment as happening once, but what if it is a complex and revisable process, reversible in time for those who have been wrongly assigned? To argue this way is not to take a position against science, but only to ask how science and law enter into the social regulation of identity. “But there are two sexes!” Generally, yes, but even the ideals of dimorphism that govern our everyday conceptions of sex are in many ways disputed by science as well as the intersex movement, which has shown how vexed and consequential sex assignment can be.

To ask questions about gender, that is, how society is organized according to gender, and with what consequences for understanding bodies, lived experience, intimate association, and pleasure, is to engage in a form of open inquiry and investigation, opposing the dogmatic social positions that seek to stop and reverse emancipatory change. And yet, “gender studies” is opposed as “dogma” by those who understand themselves on the side of “critique”.

One could go on at length to explain the various methodologies and debates within gender studies, the complexity of scholarship, and the recognition it has received as a dynamic field of study throughout the world, but that would require a commitment to education on the part of the reader and listener. Given that most of these opponents refuse to read any material that might contradict their beliefs or cherrypick from complex texts to support a caricature, how is one to proceed?

Still others claim that the very concept of “gender” is an attack on Christianity (or, in some countries, traditional Islam), and accuse the proponents of “gender” of discriminating against their religious beliefs. And yet, the significant field of gender and religion suggests that the enemies do not come from the outside, and that the dogma is to be found on the side of the censors.

For this reactionary movement, the term “gender” attracts, condenses, and electrifies a diverse set of social and economic anxieties produced by increasing economic precarity under neoliberal regimes, intensifying social inequality, and pandemic shutdown. Stoked by fears of infrastructural collapse, anti-migrant anger and, in Europe, the fear of losing the sanctity of the heteronormative family, national identity and white supremacy, many insist that the destructive forces of gender, postcolonial studies, and critical race theory are to blame. When gender is thus figured as a foreign invasion, these groups clearly reveal that they are in the business of nation-building. The nation for which they are fighting is built upon white supremacy, the heteronormative family, and a resistance to all critical questioning of norms that have clearly restricted the freedoms and imperiled the lives of so many people.

T he vanishing of social services under neoliberalism has put pressure on the traditional family to provide care work, as many feminists have rightly argued. In turn, the fortification of patriarchal norms within the family and the state has become, for some, imperative in the face of decimated social services, unpayable debt, and lost income. It is against this background of anxiety and fear that “gender” is portrayed as a destructive force, a foreign influence infiltrating the body politic and destabilizing the traditional family.

Indeed, gender comes to stand for, or is linked with, all kinds of imagined “infiltrations” of the national body – migrants, imports, the disruption of local economics through the effects of globalization. Thus “gender” becomes a phantom, sometimes specified as the “devil” itself, a pure force of destruction threatening God’s creation (not, I gather, climate change, which would be a much more likely candidate). Such a phantasm of destructive power can only be subdued through desperate appeals to nationalism, anti-intellectualism, censorship, expulsion, and more strongly fortified borders. One reason, then, we need gender studies more than ever is to make sense of this reactionary movement.

The anti-gender ideology movement crosses borders, linking organizations in Latin America, Europe, Africa, and east Asia. The opposition to “gender” is voiced by governments as diverse as Macron’s France and Duda’s Poland, circulating in rightwing parties in Italy, showing up on major electoral platforms in Costa Rica and Colombia, boisterously proclaimed by Bolsonaro in Brazil, and responsible for closing gender studies in several locations, most infamously at the European University in Budapest in 2017 before it relocated to Vienna.

In Germany and throughout eastern Europe “genderism” is likened to “communism” or to “totalitarianism”. In Poland, more than one hundred regions have declared themselves “anti-LGBT zones”, criminalizing an open public life for anyone perceived as belonging to those categories, forcing young people to leave the country or go underground. These reactionary flames have been fanned by the Vatican, which has proclaimed “gender ideology” “diabolical”, calling it a form of “colonizing imperialism” originating in the north and raising fears about the “inculcation” of “gender ideology” in the schools.

According to Agnieszka Graff, co-author with Elzbieta Korolczuk of Anti-Gender Politics in the Populist Moment, the networks amplifying and circulating the anti-gender viewpoint include the International Organization for the Family, which boasts thousands of participants at its conferences and the online Platform CitizenGo, founded in Spain, which mobilizes people against lectures, exhibitions, and political candidates who defend LGBTQI rights. They claim to have more than 9 million followers, ready to mobilize at an instant (they mobilized against me in Brazil in 2018 when a furious crowd burned the effigy of my “likeness” outside the venue where I was to speak). The third is Agenda Europe, consisting of more than 100 organizations, which casts gay marriage, trans rights, reproductive freedom, and LGBTQI anti-discrimination efforts as assaults on Christianity.

Anti-gender movements are not just reactionary but fascist trends, the kind that support increasingly authoritarian governments. The inconsistency of their arguments and their equal opportunity approach to rhetorical strategies of the left and right, produce a confusing discourse for some, a compelling one for others. But they are typical of fascist movements that twist rationality to suit hyper-nationalist aims.

They insist that “gender” is an imperialist construct, that it is an “ideology” now being imposed on local cultures of the global south, spuriously drawing on the language of liberation theology and decolonial rhetoric. Or, as the rightwing Italian group Pro Vita maintains, “gender” intensifies the social effects of capitalism whereas the traditional heteronormative family is the last bulwark against social disintegration and anomic individualism. All this seems to follow from the very existence of LGBTQI people, their families, marriages, intimate associations, and ways of living outside the traditional family and their rights to their own public existence. It follows as well from feminist legal claims to reproductive freedom, feminist demands to end sexual violence as well as the economic and social discrimination against women.

At the same time, opponents of “gender” seek recourse to the Bible to defend their views about the natural hierarchy between men and women and the distinctive values of masculine and feminine (although progressive theologians have pointed out that these are based on debatable readings of biblical texts). Assimilating the Bible to natural law doctrine, they claim that assigned sex is divinely declared, suggesting that contemporary biologists and medical doctors are curiously in the service of 13th-century theology.

It does not matter that chromosomal and endocrinological differences complicate the binarism of sex and that sex assignment is revisable. The anti-gender advocates claim that “gender ideologists” deny the material differences between men and women, but their materialism quickly devolves into the assertion that the two sexes are timeless “facts”. The anti-gender movement is not a conservative position with a clear set of principles. No, as a fascist trend, it mobilizes a range of rhetorical strategies from across the political spectrum to maximize the fear of infiltration and destruction that comes from a diverse set of economic and social forces. It does not strive for consistency, for its incoherence is part of its power.

In his well-known list of the elements of fascism, Umberto Eco writes, “the fascist game can be played in many forms,” for fascism is “a collage … a beehive of contradictions”. Indeed, this perfectly describes anti-gender ideology today. It is a reactionary incitement, an incendiary bundle of contradictory and incoherent claims and accusations. They feast off the very instability they promise to contain, and their own discourse only delivers more chaos. Through a spate of inconsistent and hyperbolic claims, they concoct a world of multiple imminent threats to make the case for authoritarian rule and censorship.

This form of fascism manifests instability even as it seeks to ward off the “destabilization” of the social order brought about by progressive politics. The opposition to “gender” often merges with anti-migrant furor and fear, which is why it is often, in Christian contexts, merged with Islamophobia. Migrants, too, are figured as “infiltrating”, engaging in “criminal” acts even as they exercise their rights of passage under international law. In the imaginary of the anti-gender ideology advocates, “gender” is like an unwanted migrant, an incoming stain, but also, at the same time, a colonizer or totalitarian who must be thrown off. It mixes right and left discourses at will.

