It has been found that a low level of trust among members of a construction project team leads to poor performance in China. Many researchers have described the challenges, consequently advocating partnering as an attractive approach for more valuable cooperation. Because substantial investments have been poured into construction projects since the year 2000, trust research will improve the performance of construction projects and will be meaningful to the Chinese construction industry.The purpose of this paper is to investigate the attributes affecting owners’ trust of contractors, to understand the potential properties of these factors, and to rank the factors in order of importance.Twenty-four attributes are identified from a literature review. Supported by qualitative reviews, a questionnaire is conducted to obtain relevant data, and 168 valid responses are obtained for data analysis. Principal component analysis (PCA) is employed to find the factor structure of the identified trust attributes. By the method of PCA, the attributes are extracted into eight factors, including interaction history, information sharing and communication, contract and institution, relation-specific investment, reputation, integrity, competence, and opportunistic behaviour.The value and originality of this paper are embodied in using PCA to understand the various attribute groupings and to illuminate trust impact factors in the Chinese context. When they understand the critical factors affecting trust better, owners and contractors can devise more appropriate strategies to improve performance.The online version of this article (doi:10.1186/s40064-016-3393-9) contains supplementary material, which is available to authorized users. Many studies have identified the importance of trust in construction projects . For each of the 24 attributes, the participants were asked to state whether they agreed that the attribute has a high impact on trust in construction projects using a 5-point Likert scale (1 = Strongly Disagree and 5 = Strongly Agree).PCA was employed to find groupings of the 24 identified variables and to investigate the potential characteristics. The goal of PCA is to find the crucial information from the data and to show the information as a set of new orthogonal variables, the principal components  test and Bartlett’s Test of Sphericity were conducted. The KMO is expressed as an index ranging from 0 to 1. The literature suggests that the value of KMO should be greater than .70 for factor analysis Stern . BartletAfter all of the necessary requirements are satisfied, we conducted the factor analysis by PCA with varimax rotation. The rotation method is employed because it maximises the variance of the factor loadings by making the high loadings higher and the low loadings lower on each factor (Chiu and Lau A clear component structure exists if a variable has a significant factor loading (loading > 0.50) on one component only Spector . The loaThe rotated component matrix is shown in Table Followings are to explain the eight principal components extracted. Since the paper employs an exploratory approach involving many attributes, the explanation of the components is challenging. Another challenge is that the combinations of variables that load high on a component have patterns that are difficult to interpret. Therefore, the explanation of factors needs a certain amount of imagination and ingenuity (Wai et al. After a critical inspection of variables in the components, a proper name is given to each extracted factor. The eight factors are named as follows: the interaction history factor, the contracts and institutions factor, the information sharing and communications factor, the relation specific building factor, the competence factor, the reputation factor, the integrity factor, and the opportunistic behaviours factor.Based on the findings from the survey and the opinions from interviews, the meanings of the eight factors are explained as follows.The first factor includes four variables, namely “long-term cooperation”, “interaction experience”, “similarity”, and “common goals” (see Table Because of the dynamic, challenging, and complex nature of construction projects, interaction history is very important. For instance, relational bonding is identified as one of the trust factors because it explains trust between organisations derived from repeated interactions over time Kadefors .The Chinese construction industry has blossomed since the year of 2000, which has created many contracting opportunities in construction market. Therefore, behaving trustworthy in past projects provides more opportunities for future projects.The results from semi-structured interview also confirm the findings, and most of the participants noted that interaction history is very significant, especially long-term cooperation. Long-term interaction experience can significantly reduce uncertainties in terms of the other party’s behaviours and thus improve trust.From Table A contract with rigorous and comprehensive terms, a fair allocation of risks, an effective dispute resolution mechanism, and reliable supervision by independent agencies, is an institutional guarantee that protects the owners’ interests. Therefore, the contracts and institutions factor plays an important role in trust. Cheung et al.  found thThis factor is confirmed by the interviews. Some interviewees feel safer and more likely to trust the contractors if their interests are protected by a good contract and institutional arrangements.Factor 3 consists of three variables, information sharing, frequent communication and effective communication, which account for 8.713 % of the total variance. This factor is labelled “information sharing and communication”. By exchanging of information and reducing misunderstandings, communication enables the parties to recognise mutual benefits. Information sharing can signal the willingness of a partner to be transparent, which is a key attribute of trustworthiness in a relationship (Wong and Cheung The importance of frequent and effective communication and information sharing to increasing trust levels was confirmed by Wong and Cheung . If cleaFactor 4 includes “good intentions”, “mutual respect”, and “mutual interdependence”, which account for 7.536 % of the total variance (see Table Heide and John  argued tTo some extent, mutual respect, good intentions and mutual interdependence are the result of a relation specific investment. Therefore, this factor is called relation specific investments.Factor 5 consists of three variables: competence, confidence in the other, and goal achievement, which account for 7.177 % of the total variance (see Table Factor 6 consists of “consistency between efforts and rewards”, “reputation”, and “sense of social responsibility”, which account for 6.901 % of the total variance. Reputation is an opinion about a contractor that is typically the result of a social evaluation based on a set of criteria. Reputation is difficult to build but is easy to destroy. A reputable contractor always tends to behave ethically and in a trustworthy manner. If a contractor has high social responsibility, he cares about the interests and welfare of the public. Therefore, this factor is called reputation.Factor 7 consists of three variables: “honesty”, “promise keeping”, and “behaviour reliability”, which account 6.329 % of the total variance. The factor is easy to interpret. If contractors always match their word with their deeds, they will be considered to be trustworthy.Factor 8 includes only one variable: “opportunistic behaviour”. Opportunistic behaviour means that a contractor takes advantage of the owner’s weaknesses to improperly benefit. Obviously, opportunistic behaviour harms trust.These factors can be classified into three different categories. Reputation factor, competence factor, promise-keeping factor, and opportunistic behaviours factor are attributes of the contractor. These attributes represent the premise and preconditions for establishing trust. Information sharing and communication factor, interaction history factor and relation-specific investment factor involve both parties and belong to the relational dimension. They are methods and channels for maintaining and improving trust. The contract and institution factor is an institutional aspect that guarantees trust establishment and maintenance.Trust between the owner and the contractor is currently an important concern in China. The poor performance of many construction projects has brought attention from construction professionals to know the key factors affecting trust. Taking a lead from previous studies, twenty-four attributes that affect trust are identified in this study, and the method of PCA is employed to obtain factor structure of the trust attributes. The 24 trust attributes are extracted into eight factors, including information sharing and communication, interaction history, contracts and institutions, competence, relation-specific investment, reputation, integrity, and opportunistic behaviours. These factors form basis for improving owners’ trust of contractors in China. The value and originality of this paper is to use PCA to group these various trust attributes and expound these eight trust factors for construction in China.This paper has two contributions. Firstly, it is a context-driven research that identifies trust factors. Second, by grouping these factor components, the findings provide implications that will assist owners and contractors to improve the trust between them. The factor component groupings represent the critical trust attributes, implying that these eight factors should be considered carefully. The enhanced understanding presented in the paper enables the development of methods and strategies for building trust.However, this research has some limitations. In terms of its methodological approach, this paper is a exploratory and confirmatory research. In addition, a larger sample size would have provided a more robust factor analysis. Future research to explore exactly how these trust impact factors can be enacted is important for improving trust between owners and contractors.


Given that an estimated 0.6% of the U.S. population is transgender (trans) and that large health disparities for this population have been documented, government and research organizations are increasingly expanding measures of sex/gender to be trans inclusive. Options suggested for trans community surveys, such as expansive check-all-that-apply gender identity lists and write-in options that offer maximum flexibility, are generally not appropriate for broad population surveys. These require limited questions and a small number of categories for analysis. Limited evaluation has been undertaken of trans-inclusive population survey measures for sex/gender, including those currently in use. Using an internet survey and follow-up of 311 participants, and cognitive interviews from a maximum-diversity sub-sample (n = 79), we conducted a mixed-methods evaluation of two existing measures: a two-step question developed in the United States and a multidimensional measure developed in Canada. We found very low levels of item missingness, and no indicators of confusion on the part of cisgender (non-trans) participants for both measures. However, a majority of interview participants indicated problems with each question item set. Agreement between the two measures in assessment of gender identity was very high (K = 0.9081), but gender identity was a poor proxy for other dimensions of sex or gender among trans participants. Issues to inform measure development or adaptation that emerged from analysis included dimensions of sex/gender measured, whether non-binary identities were trans, Indigenous and cultural identities, proxy reporting, temporality concerns, and the inability of a single item to provide a valid measure of sex/gender. Based on this evaluation, we recommend that population surveys meant for multi-purpose analysis consider a new Multidimensional Sex/Gender Measure for testing that includes three simple items  to assess gender identity and lived gender, with optional additions. We provide considerations for adaptation of this measure to different contexts. Until recently, developers of population surveys tended to give little thought to methods for ascertaining biological sex and social gender. In 2004, an authoritative guide on developing questionnaire items for telephone surveys stated that sex/gender should be queried with “what is your sex? ”, if not “obvious” from the respondent’s name or voice. The authors