Over half of transgender and nonbinary people who died in the Portland metro area over the past decade were misgendered on their death certificates, a new study from tri-county officials found. The findings underscore how the region’s death investigation system is not set up to record valuable gender identity information.

“What we learned will likely alarm anyone who identities as transgender or nonbinary–or anyone who cares about the rights of transgender and gender nonconforming people,” said Kimberly Repp, chief epidemiologist for Washington County, in a press release. “When a population is not counted, it is erased.”

In a first-of-its-kind study, epidemiologists from Multnomah, Clackamas, and Washington counties compared death certificates from 2011 to 2021 to medical death investigator logs—software used by investigators to record information relating to the death investigation. Researchers searched the logs for mentions of “transgender” and “nonbinary” in the log notes. If a death is suspected to be a suicide, investigators can fill out a supplemental suicide-related form that does include a standardized “transgender” option to record gender identity, which researchers also used to compare against death certificates. There is no requirement for medical examiners to collect gender identity information in both suicide and non-suicide cases.

Researchers found 47 cases where a decedent was identified as transgender in the medical examiner’s log notes or suicide-related form. Of those 47 cases, 29 people were misgendered on their death certificate. Transgender women were most commonly misgendered, with 20 out of the 33 who died being labeled as “male” on their death certificate.

“In the rare instance where a person’s gender identity is collected by the [medical examiner], it is essentially not represented on the final death record, essentially non-consensually de-transitioning the individual in death and contributing to the erasure of the transgender population in public health mortality surveillance,” the report states.

According to the report, current training standards and medical examiner software create barriers to accurate gender reporting. The medical examiner reporting software Oregon uses has hundreds of possible data fields to include in a report, including a person’s education level, whether their death occurred “within city limits,” and their fitness level. But when it comes to reporting sex or gender, the software only allows examiners to mark “female,” “male,” or “unsure.” According to the report, “unsure” is only used in cases where sex cannot be determined due to the state of the remains.

“It's concerning on a couple of different levels,” said Blair Stenvick, a spokesperson for LGBTQ advocacy organization Basic Rights Oregon. “One is the basic dignity of everyone deserving to be understood and, in this case, remembered as the person that they are.”

This faulty reporting can contribute to a lack of accurate data on transgender people in the Portland area. Not only do local governments use identity information from death certificates to inform how funding for social services and health programs should be invested, but accurate identity information is critical to understanding critical population statistics. Transgender people are four times as likely as cisgender people to be the victims of a violent crime and have higher mortality rates than their cisgender counterparts. Addressing that disparity requires an accurate understanding of the problem.

“Having accurate data on how and why trans people are dying is also really important to helping prevent that from happening more in the future,” Stenvick said. “If we don't even know how people in our community are dying, we don't know what problems we necessarily need to solve.”

One seemingly simple fix for the problem is to add gender identity reporting fields to the death investigation system. However, county officials say they have been advocating for a change to the reporting system—a private software contracted through the Oregon State Medical Examiner—but have yet to see changes made. According to county spokespeople, Multnomah and Washington counties have already been training death investigators on the importance of collecting gender identity information and tri-county health officials are planning more formal training with death investigators on the topic, however the study authors are urging for national standards to be changed.

The report also recommends creating laws, at a state or national level, that mandate the recording of gender identity.

“The systems just need more inclusive boxes,” said study co-author Molly Mew. “Death investigators, medical examiners, and funeral directors often know how a decedent identifies, they just don’t have anywhere to document that. The bigger challenge is the culture shift we need for people to recognize why we need good data on gender identity.”