As a fascist trend, the anti-gender movement supports ever strengthening forms of authoritarianism. Its tactics encourage state powers to intervene in university programs, to censor art and television programming, to forbid trans people their legal rights, to ban LGBTQI people from public spaces, to undermine reproductive freedom and the struggle against violence directed at women, children, and LGBTQI people. It threatens violence against those, including migrants, who have become cast as demonic forces and whose suppression or expulsion promises to restore a national order under duress.

That is why it makes no sense for “gender critical” feminists to ally with reactionary powers in targeting trans, non-binary, and genderqueer people. Let’s all get truly critical now, for this is no time for any of the targets of this movement to be turning against one another. The time for anti-fascist solidarity is now.

Judith Butler is visiting distinguished professor of philosophy at the New School University. Butler’s latest book is The Force of Nonviolence (Verso)

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A qualitative study on gender inequality and gender-based violence in Nepal

• Pranab Dahal 1 ,
• Sunil Kumar Joshi 2 &
• Katarina Swahnberg 1  

BMC Public Health volume  22 , Article number:  2005 ( 2022 ) Cite this article

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Gender inequality and violence are not mutually exclusive phenomena but complex loops affecting each other. Women in Nepal face several inequalities and violence. The causes are diverse, but most of these results are due to socially assigned lower positioning of women. The hierarchies based on power make women face subordination and violence in Nepal. The study aims to explore participants' understanding and experience to identify the status of inequality for women and how violence emerges as one of its consequences. Furthermore, it explores the causes of sex trafficking as an example of an outcome of inequality and violence.

The study formulated separate male and female groups using a purposive sampling method. The study used a multistage focus group discussion, where the same groups met at different intervals. Six focus group discussions, three times each with male and female groups, were conducted in a year. Thirty-six individuals, including sixteen males and twenty females, were involved in the discussions. The study used constructivist grounded theory for the data analysis.

The study participants identify that a power play between men and women reinforce inequality and increases the likelihood of violence for women. The findings suggest that the subjugation of women occurs due to practices based on gender differences, constricted life opportunities, and internalization of constructed differences among women. The study identifies that interpersonal and socio-cultural violence can result due to established differences between men and women. Sex trafficking, as an example of the outcome of inequality and violence, occurs due to the disadvantageous position of women compounded by poverty and illiteracy. The study has developed a concept of power-play which is identified as a cause and consequence of women's subordination and violence. This power play is found operative at various levels with social approval for men to use violence and maintain/produce inequality.

The theoretical concept of power play shows that there are inequitable power relations between men and women. The male-centric socio-cultural norms and practices have endowed men with privilege, power, and an opportunity to exploit women. This lowers the status of women and the power-play help to produce and sustain inequality. The power-play exposes women to violence and manifests itself as one of the worst expressions used by men.

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Violence against women is identified as an attempt by men to maintain power and control over women [ 1 ] and is manifested as a form of structural inequality. This structural inequality is apparent with greater agency among men [ 2 ]. The differences between sexes are exhibited in the attainment of education and professional jobs, ownership of assets, the feminization of poverty, etc., and these differences increase the risk of violence towards women [ 3 ]. The global estimate identifies that thirty percent of women experience physical and/or sexual violence during their lifetime, illustrating the enormity of this problem [ 4 ]. From a feminist perspective, lending ideas of patriarchy [ 5 ] and gender performativity [ 6 ], the understanding of gender roles prescribed by male-dominated social structures and processes helps further explore the violence and abuse faced by women [ 7 ]. According to Heise [ 8 ], men who adhere to traditional, rigid, and misogynistic views on gender norms, attitudes, and behaviors are more likely to use violence towards women. The individual and collective attitudes of men toward different established gender norms, and their reproduction explain men’s use of violence toward women [ 9 ]. It is known that gender norms influence violence, but at the same time violence also directs and dictates gender performance with fear, sanction, and corrective measures for enacting respective prescribed gender functions [ 10 ].

It is difficult for women subjected to violence to enjoy legitimate rights, as most of the infringement of their rights and violence takes place inside a private sphere of the home [ 11 , 12 ]. Violence against women is the major cause of death and disability for women [ 13 ] and globally a major public health concern [ 14 ]. Establishing gender equality is fundamental for fostering justice and attaining sustainable development [ 15 ]; moreover, violence against women has to be acknowledged as a fundamental abuse of human rights [ 16 ]. A report on global violence has identified that violence against women exists at all levels of the family, community, and state. The report recommended the development of frameworks for respecting, protecting, and fulfilling women’s rights [ 17 ]. Fifteen years later, a review of the same identifies that violence continues with impunity, reaffirming violence as a major obstacle to the attainment of justice [ 18 ].

The inclusion of the gender lens to violence against women has provided more contextual evidence to explore these processes of violence. This requires the identification of unequal power relationships and an inquiry into the differences-producing various gender stereotypes [ 19 ]. This analysis of violence requires an understanding of behaviors that promote women’s subordination and factors that favor men to sustain these malpractices [ 8 ]. A closer look at the male-centric structural arrangements embedded in the social, political, and economic organization of life reveals that these structures provide lesser access and lower accountability toward women, promote systemic subordination, and create hierarchies, resulting in the increase of violence against women [ 20 ]. This unequal gender power relationship reinforced and manifested by social approval of men’s authority over women is found operative at multiple levels and helps to produce diversities of inequalities and violence [ 21 , 22 ].

The inequalities faced by women in Nepal majorly stem from socio-cultural, economic, and religious factors and influencers that define traditional roles and responsibilities between men and women [ 23 ]. The inequalities are more evident and pronounced in settings exhibiting prominent patriarchal norms restricting advantages and opportunities for the majority of women [ 24 ]. Women in Nepal are restricted inside their homes, have lesser access to life opportunities, and have limited or no involvement in decision-making on important issues directly affecting their lives [ 25 , 26 ]. Figures indicative of women’s inequalities in Nepal suggest that one-third of women have no education, fifty-two percent of women are involved in non-paid jobs, and women are less likely than men to own a home or land [ 27 ]. The men in Nepalese society are positioned higher and are expected to be the breadwinner and protectors of their families. Most of these men intend to earn respect and obedience from women and are socially expected to discipline women to achieve it [ 28 ]. Many societies across the world including Nepal, recognizes violence as a private affair requiring discussion only within a family. This has led to a serious underreporting of violence committed toward women in Nepal [ 29 ]. The national gender data in Nepal is scarce, the available Nepal Demographic Health Survey 2016 identifies that since the age of fifteen, twenty-two percent of women and seven percent of women experience physical and sexual violence, respectively in the past twelve months [ 27 ].

The contributing factors for violence against women in Nepal include the lower social status of women, illiteracy, economic dependency, patriarchal society, sex trafficking, alcohol-related abuse, dowry-related violence, infidelity, extramarital affairs of husband, unemployment, and denial of sex with husband [ 30 , 31 , 32 ]. Nepalese women have been repressing violence with silence due to the fear of breaking relationships, receiving less love and affection from family, fear of social norms by going against men, lack of faith in the justice system, and the threat of increased violence [ 33 ]. Women and girls in Nepal are sex trafficked to various countries. Sex trafficking in Nepal is prevalent due to persistent gender inequality, violence, stigma, and discriminatory socio-cultural structures; however, the actual extent of sex trafficking is still undetermined [ 17 , 34 , 35 ].