add that “most people will recognize it [asking about sex/gender] as merely a formality” . Yet, suIn recent years, government and research organizations have increasingly sought to remedy this exclusion by developing and fielding trans-inclusive sex/gender measures in population surveys and health surveillance systems , 2, 8–10In broader population surveys, measures need to be consistently understood by all respondents . EnsurinGeneral principles of questionnaire design and implementation suggest additional issues for sex/gender measures, such as mode of administration, ease of pronunciation (for interviewer-administered surveys), and item ordering effects . Proxy rFor cisgender respondents to trans-inclusive survey items, comprehension is of primary concern. Approximately 30% of Americans were unfamiliar with the term “transgender” or unsure of its meaning as recently as 2011 . As mostTransgender respondents face different challenges in responding. They must comprehend which dimension of their sex/gender is being queried , make a judgement regarding the ideal response, and then map that response onto the available options or decide to skip. This may be particularly complex if the sex/gender dimension being queried is unclear, or if response options do not accommodate the diversity of sex and gender within trans communities. One-fifth to one-quarter of trans people in Canada and the United States identify beyond the gender binary . OtBoth single-item and two-item measures of gender identity have been evaluated, though to date no single-item measure has adequately identified trans participants. No evaluations of dimensions of sex or gender other than gender identity and birth-assigned sex have been conducted. Tate et al.  found thCommunity-based surveys of transgender persons began employing two-step measurement of assigned sex and gender identity in the late 1990s . While tA small number of studies in addition to Tate et al.’s study have evaluated self-administered versions of two-step measures. Lombardi and Banik  conducteComparisons across studies are complicated by variations in the measures evaluated. An important limitation of the studies by Tate et al.  and LombSome studies have added a survey item to identify transgender respondents to their usual sex/gender measure. The U.S. Behavioral Risk Factor Surveillance System survey assessed sex/gender indirectly (by voice) and included an opt-in module which asked “Do you consider yourself to be transgender?”. This measure was used to produce the first national estimates of transgender population prevalence for the United States, but does not allow for differentiation by gender spectrum and may underestimate prevalence through misclassification of trans persons who do not identify themselves as “transgender”. Indeed, cognitive testing indicated that while the question was easily understood and answered by cisgender participants, some respondents of transgender experience answered “no” . In an aImportantly, sex/gender measures differ regarding dimensions of sex and gender captured. It is generally not clear which dimensions are captured by single items. Currently used “two-step” measures capture three dimensions of sex/gender: sex assigned at birth, current gender identity, and trans status (through cross-classification). Bauer’s  multidimAdditionally, except for one study , trans-iThis analysis aims to 1) evaluate missingness, comprehension, and clarity for two questionnaire item sets for trans-inclusive sex/gender measures that are currently in use, 2) evaluate agreement between the two measures for the dimension of gender identity, 3) examine the extent to which those coded as trans on gender identity measures may represent other study populations of interest , 4) explore, using an intersectional approach, how conceptualizations of sex/gender across different ages, ethnicities, and sexualities relate to participants’ approaches to these survey questions, and 5) conduct a mixed-methods analysis of methodological issues in trans-inclusive sex/gender measures for population surveys. Our ultimate goal is to propose next steps for the development of trans-inclusive sex/gender items that will function well in a multi-cultural, multi-generational Canada, and to lay out considerations in adapting these to other contexts.Survey data were collected between October 2015 and March 2016 using an online questionnaire. After first reading the letter of information, participants indicated their consent to participate by clicking on a button. Anyone who was 14 years old or older, lived in Canada, and was able to complete an English-language survey was eligible to participate. Consent from a parent or guardian was not required for minors. Methods for this study were approved by the Research Ethics Board at The University of Western Ontario. The study was promoted through Facebook ads, Facebook postings, and e-mails to listservs chosen to generate a diverse sample with high frequencies of sexual and gender minorities; 588 individuals completed the first of two randomly assigned sets of survey items (approximately 5–10 minutes) and provided contact information for follow-up. These participants were contacted via e-mail one to three weeks after participation, with an invitation to either complete the remaining measures (3 minutes) or participate in both the follow-up survey and an immediate semi-structured cognitive interview. Interview participants received a $50 gift card as an honorarium; no honorarium was provided for survey participation.Interview participants were selected to maximize demographic variation with regard to transgender status, sexual orientation, age, province of residence, immigration status, linguistic background, Indigenous identity, race/ethnicity, education, religiosity, and religious affiliation. Interviews were conducted via telephone or Skype by two of the authors  and were audio recorded; they ranged in length from 24 to 81 minutes, and covered measurement of race/ethnicity and sexual orientation as well as sex/gender.This mixed-methods analysis is based on participants who completed both surveys (n = 311) and the subgroup who participated in individual interviews (n = 79).Survey measures evaluated in this study included a measure of multiple dimensions of sex and