Death Certificates Often Misgendered Transgender and Nonbinary People, First-of-a-Kind Study Finds

Transgender and nonbinary people are often misgendered on their death certificates. Those are the findings of a new study published by a group of Oregon epidemiologists in the January 2023 issue of the Journal of Public Health Management and Practice. The authors are calling for legislative and practical reform to make sure that trans and non-binary people’s wishes are respected after they die. 

You can learn a lot about a person by reading their death certificate. This vital record tells you the cause and manner of death, the person’s age, race, ethnicity and it tells you the day they were born and the day they died. There is also a field to list the person’s sex. In most cases the only choices are male, female or “unknown” — for situations where the body is so damaged the sex can’t be determined by physical examination.

But there is no field on death certificates (and in the software medical examiners and death investigators use to record details about deaths) to enter gender identities for people who have transitioned to another sex or for those who identify as neither male nor female. The result is that thousands of transgender and nonbinary people in the US are misgendered on their death certificates.

In our paper in the January issue of the Journal of Public Health Management and Practice, “Transgender and Nonbinary Deaths Investigated by the State Medical Examiner in the Portland, Oregon, Metro Area and Their Concordance with Vital Records, 2011-2021,” we document this disturbing finding and recommend practical and policy changes to ensure that transgender and nonbinary people are respected after they die.

When a population is not counted, it is erased

Our findings are upsetting, not just for the families and friends of transgender and non-binary people and those who care about them, but also on a population level.

Transgender people experience violence and discrimination at rates far higher than cisgender people (people who identify as the same sex they were assigned at birth). Transgender and nonbinary people also experience higher rates of poverty, mental illness and substance use disorders. And they are more likely to become victims of homicide and suicide. In our study, 69% of the deaths were attributed to suicide.

We and other researchers are unable to establish the full extent of these disparities because no agency routinely collects this information and national and state-level databases do not offer easy paths for entering this data.

If we had a more accurate picture of deaths among transgender and nonbinary people, we could make a better case for increased funding to prevent these deaths.

Oregon study points to a larger, national problem

Our study was relatively small, including 51 deaths among transgender people that took place in the Portland, Oregon metro region over a 10-year period — and it only included deaths investigated by the medical examiner’s office.

But we believe this is a problem of national significance, and that many trans and nonbinary people in every state are misgendered after they die — whether or not their death is investigated by a medical examiner.

Some states and health departments have instituted reforms to try to correct the problem. California passed a law adding “nonbinary” to the list of options for the person completing the death certificate. New York City Health Department and the Oregon Health Authority added ‘X” as an option on death certificates in addition to male, female, unknown or undetermined.

These reforms are a start, but they don’t go far enough. Many trans and nonbinary people do not have the resources to legally change their identity on their driver’s license, birth certificate or social security card. These are the documents that many death investigators use — along with a physical examination — to determine the dead person’s sex. Right now, there is no national requirement that death investigators learn how to capture gender identity.

In many states, including Oregon, funeral directors enter the final sex designation on death certificates, but next of kin, who may not support the dead person’s gender identity, have the final say and can tell funeral director what to enter.

This process is known as “nonconsensual detransitioning.”

How we conducted our study

To conduct our study, my co-authors Jaime Walters, a senior epidemiologist with Multnomah County Public Health, and Molly Mew, a population epidemiologist with Clackamas County Public Health, combed through the narrative section of medical examiner reports in our three counties from January 2011 through September 2021.

This was the only way to identify transgender and nonbinary deaths because there is no field in the medical examiner case management software that captures this information. We then compared the medical examiner notes in the narrative section with the official death certificates for 47 of the deaths.

More than half — 29 out of 47 — were misgendered on their death certificates, with the highest error rate occurring in transgender women. Of the 33 transgender females who died during that time, 20 were identified as male on their death certificates. 

National reforms needed

In the Portland metro area, we have taken steps to address this issue, lobbying for changes in the national medical examiner database and proactively training staff to record gender identity. But we need national reforms, including:

  • Laws that mandate recording of gender identity on death certificates.
  • Fields on death certificates and case management systems that allow for gender identity to be recorded in place of, or in addition to, sex assigned at birth.
  • Mandatory training for death investigators and funeral directors on how and why to collect gender identity information.
  • Laws that give funeral directors the power to use gender identifying documentation enacted by the decedent prior to death, rather than relying solely on the opinion of the next of kin.

We hope that our research calls attention to the need for systemic changes that will give transgender and nonbinary people the same rights that cisgender people receive after they die.

Author Profile

Kimberly Repp
Dr. Kimberly Repp is the chief epidemiologist and supervisor of the Washington County Medical Examiner’s Office in Oregon. Dr. Repp and her medical examiner team won the 2018 Susan P. Baker national public health impact award which integrated death investigators as a key part of public health prevention.