The recent trends in Nepal with the increasing number of out-migration of men for employment have provided women with temporary autonomy, and a shift in the gender roles. Earlier research has identified that migration of male spouses has provided a resistance to the power dynamics for women on the other hand it has limited their mobility, required them to share decision-making with household structures, face continued social vigilance on the money received from remittance, and get central attention with their personal sexual lives [ 36 , 37 ].

Morang district lies in the eastern region of Nepal. A district profile report based on a census survey [ 38 ] identifies that the place is inhabited by a close to a million population, out of which ethnic groups ( close to forty percent) live in the district with a majority (seventy-eight percent) of its population living in the rural areas. Tharu an ethnic group is one of the dominant population in the study area and all study participants for this study were from same Tharu population. A close to thirty-six percent of women in the district are illiterate and the average age of marriage is eighteen years. The report identifies that only twenty-three percent of women engage in economic activities apart from agricultural work and less than fourteen percent of women head the household. Almost eighty percent of the population in the district practice Hinduism.

This study is a part of a large intervention project and it was focused to establish a qualitative baseline of the gender status in the study area. This study aimed to explore participants’ experiences and understanding of gender inequality, violence against women, and information on sex trafficking in the Morang district of eastern Nepal. The selection of sex trafficking topic was motivated to assess the respondents’ general understanding of one of the consequences of inequality and violence faced by women. The study focused to explore factors that help to produce and sustain the practice of gender inequality and violence against women in the local community.

Participants

This study was part of a larger control-comparison project that used Forum Theatre interventions to promote gender equality, reduce violence against women, and increase awareness of sex trafficking [ 39 , 40 ]. The participants for the focus group discussion included the intervention population from one of the randomly sampled intervention sites. A multistage focus group discussion [ 41 ] was used involving the same participants discussing various emerging topics at different periods. The participants were recruited voluntarily during an earlier quantitative data collection for the project. The study used a purposive sampling method for the selection of participants. The local field staff at the study site facilitated the recruitment of the participants. The study formulated separate male and female groups. A total of six focus groups, three each with male and female groups were conducted over twelve months. Two inclusion criteria were set for participation. First, the participants had to be part of the population of the larger study. Secondly, they had to witness and/or participate in the Forum Theatre interventions conducted in between the study. The set inclusion criteria served a dual purpose of understanding the causes of inequality and violence and further helped to develop and determine the efficacy of participatory Forum Theater intervention for awareness-raising among the study intervention groups [ 39 ].

A total of thirty-six participants consisting of sixteen males and twenty females joined the discussions. The first discussion consisted of eight participants each from groups while the second and the third discussion missed two female and four male participants respectively. The majority of the participants were 20–29 years old. Tharu, an ethnic community of Nepal, is a dominant population in the study area, and all the participants belonged to the same Tharu community. Only one female participant was unmarried, and a single married male participated in the discussions. All participants were literate, with four males completing a bachelor's level of education. Seven female participants had education below the high school level. The nuclear family with parents and their children was the major family type identified in both male and female groups. Table 1 provides the detail of the participants.

The focus group discussions were conducted in January 2017, April–May 2017, and January 2018. The discussions were conducted in a place recommended by the participants. An isolated place in an open setting at the premise of a local temple was used for conducting all discussions. The participants were briefed about the objectives of the discussion and written consent was obtained for their participation. Verbal consent was taken for the audio recording of the discussions. Each participant was assigned a unique numerical code before the discussions to ensure anonymity during recording, note-taking, and analysis. The discussions averaged ninety minutes during each session. The discussions were conducted with the same participants and no new participants were added during the follow-ups. A single male and female participant were missing in the second follow up and two male participants missed the final follow-up. The reason for missing participants was due to their unavailability as they were out of the village due to personal reasons.

The discussions were conducted in the Nepali language. The first author moderated all six discussions, a support field staff member took the notes, and the last author observed the discussions. The audio recordings were translated into English, and the transcriptions were checked with the recordings to verify accuracy. The field and the discussion notes were used during various stages of data analysis. The notes provided information on the discussion setting, as well as the verbal and nonverbal expressions of the participants. The notes helped to assess the impressions, emphasis, and feelings of the participants during the discussions.

The discussions used pre-formulated discussion guides with open-ended questions on inequalities, gender practices, violence, and sex trafficking. The guiding questions were based on the theoretical premise of discrimination, patriarchy, oppression, hegemony, and participation of women. Three separate discussion guides were developed for each of discussions. The guides were developed by the first and last authors. Probing was done on several occasions during the discussion to gain more clarity on the issue. Cross-checking among the participants and between the groups was done to triangulate received information. Any topic deemed appropriate for discussions and/or any unclear issues identified during the initial data analysis came up subsequently in the discussion guide during the follow-ups.

Data analysis

This study used the constructivist grounded theory method. This method adheres to a constructivist philosophical approach wherein both researchers and participants mutually co-construct the meaning of a phenomenon [ 42 ]. This interaction is important since it helps to impart the meaning of shared experiences [ 42 ]. The constructivist grounded theory made it possible to (re) discover gender issues, important for both the researcher and the study participants. This method allowed the study to progress with responsiveness to emerging issues with an in-depth exploration of the identified issues. This clarity was achieved through repeated interactive discussions, analysis of explanations, and sharing of emergent findings with the study participants.

The audio recordings were translated and transcribed into English. Six transcripts from discussions were initially analyzed using a line-by-line coding process. The coding process helped with the fragmentation of data through interactive comparisons. Fifty-two initial codes such as gender differences, restricting women, alcohol-related violence, underreporting of sexual violence, coping, etc. were identified. The later stage of focused coding helped to achieve categorized data, providing logical sense to the developed initial codes. Three focused codes, namely, the subjugation of women, violence, and chasing dreams were formulated during the analysis. The abductive reasoning from the codes, memos, and discussion notes helped to develop the theoretical concept. The development of conceptual abstraction involved an iterative comparison of the data, codes, categories, memos, and discussion notes.

The constant communication between the authors during the stages of data analysis such as the formulation of codes, explanations of concepts, and categories helped to refine the analysis. The shared experiences of the participants and the description of the data collection and analysis included substantial details, enabling comparisons for future research and application to other similar contexts. The reliability of the study is warranted by the theoretical saturation [ 42 ] achieved by this study. This is supported by prolonged engagement with the study participants with communication on the emerging findings, and triangulation.

Reflexivity has a greater significance for the constructivist approach. The first and the second author of Nepalese origin were aware of the socio-cultural norms, stereotypes, values, and stigmas associated with gender in the local context. This helped the study to ascertain the depth of inquiry within the acceptable local normative limits. The non-Nepalese author, familiar with the study participants and Nepalese contexts, witnessed the discussions as an observer. The prior knowledge of the authors helped to critically assess different schemas, perspectives, and explanations shared by the participants. The universality of gender inequality and violence against women and its re-examination in the local context helped the authors to build upon existing knowledge by providing contextual explanations. The diversities among the authors and research participants established a basis for co-creating the perceived and observed realities.

The section below describes the participants’ perceptions and understanding of inequality and violence. The section contains subheadings that were derived as themes in the data analysis. The first theme subjugation of women; discusses how norms, beliefs, and practices produce inferior status and positions for women. The second theme domestic and gender violence; provides a narrative of interpersonal and socio-cultural violence present in the study area. The theme of chasing dreams; discusses the process of sex trafficking as an outcome of violence. The theoretically abstracted concept of power-play identifies the cause for the generation of power imbalance producing inequality and the use of violence by men.