gender developed by one of the authors , originaThis measure included two base questions viewed simultaneously and asked of all participants, followed by four additional questions asked only of the sub-group that indicated they were trans or were unsure if they were trans. The measure is included in This measure included two items, assessing current gender identity and sex assigned at birth. Item wordings are included in Age and first language of participants were self-reported. Province or territory of residence was determined from the first digit of postal code. Questions on race/ethnicity, Indigenous identity, sexual orientation and education were taken from Canadian Community Health Survey questionnaires . ImmigraSurvey methodologists have proposed four cognitive steps involved in responding to questionnaire items: comprehension, retrieval, judgement, and reporting . CognitiThe Questionnaire Appraisal System (QAS) was used to assess the two sex/gender measures evaluated  for probStatistical analyses were performed using SAS software version 9.4  to estimGiven that a majority of interview participants reported problems with survey questions, and that many of the issues emerging in the qualitative data applied to both sets of questions, we present results in a combined Results and Discussion section, focused around issues that emerged in the analysis, rather than a sequential evaluation of each question set.For both the survey sample and the interview sample, sociodemographic frequencies are presented in Missingness was very low; of 311 survey participants, 1 (0.3%) was missing a response for the MSGM. Of the 43 participants interviewed regarding the multidimensional measure, no one stated that they were unfamiliar with the question or response terminology. While participants were able to complete these two items, some dissatisfaction was common. Frequencies of specific problems from the QAS are presented in Of 311 survey participants, 2 (0.6%) were missing for the two-step measure. Among 36 interview participants who were queried on this measure, no one stated that they were unfamiliar with the response options included, though some cisgender persons could not specifically define terms used in each gender option. Also similar to the multidimensional measure, dissatisfaction was high in our cognitive interview sample who were asked to reflect in depth on the measure. Frequencies of specific problems from the QAS are presented in Both measures were clear and straightforward for cisgender participants. When asked about his decision-making in the multidimensional measure, one participant said, “I think this question’s pretty obvious. Like, I’m male. I don’t know how else to explain [laughs] it better.” Similarly, another participant explained her ease with the two-step measure as almost automatic: “I think the only thinking that I really did was actually reading the question just to make sure I clicked the right one. [Laughing] […] I know that I’m female, and I’ve always identified as female. And I know what my birth certificate says.”While these items worked for cisgender participants themselves, those who were lesbian, gay or bisexual more often recognized the limitations of both measures for trans people. This is not to say that straight cisgender participants were unknowledgeable about gender minorities or the changing social milieu organizing notions of sex and gender. For example, when asked about his understanding of the two-step measure, an older participant  spoke about the “current fashion” today that he describes has replaced the term “sex” with “gender” and reclaimed the previously taboo term “queer.” Although this revised way of thinking does not mirror his own, he did not report any challenges with the question and was easily able to place himself within the response categories.Our findings are consistent with other research showing that cisgender participants did not have comprehension difficulties with trans-inclusive survey measures , 23. HowThe first question in the multidimensional measure  reflects a question sometimes asked as a single item. While it was clear and easily answered by cisgender participants, it did not identify trans participants, nor did it clearly identify birth-assigned sex or gender identity. Among 23 transfeminine survey participants, 9% selected “male”, 61% “female” and 30% “other. Among 41 transmasculine survey participants, 21% selected “male”, 19% “female” and 60% “other”. As trans participants responded with different dimensions of their own sex/gender, it is important to note that even with the addition of a second question as to whether one was trans, transfeminine and transmasculine participants could not be differentiated.While this item alone did not perform well, cognitive interview participants did generally find it acceptable, one commenting with a laugh that “[T]here seem to be more questions now that have gone from a gender binary to a gender trinary.” However, this item was cognitively taxing for trans interview participants, who tried to figure out exactly what the researchers were asking, and reached different conclusions. Our results are consistent with previous research showing that single measures under-identify trans respondents who choose “male” or “female” over other options , 21. ThiI recognize that I have transitioned but it’s not part of my identity. So, I don’t really identify as a trans person […] But I generally do say like I’m a person with a history of like, a medical history whatever, more so. This distinction between trans identity and trans experience was clear in the gender identity options chosen by those who were ultimately classified on the two-step measure as trans; of 66 participants coded as trans, 26 chose an identity as trans man or trans woman, 11 as man or woman, and 29 as genderqueer or gender non-conforming. Some participants found the separate categories of, for example, “male” and “trans male/trans man” to be problematic, seeing “trans male/trans man” as a lesser type of man. Thus, while a single item may be attractive to researchers in preserving a shorter survey length, even single items that allow for identification of trans gender spectrum cannot identify trans participants who identify solely as men or women.Both measures captured the