in 2011 in its adult HIV case report form and its Enhanced HIV/AIDS Reporting System. She added that CDC data collected using the two-question system registered a 64 percent increase in transgender people compared to just asking current gender identity without asking about sex assigned at birth.

The next step in implementation is to train all staff and health care professionals to ask questions about gender identity correctly and consistently. Then, it is important to educate funders, health departments, and government agencies about the need to aggregate and disseminate the collected data. Only through data aggregation and dissemination will it be possible to determine the size of the transgender population and identify specific health risks and health care needs of transgender people. The last step is to use the disseminated data to improve services and programs for transgender people.


Developing the sexual identity question for the National Health Interview Survey (NHIS) involved multiple steps that Kristen Miller described, starting with settling on what exactly the survey needed to measure. Sexual orientation, she said, is not a measurable concept, but rather is a generic catch-all term that describes an essence of how an individual feels. Instead, sexual orientation is an amalgam of three other concepts: sexual behavior, sexual attraction, and sexual identity.

Sexual behavior looks at actual same-sex versus opposite-sex sexual behavior and is not necessarily consistent with self-conception or presentation of self. One problem in designing a question to quantify sexual behavior is that definitions of what counts as “sex” vary across sub-groups. Sexual attraction refers to same sex versus opposite sex or gender desire, and it, too, is not necessarily consistent with self-conception or presentation of self. Sexual attraction is a latent and elusive phenomenon that is neither tangible nor observable. Miller said that the problem with designing a question to quantify sexual attraction is that there are different variations in what people think of as sexual attraction. Sexual identity describes an individual’s conscious identification of an understanding of self, and in that respect, is similar to racial identity because it represents the individual’s relationship to their social world. Sexual identity is a complex phenomenon that may fluctuate.

The key to designing questions around these three concepts is to not conflate them, Miller stated, adding that the term “sexual orientation” should be eliminated when used with scientific data because it does not reflect the realities of people’s lives. This is particularly true, she added, for women, and in her mind, the use of the term “sexual orientation” does

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