Subjugation of women

The subjugation of women reflected practices and beliefs imparting positional differences for women and their social situation compared to men. The participants shared a common understanding that belief systems adhering to male supremacy have positioned women in a lower status. They provided examples of social practices of male supremacy such as males being considered as the carrier of a family name, legacy, and heritage, while women were referred to as someone else’s property. The socialization of the idea that girls will be married off to a husband and relocate themselves to their homes was identified as the major reason for instilling and perpetuating early gender differences. The participants mentioned that discriminatory practices and seclusion have situated women at the bottom rung of the gender hierarchy, establishing them as socially incompetent individuals or groups. Moreover, they inferred that selective preferences provided preparatory grounds for inequalities, and they remain attached to women throughout their lives. The participants provided examples of unequal access to education and life opportunities as a practice of selective preferences occurring in the community. They mentioned that socialization with these discriminatory beliefs and their practice helped to develop specialized gender roles from an early age. The participants provided an example of how gender intersected with mobility and resource generation in the community, it was clear from the discussions that this has restricted women inside homes but provided freedom and opportunities for men. A female participant expressed,

A woman from a poor family is more than willing to work and support her family. But she is not allowed by the men in the family to work outside of the home.

The participants informed that differences between the sexes were visible for women from a young age. Sharing practical examples from the community, the participants from both groups stated that girls received education mostly in low-cost government and community schools, while boys were enrolled in expensive private schools. They raised concerns that this selective investment for education, cited as the ‘building block of life’ by the participants, installed lesser capacity, and negotiating abilities in girls. A female participant stated,

There are differences in educational opportunities for boys and girls in our community. Family provides more support for a boy’s education by enrolling him in private schools, while a girl mostly gets her education in a community school together with engagement in household work.

The discussions revealed that women required several male anchors for their survival during their various stages of life. The participants provided examples of the shift of anchors for women which traversed from a father to a husband during marriage and later to the male child during her old age. They believed that this tradition of transferring women’s identity established men as a higher social category and stripped women of their individuality and identity. A male participant added,

Women have to remain dependent on men throughout their lives, first with their fathers and later with their husbands. They remain completely dependent as they are not economically active. This makes men believe that they have higher authority.

The female participants provided an example of marriage to illustrate how someone else’s decision-making had been affecting women’s lives. A participant explained that women were held responsible for household activities after marriage and any support for career progression or education was restricted despite her desire for its continuation. It was inferred that women had to drop their hopes and aspirations as the husband and his family made decisions for them. The female participants agreed that this continuous exposure to the ideas of male supremacy makes them start to believe and internalize the idea that women have lesser cognitive abilities and intelligence compared to men. A female participant stated,

Men and women certainly have different mental abilities. Men think and act differently often in a smart way compared to women.

The participants from both groups expressed that youth in the community were developing flexible attitudes and beliefs towards gender roles and responsibilities. They agreed that both young men and women were observed altering their roles and responsibilities shifting from traditional gender ideologies. The participants expressed that instilling these fluidity and flexible approaches in the older generation was impossible as they strictly followed traditional beliefs and practices. Few of the female participants admitted that at times young women also fail to accommodate the situation and reap benefits from available opportunities. The discussions revealed that a few of the women in the community received opportunities for independence and economic empowerment. These women had received entrepreneurial training and various skill development activities for sustaining livelihoods with practical skill-based training in tailoring, beautician, and doll-making. The female participants expressed that opportunities for independence and growth slipped away from them due to a lack of family support, financial constraints, and self-passivity. They explained that starting a business required approval from a family which was difficult to obtain. Moreover, if women made a self-decision to start up on their own, they lacked the initial capital and had to rely on men for obtaining resources. The participants further explained that the denial of men to support women were majorly due to the fear that norms of staying indoors for women will be breached and economic independence may enable women to have a similar financial footing as men. The participants stated that self-passivity in women emerged due to their engagement in household multiple roles, dependency upon males, and lack of decision-making power and abilities. A female participant summed it up by stating,

Some of us women in the community have received entrepreneurial skills training, but we have not been able to use our skills for our growth and development. Once the training finishes, we get back to our household chores and taking care of the children.

The female participants admitted that acceptance of belief systems requiring women to be docile, unseen, and unheard were the reasons for this self-passivity. The female participants resonated that the external controlling and unfavorable environment influenced by practices of discriminatory norms and beliefs developed self-passivity for women. A female participant expressed the cause and consequence of self-passivity as,

Women have inhibitions to speaking their minds; something stops us from making our position clear, making us lose all the time.

The discussions identified that gender norms were deeply engraved in various social interactions and daily life, and any deviance received strict criticism. The participants shared common examples of sanctions for women based on rigid norms like restrictive movements for women, social gossiping when women communicated with outsider men, prohibition for opinion giving in public, and lesser involvement during key decision-making at home. The participants shared that norms dictating gender roles were in place for both men and women with social sanctions and approval for their performance. A male discussion participant who occasionally got involved with cooking which was a so-called “women’s job” faced outright disapproval from his female relatives and neighbors. The male participant stated,

If I cook or get engaged in any household jobs, it is mostly females from the home and neighborhood who make fun of me and remind me that I am a man and that I should not be doing a woman’s job.

The foreign migration of youth looking for job opportunities has affected the Tharu community. It was known that a large number of men were absent from the community. The participants stated that women in such households with absent men had gained authority and control over resources, moreover, these women have been taking some of the men’s roles. The participants disclosed that these women had greater access and control over resources and were involved in the key decision-making positioning them in a relatively higher position compared to other women. It was known that this higher position for women came with a price, they were under higher social vigilance and at higher risk of abuse and violence due to the absence of ‘protective men’. It was known that women's foreign employment was associated with myths and sexist remarks. The participants shared that women had to face strict social criticisms and that their plans for livelihood and independence were related to an issue of sexual immorality and chastity. The participants from both groups strictly opposed the norms that associated women with sexual immorality but lamented that it continues. A male participant provided an insight into the social remarks received by women if she dares to go for foreign employment,

If a woman wants to go for a foreign job, she is considered to be of loose character. The idea that she is corrupt and will get involved in bad work will be her first impression of anyone.

Although the participant did not explicitly describe what bad work referred to as but it was inferred that he was relating it to sex work.

Domestic and gender violence

The participants identified violence as control, coercion, and use of force against someone will occurring due to unequal status. They primarily identified men as the perpetrators and women as the victims of violence. They explained that two types of violence were observed in the community. The first type occurred in an interpersonal relationship identified as physical, emotional, and sexual violence. The second type, as explained by the participants had its roots in socio-cultural belief systems. They provided examples of dowry exchange and witchcraft accusations for the latter type. The participants identified women as primary victims and listed both men and women as the perpetrators of both types of violence. They reported that physical violence against women by men under the influence of alcohol was the most commonly occurring violence in the community. The participants from both groups confirmed that wife-beating, verbal abuse, and quarrel frequently occurred in the community. It was known from discussions that alcohol consumption among men was widespread, and its cultural acceptance was also increasing episodes of violence. One of the female participants clarified further,

The most common violence occurring in our society is wife-beating by a husband under the influence of alcohol. We see it every day.