dimension of trans-ness based on gender identity, using birth sex cross-stratified with gender identity, and agreement between these two measures was very high (Cohen’s K = 0.9081). Results are presented in The only discordant cell with more than one participant included seven participants who were identified as cisgender women on the multidimensional measure and as non-binary  on the two-step measure; these accounted for nearly all of the discrepancy in frequency of trans persons by identity . All seven indicated “no” to the multidimensional measure’s item “Are you trans ?”, checked the two-step measure’s identity option of “genderqueer/gender non-conforming”, and indicated a sexual minority identity; write-in gender identity responses from this group included “queer” and “female genderqueer questioning”. Of these seven, five were interviewed, including one who indicated that her response was a mistake. The others clearly indicated a female gender presentation, saying they “stick to the norm”, were “never going to pass as anything other than female”, “present myself as female”, and “I’m definitely too female to be androgynous, but there is an androgynous fit-flavour to how I present”.This discrepancy suggests that the “genderqueer/gender non-conforming” wording in the two-step measure response option may possibly be too broad. We note that the version of the two-step measure we evaluated was one recommended by The GenIUSS Group  for furtAmong trans participants, gender identity served as a poor proxy for other dimensions of gender or sex that may be of interest to researchers . Of tranTransmasculine and transfeminine gender spectra defined using the two-step measure.Gender identity and lived gender (often cross-tabulated with sex assigned at birth) will be the dimensions most relevant for population health studies of outcomes shaped by social experiences , and for assessing health-related inequalities on a population level. Collection of both variables also allows for more appropriate grouping of trans and cisgender respondents, based on the dimension most relevant to the outcome under study . In studies with sufficient numbers of trans respondents, gender identity and lived gender can also be cross-tabulated to examine the impacts of identity disclosure or “outness” . Those who are intersex will typically have a sex assigned at birth, a gender identity, and a lived gender that may be captured with the measures studied. Including intersex in survey items for sex assigned at birth may be problematic in at least two ways; intersex individuals typically are assigned a sex at or shortly after birth and raised in the corresponding gender, and classifying sex at birth as intersex does not allow for the identification of those intersex people who have had trans experience (i.e. has an identity that varies from birth-assigned sex ). IntersTwenty participants reported a non-binary gender identity on the multidimensional measure, and 29 on the two-step measure (including the seven cisgender participants discussed earlier). Write-ins that indicated non-binary identities included “agender”, “gender queer”, “female questioning” and “non-binary”. The multidimensional measure’s gender identity item asked of trans respondents (and those who didn’t know whether they were trans) was interpreted as clear and straightforward for about half of the 14 trans/unsure participants queried on it in interviews, with concerns focused on the ways in which follow up questions may perpetuate a gender binary. For example, one participant reported that the felt gender question was difficult because “it’s hard to distinguish for me between feeling both male and female and feeling neither.”The issue of whether genderqueer persons are included within a broad definition of “trans” came up in multiple interviews, with genderqueer participants themselves holding differing views on whether they are trans, but agreeing that this was a point of community disagreement. This is illustrated in the following pair of quotes:But often there’s an assumption that they’re—they’re separate things [trans and non-binary].... I’ve sometimes encountered a little bit of friction maybe around the idea that—I guess I don’t want to be appropriating anyone’s identity either, right. … I actually am non-binary and for me being trans is a pretty broad term, which includes anyone whose gender is different than their assigned sex at birth. And that’s not everyone’s understanding. So I identify as genderqueer, which I think of as a separate thing from issues of transgender. … Well, [genderqueer] to me means that you conceptualize yourself, I guess primarily not on the strict binary, but of an identity other than the identity that you physically present as, without necessarily—and I guess I draw the line between that and transgender as someone who specifically identifies as a presentation that they may want to physically transform into. … And I understand that that’s not a hundred percent [laughs] how other people see that distinction… For researchers, these differing understandings among genderqueer persons and within broader trans communities highlight the importance of defining the trans population under study, and of not assuming that genderqueer persons will identify as trans.Some Indigenous participants identified as two-spirit, an umbrella term adopted in 1990 at an intertribal conference in Winnipeg, Canada, as a way of communicating a broad range of traditional Indigenous gender-diverse identities and social roles . Two-spiWell, I chose gender—gender fluid or genderqueer, because that’s representative of my identity. I do identify as two-spirited, but sometimes that more gender fluid and gender—but having almost kind of like that balance of sometimes that I feel that I have—I’ll have a more of a masculine day and more—as compared to having more of a feminine day. … it fluctuates, and it’s not that I think that I’m transgendered at all. I think whereas some people, they misunderstand that two-spiritedness can be—is considered to be something under the transgender spectrum, when really it’s something that’s more of a spectrum in itself that is inclusive of sexuality and gender identity… but very exclusive to First Nations and Indigenous people. So—and sometimes it’s a lot—a little more complicated than just saying gender fluid [laughs]. As relayed by this participant and other Indigenous participants, two-spirit identities may be more “gender fluid” than “trans”, and more complicated than “gender fluid”, and in fact represent a different paradigm. The distinctions made between two-spirit and other newer gender-diverse identities in North American colonial contexts reflects considerations internationally with regard to the many traditionally held genders. Despite being developed in the U.S. and Canada, neither of the measures we tested had options for a traditional Indigenous identity, and required that those with traditional cultural gender identities categorize their identity as male or female, or under newly emerged terms such as “trans woman” or “genderqueer”. This should be remedied to both provide an appropriate response option and to affirm Indigenous identities in survey measures. We note that this does not preclude also including an Indigenous response option in survey questions on sexual orientation, though this is beyond the scope of this evaluation.The multidimensional measure can be adapted to include only information relevant to a particular study’s aims, if needed. While we found no issues with trans participants being unable to answer this question, several trans participants had suggestions. They reported that the stem of the question on hormones and surgeries was embedded within a gender binary  that assumes that trans people are moving or have moved from one gender to another. As one participant explained, their decision to take hormones was not about medically moving towards an opposite gender. Instead, it was about “help[ing] me feel more congruent with who I am. […]for me it’s more about being androgynous.” the question stem could likely be edited to avoid these implications by changing from “Have you undertaken any of the following to medically transition sex?” to “Have you undertaken any of the following related to your gender?”.One trans participant also cautioned against researchers making ableist assumptions with regard to what a medical transition does or does not mean with regard to gender.There are some things that I would never be able to do because they’d be medically contraindicated in my situation. There are other things that—you know, there’s nothing left to do because other kinds of surgeries for other lifesaving interventions, um, didn’t leave anything behind to work with. So the question is kind of fine if you are an otherwise able-bodied person. cisgender participants.This is important in avoiding assumptions that medical procedures represent a more complete transition; indeed research shows that a substantial proportion of trans persons who indicate they have “completed” a medical transition have not had any surgeries . MoreoveWhile our survey randomly allocated which of the two measures was given in the initial survey (with the other at follow-up), we did not vary the order of items within each question set. For this online evaluation, the first two items in the multidimensional measure were visible together on the screen, as were both items in the two-step measure. While many cisgender participants did not see much distinction between the two questions (true for both sets), their clarity for trans participants may have been dependent on both being visible. Thus, we recommend that the questions be simultaneously visible for online and paper surveys. We reviewed our interview transcripts for any information to inform ordering of items, and found little evidence for the influence of ordering on decision-making where both were visible. For telephone or in-person interviews in which a participant receives one question at a time, order may matter much more. Thus, we would recommend that interviewer-administered questionnaires begin with the more concrete question, sex assigned at birth. Finally, while we did not evaluate the order of response options within each measure, given the potential for accidental responses, it may be preferable to list more numerically common response options first to avoid error.While our findings represent self-reported measures, they also highlight potential concerns with accuracy of proxy-reported measures, for example in censuses or household surveys wherein one member of the household is reporting on all members. Among participants who were classified as trans based on gender identity in the multidimensional measure, 8 of 58 (13.8%) were living in their birth-assigned gender. Moreover, while we did not ask directly about level of disclosure to others in our interviews, the issue did come up. One genderqueer participant reported that “because my family is Muslim it’s easier for me to […] identify [my sex] as female because then it’s, because otherwise it’s problematic.” When asked if they had told their family, they replied “No, no.” While most trans people were aware that they were trans as preadolescents or adolescents , there iWhile we were not able to examine changes in sex and gender dimensions over time in our cross-sectional survey, the issue of temporality and changes in identity over the lifecourse emerged among trans (but not cisgender) participants in the interviews. One participant who reports living in a gender other than male or female explains the process of defining their identity.I initially thought that I was a trans man because I was raised as a girl, and I thought that my only other option, if I wasn’t a girl, meant that I was a boy. … eventually, I kind of realized [..] I’m not a girl, but there has to be more options than this. … So when I found out about being agender, I’m like, yeah, this is it. Data collected in cross-sectional surveys must then be understood as a momentary capture of sex/gender dimensions, rather than a capture of stable identity groups or points in a unidirectional process of transition or identity consolidation. Instead, individuals follow a process of reconsideration in light of new knowledge of self, learning of new identity options, undertaking of medical procedures, and/or the social context in which participants were embedded. This poses a special methodological challenge for cohort studies, many of which collect sex/gender only at baseline. Temporal changes indicate the need to also include sex/gender