The participants reported the occurrence of sexual violence in the community but also pointed out that people refrained from discussing it considering it a taboo and private affair. The participants had hesitation to discuss freely on sexual violence. During the discussions, participants from both groups informed only of rape and attempted rape of women by men as sexual violence present in the community. Despite repeated probing, on several occasions, none of the participants from either group brought up issues and discussions about any other forms of sexual violence. Participants from both groups confirmed that stories about incidents of rape or attempted rape emerged only after cases were registered with the local police. The participants presumed that incidents of rape and attempted rape were not known to the wider community. A female participant stated,

Sexual violence does occur in our community, but people mostly do not report or disclose it, but they tend to keep it amongst themselves and their families.

The participants explained the identity of the rape perpetrator and victim. They identified the perpetrator as a rich, influential, and relatively powerful man from the community. The victim was portrayed as a poor and isolated woman which lesser social ties. It was known from the discussions that most of the rape cases in the community were settled with financial negotiations and monetary compensations for the victim rather than finding legal remedies. It can be inferred that the victimization of women intersects with gender, wealth, social stature, and affluence. The participants feared that this practice of settlement of rape with money could make rape a commodity available for the powerful, rich, and affluent men to exploit and victimize women. A male participant clarifies,

Recently, a man in his sixties raped a young girl near our village. The victim's family was ready to settle with monetary compensation offered by the rapist, but the involvement of the community stopped it and the rapist was handed over to the police.

The participants shared available coping mechanisms against violence practiced in the community by women. It was learned that the victim of household violence mostly used community consultation and police reporting to evade further violence. They divulged that community consultation and police reporting resulted in decisions in favor of victim women, directing abusive husbands to show decency and stop committing violence. The fear of legal repercussions such as spending time in police custody and getting charged under domestic violence cases was understood as the reasons for husbands to stop abuse and violence. The discussions revealed that women who file a formal complaint about their husband’s violent behavior could face an increased risk of violence. The participants disclosed that sharing such incidents publicly brought shame to some of the men and increased their anger, and often backlashed with increased violence. The participants in both groups stated that not all women in the community reported violence. They identified that women tend to be quiet despite facing continuous violence due to the fear of encountering more violence and to keeping their families together. A female participant clarifies,

Lodging public complaints against the abusive husband can sometimes escalate the violence. The husband’s anger for being humiliated in public must be faced by the woman inside the closed doors of the house with more violence and the men’s threat of abandoning the relationship.

The participants stated that socio-cultural violence against women in dowry-related cases was widespread and increasing. The dowry exchange was explained as a traditional practice with the family of the bride paying cash and kind to the groom's family. The participants clarified that the practice of dowry in the earlier days must have been an emergency fund for the newly wedded bride in a newer setting. According to the participants, the system of dowry has now developed and evolved as a practice of forced involuntary transfer of goods and cash demanded by the groom’s family. The discussions disclosed that the demands for dowry were increasing with time and failing to provide as promised immediately resulted in violence for the newly wedded bride. The participants described that dowry-related violence starts with taunts and progresses to withholding of food, verbal abuse, and finally, physical violence. They added that perpetrators of such violence were both men and women from the groom’s family. They stated that due to poverty not all bride families in the community were able to supply all demanded dowry which has exposed a large number of women to face dowry-related abuse and violence. The discussions also informed of a newer trend among girls by demanding goods during their wedding. It was shared that this new emerging trend had increased a two-fold financial burden on the bride’s family with heavy marriage debts. The male participants when questioned about the dowry demands cunningly shifted the responsibilities towards family and stated that it was not the groom but their families who were making such dowry demands. The discussions verified that dowry practice was so engraved in the community that it was impossible to even imagine a marriage without any dowry. A male participant reflected,

If I marry without any dowry, my family, neighbors, and all whom I know would consider that I am insane.

The participants also discussed and identified harmful traditional practices present in the community. The participants informed a common practice of accusing women of as witches existed in the community. It was mentioned that women faced witchcraft allegations in different situations. They provided examples of witchcraft allegations in common situations such as when someone’s cow stops producing milk when a child has a sore eye, when someone is bedridden due to sickness for days, or when a woman undergoes a miscarriage, etc. The participants stated that women accused of witch were always elderly/single women living in seclusion, poverty, and with fewer social ties. They also shared that the witch doctors, who ascertain whether a woman is a witch or not, were surprisingly mostly always men and hold higher status, respect, and social recognition. The consequences of being labeled as a witch, as explained by the participants, haunted victim women with torture, name-calling, social boycott, and extremes of physical violence. The participants informed that inhumane practices such as forceful feeding of human excreta prevailed during the witch cleansing sessions. A female participant explaining the witchcraft situation stated,

Witchcraft accusation is very real in our community; I know someone who has tortured his mother, citing reasons for his wife being childless. The old woman was called names, beaten, and later thrown out of the home.

The participants felt that men’s use of violence and its legitimization primarily existed due to gender hierarchy and internalization of the belief that violence was the best method to resolve any conflict. They inferred that men’s use of violence was further reinforced by women's acceptance and belief that violence had occurred due to their faults and carelessness. The female participants shared examples of common household situations that could result in an episode of violence such as women cooking distasteful food, failing to provide timely care to children and the elderly due to workload, and forgetting to clean rooms. These incidents make women believe that violence majorly occurred due to their mistakes. Furthermore, the participants believed that this self-blaming of the victim resulted due to constant exposure to violence and a non-negotiable social positioning of women for raising questions. The participants stated that beliefs instilled by religion increased the likelihood of victimization for women. They explained that religious practices and ideologies required women to refer to their husbands as godly figures, and a religious belief that anything said or done against husbands was a disgrace bringing sin upon her and family positioned women in an inferior position. A male participant added,

We belong to a culture where females worship their husbands as a god, and this might be an important reason for men to feel powerful as a god to exploit and abuse women.

The discussions put forward the idea that the existence of discriminatory beliefs, reinforcement of such beliefs, and a blind following of such practices produced differences and violence. The male participants acknowledged that the idea of male supremacy not only produced violence but also established a belief system that considered violence as an indispensable way to treat deviated women. One male participant stated this idea of male supremacy and privilege as,

The language of the feet is essential when words fail.

The participants also discussed violence committed toward men by women. The male participants burst into laughter when they stated that some men were beaten by their wives when they were drunk. The male participants admitted that intoxication reduced their strength and they got beaten. The female participants, on the other hand, assumed that women hit intoxicated men due to frustration and helplessness. They further clarified that the act of husband beating was a situational reaction towards men who had spent all of their daily earnings on alcohol. They stated that women with the responsibility to cook and feed family find themselves in an utterly helpless situation by the irresponsible drinking behavior of men. The male participants shared incidences of violence against men due to foreign migration. It was revealed in the discussions that some of the migrating men’s wives had run away with remitted money, abandoning marriage, and breaking up the family. The male participants identified this as a form of victimization of men, furthermore, the spreading of rumors and gossip caused emotional instability in those men. The female participants confirmed that some returning men failed to find their homes, property, money, and/or their wives. The discussion participants in both groups identified that this practice was on the rise in the community. It became apparent from the discussions that this increasing trend of women running away with the money and breaking away from family was a personal issue requiring social remedies.

Chasing dreams

The participants referred to sex trafficking as the exploitation of women, arising from poverty, illiteracy, and deceit. Explaining the causes of trafficking, the participants stated that women living in poverty, having dreams of prosperity and abundance were tricked by the traffickers making them victims of sex trafficking. The participants mentioned that women who had dreams larger than life and yearned for a comfortable and luxurious life in a short time were at a greater risk for sex trafficking. The participants from both groups resonated that the traffickers had been manipulating the dreams of poor women and deceiving them into trafficking. A female participant elaborated,

Women in poverty can be fooled easily with dreams. She can be tricked by a trafficker by saying I will find you employment with good pay abroad, and she gets into the trap easily.

A male participant further clarified,

Women readily fall into fraud and trickery shown by the traffickers who assure of luxurious life with foreign employment and this bait often leads to sex trafficking.

They identified that false hopes for foreign jobs were primarily used as an entry point by the traffickers to trap potential victims. Besides, they stated that some traffickers tricked women with false romantic relationships and marriages to win over their trust enabling traffickers to maneuver women as they wished.

It was identified that traffickers were not always strangers but known and familiar faces from the community, allowing the traffickers to gain the victim’s trust. The discussions divulged that traffickers strategically chose women who were less educated and poor. The participants explained that sex trafficking mostly occurred among women from a lower caste (the caste system is hierarchy-based in Hindu society which is determined by birth and unchangeable). They further explained that if one of these lower caste women went missing, it seldom raised any serious concerns in society, making these women easy targets for the traffickers. The discussions revealed that life for the survivors of sex trafficking was difficult. They identified that the survivor had to face strong stigmas and stereotypes which further increased their risk for re-victimization. The participants explained that the social acceptance of the trafficking survivors was minimal and finding a job for survival was very difficult. It was reported that social beliefs, norms, and practices were rigid for sex trafficking survivors and provided lesser opportunities for complete social integration. A female participant stated,

The story of a sex-trafficked woman does not end after her rescue. It is difficult for her to live in society, and this increases her chances of being a further victim.

The discussions in both groups highlighted that education and awareness were important for reducing sex trafficking. The participants felt that securing a livelihood for women was essential, but they identified it as a major challenge. The female participants recommended the use of education and awareness for reducing sex trafficking. They demanded effective legal actions and stringent enforcement of the law with maximum punishment for offending sex traffickers. They mentioned that the fear of law with maximum punishment for culprits could help decrease cases of trafficking.

The theoretical concept of power play

The discussions identified that gender inequality and violence against women occurred as men possessed and exercised greater authority. The participants explained that the authority emerging from male-centric beliefs was reinforced through established socio-cultural institutions. It was known that oppressive practices toward women in both public and private life have led to the domination and devaluation of women. The differences between men and women were known to be instilled by evoking discriminatory beliefs and due to internalization of them as fundamental truths by women which further helps to sustain these created differences.

The concept of power-play developed from the study has its roots in the belief systems and was found constantly used by men to maintain created differences. The power-play rise due to patriarchy, guiding discriminatory norms and unequal gender practices. These norms and practices in the canopy of patriarchy positions women inferior to men and impose control and restrictions. The power play possessed multi-dimensional effects on women such as creating further barriers, restricted life opportunities, the need for men-centered anchoring systems, and exclusion from the public arena. The power play gains its strength from the strict enforcement of stereotypical practices and committed adherence to gender performances. This leads to internalization of subordination as a natural occurrence by women. These further isolate women putting them into several non-negotiating positions. The power play at an individual level provides restrictive movement for women, barring them from quality education and other life opportunities, and is exhibited in alcohol-related assault and sexual violence. At the structural level, this power play limits women from economic opportunities, access to resources, and decision-making, and induces socio-cultural inequality exhibited in dowry and cases of witchcraft. The socio-cultural acceptance of power-play allows men to use violence as a misuse of power and use it as an effort to maintain authority. The use of power-play for committing violence was identified as the worst display of exercised power play.

Figure  1 describes the concept of power-play developed from the study. The power-play model is based on discussions and inferences made from data analysis. The model provides a description and explanation of how women are subjected to inequality and face violence. The concept of power play derives its strength from the subjugated status of women which are based on selective treatment, self-embodiment of inferiority, imposed restrictions and due to lesser life opportunities. The power play gain legitimacy through social approval of the status differences between men and women and through social systems and institutions majorly developed and favoring men. The status difference between men and women and its approval by developed social institutions and processes give rise to the concept of powerplay. It identifies that status differences allow men to gain and (mis)use power play not only to maintain differences but also enable men to use violence. The use of power-play exists at both interpersonal and cultural levels. Further, the model elaborates on influencers causing subjugation of women, display of power-play, and violence. The model identified that lodging public complaints and seeking legal remedies are the influencers that suppress violence against women. The influence of Forum Theater was perceived to have greater influence for victim, perpetrator, and bystanders. The influencers that aggravate violence are fear of further violence, the nature of the interpersonal relationship, alcohol-related abuse, and remaining silent especially on sexual violence. The cultural violence mentioned in the model refers to dowry and witchcraft-related violence and stands as systemic subordination. In the model, sex trafficking is depicted as one of the outcomes of inequality and violence faced by women majorly occurring due to deceit and fraud.

The theoretical concept of power-play developed in this study identifies that inequality produces violence and violence further reinforces inequality, creating a vicious circle. The power play situates hierarchy based on gender as the primary cause and identifies violence as an outcome of this power asymmetry. The authority to use power by men is received by social approval from embedded structures and institutions. The functioning of associated structures and norms is designed and run by men helping to perpetuate the dominance and subjugation of women. The study identifies that both interpersonal and socio-cultural violence emerges due to the positional differences and use of power. The study found that an element of control exists in interpersonal violence. The findings show that few victim women in the community took advantage of consultations and rely on the law to evade and /or cope during the occurrence of interpersonal violence. A large number of victims women however suffer silently as they are unable and unwilling to take a stand on violence due to their perceived positional differences and strict norms following. The study finds that violence originating from socio-cultural systems is widely accepted and no established means of control exists. The practice of heinous acts against a fellow human during witchcraft allegations and dowry exchanges is prohibited by the law of Nepal but is widespread. This situates that practices which are based on belief systems are more effective than prevailing national laws which try to stop them. Sex trafficking as a form of sexual violence use deceit and fraud against women. Poverty and illiteracy compel women to search for alternatives, and they become easy victims of sex trafficking when their dreams of a better life are manipulated by the traffickers. The false promise of a better life and highly paid job put women in a non-negotiating position with traffickers. The cherished dream of escaping the prevailing status-quo of oppression, subordination, violence, and poverty mesmerizes women to take risky decisions, falling into the risk and trap of sex trafficking.

The socio-cultural norms are the unwritten script of social operatives and functioning. These social norms function as codes of operation and are a major determinant for behavior and interactions between people [ 43 ]. The study has found that these norms were skewed, and most favored men, giving rise to status differences and producing inequalities for women. This is observed with lesser life opportunities, lower participation in decision-making, and a constant need to anchor women. This further helps men to maintain their hierarchical positional status and use violence. The subjugation of women does not occur in a linear process, it is influenced by the internalization of discrimination resulting in lower self-esteem, suppression, and domination of women based on norms and unequal practices. Earlier research has identified that norms and beliefs encourage men to control women, and direct them to use force to discipline women which increases the risk of violence occurrence [ 44 , 45 ]. An earlier study shows that traits of masculinity require men to become controlling, aggressive, and dominant over women to maintain status differences [ 46 ]. The study confirms that men upon receiving both normative and social approval for using violence against women can do so without hesitation.