measures at follow-up data collection time-points.Another participant who lives their gender as sometimes male, sometimes female, discussed temporality not only as an issue in their personal process of adopting identity labels, but with regard to changes in language use more broadly:So up until maybe the last six or seven months, I never, ever, ever would have identified myself as trans because I did not feel it was a label that I had access to as a non-binary person… there’s even just a lot of discussion within the trans community about what trans means. Like, you’ve got just the word transgender, or you’ve got, like, the trans asterisk [trans*], which apparently people are saying now is oppressive. I don’t know. It’s a very charged word right now. The changes in community language above relay only very recent developments. Another participant with a longer history in trans community explains how language has changed over the decades, and his identity with it:When I wrote my [newsletter], I was using the word “new men” for trans men, and later “new women” for trans women, ‘cause we were still kind of pretty binary. But then—in the ‘70s and ‘80s—but then it started opening up a bit, and then we used the word, “male transsexuals” or “transman” or “transsexual men”, and vice versa, “transsexual women”. It shifted a bit, and then of course it became much more fluid maybe in the ‘90s and so on. So, my gender evolved a little bit where it became a bit more androgynous. Repeated cross-sectional population surveys demand stability of measures over time, so that changes in health among sex/gender sub-groups may be accurately documented. Thus, population surveys must rely on language that will not change rapidly with regard to public perceptions of acceptability or understanding of terminology. Given that language is changing rapidly within trans and cultural communities, and may vary regionally and within different age or gender cohorts, it is imperative that language be as simple as possible. This serves the dual function of promoting comparability over time and within population sub-groups, some of whom will be completing surveys in a second or subsequent language, or with cultural understandings from a wide range of Indigenous or immigrant cultural backgrounds.Neither measure evaluated was considered burdensome by participants. However, in the design of population surveys there is always pressure to use the minimum number of items possible, as adding an item often means removing another. Population health surveys are also unique in that they have many secondary data users, and thus it is difficult to select a single dimension of sex/gender that will meet all user needs. Given that single-item measures cannot accurately classify trans participants, cannot clearly differentiate transfeminine and transmasculine participants (without excluding non-binary participants), and are confusing for trans participants, a minimum of two items will be needed. However, given that gender identity is the broadest classification category , additional dimensions of sex or gender (where needed) can be identified with minimal burden by asking these questions only of the subset who indicate an identity different from their sex assigned at birth.Another pragmatic concern involves the use of open-ended or fill-in-the-blank responses as “other, please specify” categories. Participants, including in this evaluation, often enter responses that are substantively similar to included responses. Thus, a reported “other” cannot be understood to be a true “other” response without verification. While an “other” option allows each participant to enter their personal identity, and avoids problems with needing to change the language of response options over time (though not necessarily with changing interpretations), recoding of write-in responses into categories for comparison will be too labour-intensive for many agencies. Write-in responses provided by trans respondents can sometimes be quite idiosyncratic and even impossible to categorize, resulting in data loss. Moreover, we believe it creates an ethical problem in that such questions appear to allow participants to avoid simple categorizations, but then participants’ identities are categorized by researchers after the fact; the final categorization may be inconsistent with a participant’s self-categorization when given those categorical options.While population surveys are often done confidentially, and sometimes anonymously, the recent increased focus on creating data linkages raises pragmatic concerns regarding consistency or comparability across data sources. Moreover, as governments move toward greater integration of data, some of the same measures being addressed in this paper with regard to population health surveys will apply to collection of sex/gender dimensions in government databases and documents, and to the sharing of this information .The use of mixed-methods for this analysis allowed for detailed analysis of two trans-inclusive survey measures, with some issues emerging initially from analysis of quantitative data, and others from the interview data. Our large number of cognitive interviews (n = 79) from a maximum diversity sample, allowed for the inclusion of perspectives from a range of ages (14 to 77), geographic regions (east to west coast), ethnicities, religions, linguistic backgrounds, and immigration histories. The intersectional approach interrogated the relationships between other aspects of identity or social position and sex/gender, to better assess whether and how these measures perform in Canada, a country with a diversity of cultures and religions, and a rapidly changing context for knowledge of trans language and issues that is likely to produce generational effects. While we were able to test agreement between measures using our survey data, the use of a convenience sample precludes applying any of the quantitative results to the Canadian population as a whole. In particular, quantitative results should be interpreted in light of the demographic composition of our sample participants, who were disproportionately female, sexual and/or gender minority, young, university-educated, non-religious, and speakers of English as a first language. A major limitation of this study is that it was