Violence against women in Nepal mostly occurs inside the home and is only reported when it reaches higher levels of severity. The acceptance of violence as a private affair has restricted women from seeking support and discourages them from communicating their problems with outsiders [ 47 ] this increases more likelihood for men to use violence. The study finds issues related to sex and sexual violence is a taboo and are seldom reported. The study could only identify cases of sexual assault registered with the police and other cases known to the wider community as sexual violence. A community with known incidents of rape may have other cases of abuse, harassment, incest, forceful sexual contact, etc. Failure to report incidents of sexual violence infer that a large number of women could be suffering in silence. Earlier research identifies that increased stigmatization associated with sexual violence, and fear of seclusion cause reluctance in victims to report or seek support [ 48 ]. This silencing of victims provides men with greater sexual control over women [ 49 ] increasing more likelihood of use of violence. Gender-based inequality and violence intersect structures, institutions, and socio-cultural processes, making inequality and violence visible at all levels. The dowry-related violence and witchcraft allegation intersect interpersonal and structural violence. This cultural violence forces women to be a victim of lifelong abuse and trauma. The intersecting relationship between gender norms, social structures, and individual is so closely knitted that it produces varieties of inequality and violence at all levels [ 50 ]. Emotional violence in this study only emerged as a type of violence, during discussions in both groups. It did not emerge as a major concern for the participants except for dowry-related violence and violence against men. The intertwined nature of emotional violence and its occurrence with each abusive, exploitative, and violent situation may have influenced the participants understand it as a result, rather than as a specific type of violence.

The power play between sexes was found in synchronicity with the established norms and prevailing stereotypes, helping to perpetuate gender power imbalance. The gender system is influenced and governed by norms and the social arena becomes the site of its reproduction through the interaction and engagement of people. This interaction provides approval to the institutions and processes that are based on constructed differences between men and women [ 51 ]. The power, as identified by Fricker [ 52 ], controls a social group and operates and operates through the agent or established social structures. A man can actively use the vested power to either patronize and/or abuse women while passively women’s internalization of social settings and embedded norms can put them docile. The social controls as reported by Foucault [ 53 ] work with the embedded systems of internalization, discipline, and social monitoring and uses coercion rather than inflicting pain. The internalization of status differences among women as indicated by the study confirms this schema of social control. The dominance of men over women with patriarchal beliefs establishes the significance of male-centered kinship. This requires women to constantly anchor with men providing grounds for inequalities to perpetuate further. This idealizes men and reinforces the belief that women are non-existent without their presence. The requirement for male anchorage has an attachment to prevailing structural inequality. The family property and resources are mostly controlled by men and it usually transfers from father to son limiting inheritance to women [ 51 ]. These glorified idealizations of men's competence as described by Ridgeway [ 54 ] idealize men as individuals with abilities, status, power, and influences. The need for women to rely on men as anchors, fear of going against the norms and social sanctions explains the positional difference and show that men possess greater competencies. The internalization of men-centric superior beliefs by women occurs due to self-passivity and devalues women creating false impressions of their abilities. The gender roles and responsibilities were strict for both sexes but provided greater flexibility, privilege, and opportunity for men. Earlier studies in congruence with this study find that socio-cultural expectations limit women from deviation, and strictly adhere to their prescribed role and expectations [ 55 , 56 ] providing an upper hand to the men. The unequal social positioning of women, as defined by a few of the participants, can help define men's use of violence. As inferred by Kaufman [ 57 ], the disadvantageous position of women and support from the established structures enable men to use aggression and violence with considerable ease. The concept of power-play derived from this study also reflects that inequalities not only create hierarchies, putting women into a subordinating position but also legitimize norms of harmful masculinity and violence [ 57 , 58 , 59 , 60 ] creating a vicious cycle of inequality and violence. The concept of power-play developed by this study requires further exploration of gender relations, injustice, and patriarchy to identify multiple operatives of power with an outcome of inequality and violence.

Strengths and limitations of the study

The study followed the same participants over a period, which helped the study to achieve clarity on the topics through constant engagement. The data collection and the initial data analysis of the study were conducted by the same person, which reduced the risk of misrepresented findings. The study used follow-up discussions, which provided an opportunity to meet the participants again to resolve any ambiguities. The constant engagement with the participants helped to develop rapport and trust, which is essential to enable meaningful discussions. The study gathered rich data for developing the theory of power play in the Nepalese context. The study has attempted to explain the interplay of men’s use of power play, gender inequality, and violence against women, which, in itself, is a complex, but important issue. The study helped to develop a platform by identifying a level of awareness and needs for a Forum Theatre intervention study, a first of its kind in Nepal.

The major limitation of the study is that it was conducted with only one of the ethnic populations of Nepal; thus, the findings from this study cannot be generalized to a completely different setting. However, the transferability of the study is possible in a similar setting. The incidences of inequality and violence shared by the participants were self-reported, and no other means of verification were available to crosscheck those claims. The differences among the participants both in and between groups based on education and marital status might have influenced the study participants to understand, observe, and experience the phenomenon. The possibility of social desirability bias remains with the study, as a constant engagement with the study participants might have influenced them to answer differently. Furthermore, the discussions were conducted in groups, and participants might have had hesitation to bring up any opposing views. The study relied on collecting information on social norms and individual experiences and the perceptions of the study participants. It cannot be claimed that the study is devoid of any data rigidity as participants were free to choose what they wanted to share and express.

Study implications

The study explains gender practices, norms, violence against women, and sex trafficking in Nepal. The study helps to increase the understanding of how gender systems are operative in the daily lives of the Tharu community in the Morang district of Nepal. Future studies can explore the established linkages of interpersonal and socio-cultural violence. Like the complex link existing between gender inequality and violence against women, interpersonal violence and socio-cultural violence cannot be studied in isolation. The study provides an opportunity for future research on exploring how changing norms have been altering the position and victimization of women. The study finds that changing gender norms and responsibilities have, on the one hand, provided agency and empowerment for women, but on the other hand, they have also increased their risk of being a victim, an area that requires further exploration. The study has identified that constant engagement with the study participants through follow-up studies ensures the richness of data, which can be useful information for a future research study design. The study can be helpful for policy development, social activists, leaders, and researchers as it discusses prevalent gender oppressions and victimization, which need to be addressed. The findings from the study can be helpful for dialogue imitation and for designing intervention projects aimed at providing justice and equality to women.

The study identifies the presence of gender inequalities and violence against women in the study area. The positional differences based on norms, institutions, and practices have assigned greater privileges to men. The concept of power-play devised by the study ascertains the maintenance of gender hierarchy to produce inequality further and victimization of women. The subjugation of women based on the social-cultural process, embedded belief systems, and norms prevent women from life opportunities and dignified life. It situates men at the highest rung of the gender and social ladder providing a comparative advantage for men to use power. Violence emerges as men’s use of power play and as a strategy for the continued subjugation of women. Sex trafficking as a consequence of inequality and violence has its origins in illiteracy and poverty with women falling prey to the deceit of traffickers. It is important that dreams for progression provide motivation for women to develop further but at the same time, dreams should not be exchanged with trickery and fraud offered by the traffickers. Awareness and attitudinal changes are imperative to challenge unequal norms, and practices, and reduce the risks of sex trafficking. This can help to develop negotiations for power-sharing which helps to reduce inequality, violence, and preparedness in chasing dreams. Changes at both individual and societal levels are necessary to develop a collective action for establishing belief systems and practices providing women with an equal position and reducing the risk of violence.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to privacy but are available from the corresponding author upon reasonable request.

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Acknowledgements

The authors are grateful to all the focus group discussion participants. The authors are indebted to Bhojraj Sharma, Deekshya Chaudhary, Subham Chaudhary, and Dev Kala Dhungana for their coordination and facilitation in reaching the discussion participants.

Open access funding provided by Linnaeus University.

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Pranab Dahal & Katarina Swahnberg

Department of Community Medicine, Kathmandu Medical College, 446 00, Kathmandu, Nepal

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Contributions

PD, SKJ, and KS were involved in the study design. PD and KS developed the discussion guides. PD was responsible for the data collection and the data analysis. All authors read and approved the final manuscript.

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Correspondence to Pranab Dahal .

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Dahal, P., Joshi, S.K. & Swahnberg, K. A qualitative study on gender inequality and gender-based violence in Nepal. BMC Public Health 22 , 2005 (2022). https://doi.org/10.1186/s12889-022-14389-x

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DOI : https://doi.org/10.1186/s12889-022-14389-x

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Gender pay gap in U.S. hasn’t changed much in two decades

The gender gap in pay has remained relatively stable in the United States over the past 20 years or so. In 2022, women earned an average of 82% of what men earned, according to a new Pew Research Center analysis of median hourly earnings of both full- and part-time workers. These results are similar to where the pay gap stood in 2002, when women earned 80% as much as men.

As has long been the case, the wage gap is smaller for workers ages 25 to 34 than for all workers 16 and older. In 2022, women ages 25 to 34 earned an average of 92 cents for every dollar earned by a man in the same age group – an 8-cent gap. By comparison, the gender pay gap among workers of all ages that year was 18 cents.

While the gender pay gap has not changed much in the last two decades, it has narrowed considerably when looking at the longer term, both among all workers ages 16 and older and among those ages 25 to 34. The estimated 18-cent gender pay gap among all workers in 2022 was down from 35 cents in 1982. And the 8-cent gap among workers ages 25 to 34 in 2022 was down from a 26-cent gap four decades earlier.

The gender pay gap measures the difference in median hourly earnings between men and women who work full or part time in the United States. Pew Research Center’s estimate of the pay gap is based on an analysis of Current Population Survey (CPS) monthly outgoing rotation group files ( IPUMS ) from January 1982 to December 2022, combined to create annual files. To understand how we calculate the gender pay gap, read our 2013 post, “How Pew Research Center measured the gender pay gap.”

The COVID-19 outbreak affected data collection efforts by the U.S. government in its surveys, especially in 2020 and 2021, limiting in-person data collection and affecting response rates. It is possible that some measures of economic outcomes and how they vary across demographic groups are affected by these changes in data collection.

In addition to findings about the gender wage gap, this analysis includes information from a Pew Research Center survey about the perceived reasons for the pay gap, as well as the pressures and career goals of U.S. men and women. The survey was conducted among 5,098 adults and includes a subset of questions asked only for 2,048 adults who are employed part time or full time, from Oct. 10-16, 2022. Everyone who took part is a member of the Center’s American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. This way nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories. Read more about the ATP’s methodology .

Here are the questions used in this analysis, along with responses, and its methodology .

The  U.S. Census Bureau has also analyzed the gender pay gap, though its analysis looks only at full-time workers (as opposed to full- and part-time workers). In 2021, full-time, year-round working women earned 84% of what their male counterparts earned, on average, according to the Census Bureau’s most recent analysis.

Much of the gender pay gap has been explained by measurable factors such as educational attainment, occupational segregation and work experience. The narrowing of the gap over the long term is attributable in large part to gains women have made in each of these dimensions.

Related: The Enduring Grip of the Gender Pay Gap

Even though women have increased their presence in higher-paying jobs traditionally dominated by men, such as professional and managerial positions, women as a whole continue to be overrepresented in lower-paying occupations relative to their share of the workforce. This may contribute to gender differences in pay.

Other factors that are difficult to measure, including gender discrimination, may also contribute to the ongoing wage discrepancy.

Perceived reasons for the gender wage gap

When asked about the factors that may play a role in the gender wage gap, half of U.S. adults point to women being treated differently by employers as a major reason, according to a Pew Research Center survey conducted in October 2022. Smaller shares point to women making different choices about how to balance work and family (42%) and working in jobs that pay less (34%).

There are some notable differences between men and women in views of what’s behind the gender wage gap. Women are much more likely than men (61% vs. 37%) to say a major reason for the gap is that employers treat women differently. And while 45% of women say a major factor is that women make different choices about how to balance work and family, men are slightly less likely to hold that view (40% say this).

Parents with children younger than 18 in the household are more likely than those who don’t have young kids at home (48% vs. 40%) to say a major reason for the pay gap is the choices that women make about how to balance family and work. On this question, differences by parental status are evident among both men and women.

Views about reasons for the gender wage gap also differ by party. About two-thirds of Democrats and Democratic-leaning independents (68%) say a major factor behind wage differences is that employers treat women differently, but far fewer Republicans and Republican leaners (30%) say the same. Conversely, Republicans are more likely than Democrats to say women’s choices about how to balance family and work (50% vs. 36%) and their tendency to work in jobs that pay less (39% vs. 30%) are major reasons why women earn less than men.

Democratic and Republican women are more likely than their male counterparts in the same party to say a major reason for the gender wage gap is that employers treat women differently. About three-quarters of Democratic women (76%) say this, compared with 59% of Democratic men. And while 43% of Republican women say unequal treatment by employers is a major reason for the gender wage gap, just 18% of GOP men share that view.

Pressures facing working women and men

Family caregiving responsibilities bring different pressures for working women and men, and research has shown that being a mother can reduce women’s earnings , while fatherhood can increase men’s earnings .

Employed women and men are about equally likely to say they feel a great deal of pressure to support their family financially and to be successful in their jobs and careers, according to the Center’s October survey. But women, and particularly working mothers, are more likely than men to say they feel a great deal of pressure to focus on responsibilities at home.

About half of employed women (48%) report feeling a great deal of pressure to focus on their responsibilities at home, compared with 35% of employed men. Among working mothers with children younger than 18 in the household, two-thirds (67%) say the same, compared with 45% of working dads.

When it comes to supporting their family financially, similar shares of working moms and dads (57% vs. 62%) report they feel a great deal of pressure, but this is driven mainly by the large share of unmarried working mothers who say they feel a great deal of pressure in this regard (77%). Among those who are married, working dads are far more likely than working moms (60% vs. 43%) to say they feel a great deal of pressure to support their family financially. (There were not enough unmarried working fathers in the sample to analyze separately.)

About four-in-ten working parents say they feel a great deal of pressure to be successful at their job or career. These findings don’t differ by gender.

Gender differences in job roles, aspirations

Overall, a quarter of employed U.S. adults say they are currently the boss or one of the top managers where they work, according to the Center’s survey. Another 33% say they are not currently the boss but would like to be in the future, while 41% are not and do not aspire to be the boss or one of the top managers.

Men are more likely than women to be a boss or a top manager where they work (28% vs. 21%). This is especially the case among employed fathers, 35% of whom say they are the boss or one of the top managers where they work. (The varying attitudes between fathers and men without children at least partly reflect differences in marital status and educational attainment between the two groups.)

In addition to being less likely than men to say they are currently the boss or a top manager at work, women are also more likely to say they wouldn’t want to be in this type of position in the future. More than four-in-ten employed women (46%) say this, compared with 37% of men. Similar shares of men (35%) and women (31%) say they are not currently the boss but would like to be one day. These patterns are similar among parents.

Note: This is an update of a post originally published on March 22, 2019. Anna Brown and former Pew Research Center writer/editor Amanda Barroso contributed to an earlier version of this analysis. Here are the questions used in this analysis, along with responses, and its methodology .

What is the gender wage gap in your metropolitan area? Find out with our pay gap calculator

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Women have gained ground in the nation’s highest-paying occupations, but still lag behind men

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