conducted in only English. Any national study in Canada will at a minimum be conducted in both official languages, English and French, while studies in the U.S. often include at minimum an option for participation in Spanish.For population surveys, we believe that gender identity and lived gender will be the most widely desired sex/gender dimensions, depending on whether health-related analyses are relevant for all those who know themselves to be trans, or for those living in a gender different from that assigned at birth . Based on our analysis, and on consultation with a small number of content experts on issues such as population survey design, Indigenous gender concepts, and data uses outside of population health (e.g. human rights), we recommend the following Multidimensional Sex/Gender Measure (MSGM)  for furtThese MSGM items should be used in the order provided for telephone or internet surveys, and at least the first two items included so that they can be viewed simultaneously on internet or paper surveys. This question set represents a combination of workable aspects of both item sets tested, and allows for the capture of sex assigned at birth, gender identity and lived gender. By cross-tabulating each of the second and third items with the first, trans-inclusive measures may be created for gender identity and lived gender, that accurately categorize both trans and cisgender respondents. For gender identity, variables can be created with four to eight categories, two of which are cisgender men and women; the remaining categories can differentiate transmasculine and transfeminine persons with Indigenous or cultural gender minority identities, non-binary identities, and male/female identities, or these can be collapsed together for analysis. For lived gender, trans options can be similarly expanded or collapsed according to the needs of the analysis. If only gender identity is desired, then the first two questions alone may be included; if only lived gender is desired, then the first and third questions alone may be included. In general, sex assigned at birth can be cross-tabulated with any other dimension of gender or sex that is relevant to different research questions, to produce a trans-inclusive measure that also differentiates by gender spectrum.We note that these items are phrased for a self-completed survey, and were tested as such. For interviewer-administered surveys, the items can also be phrased as questions that include the response options, for example “On your original birth certificate, were you assigned a sex of male or female?”This item is taken from the two-step test measure, and is used in other versions of two-step measures. It performed well in our evaluation. While participants were given an option for undetermined sex at birth on the multidimensional measure’s birth-assigned sex item, an option that is available on Ontario birth certificates, no participant chose this option. While this is not surprising given the sample size, it is unlikely that a participant would check “undetermined” as it is typically given as a short-term provisional classification for infants for whom a sex determination cannot be immediately made. Thus, it is not clear whether participants would even be aware if they had at any point been given an undetermined assignment. We note that if sex/gender markers are removed from birth certificates in the future (something being proposed in some jurisdictions), then the question item stem will need to be adapted as those without an “M” or “F” on their birth certificates become old enough to complete surveys .This gender identity option makes modifications to both the multidimensional measure and two-step gender identity items to create a new item. First, the question stem asks which option “best describes” the participant’s gender identity. This acknowledges that one’s specific personal identity may not be included, and that researchers are aware this is not a detailed or complete list. Response options do not differentiate between those who personally identify, for example, as men versus trans men, as we found no evidence this was necessary, and these categories are grouped for analysis. While some trans interview participants were clear they were men or women who did not personally identify as trans, none stated that they identified as, for example, a trans man but not a man. We have also added an Indigenous or cultural gender identity response option to recognize the traditional gender identities that exist in many Indigenous cultures within Canada and the world. We included “two-spirit” as an example even though it is a term designed to communicate the concept of Indigenous gender identities to non-Indigenous people, as it is commonly recognized and we were not able to identify any other umbrella term. Finally, we included one response option for other identities such as non-binary, genderqueer, agender, or gender fluid, as participants were not always able to differentiate between options of “both male and female” and “neither male nor female”, and no individual indicated these were particularly important wordings for them.We designed the third and fourth options to include specific identities as examples rather than in the main response option, in order to allow for changing only these examples as terminology changes over time. Moreover, we avoided including the overly broad term “gender non-conforming”, to reduce the likelihood of misclassifying queer cisgender respondents as trans. We also aimed for wordings and examples that would be clear and easy for interviewers to pronounce, regardless of whether they were part of our cognitive testing. Some options were rejected based on this criterion, e.g. when spoken, “agender” may sound like “a gender” or “agenda”. We believe our suggested response options for Q2 will work well, and that similar to our findings, cisgender participants who are unable to define them will still easily recognize that they do not identify personally with these terms; however, additional testing is required with both Indigenous and non-Indigenous participants.We note that response options for this second question in particular may need to be adapted for use in other regions. In other contexts, one particular cultural gender identity may be common , and can be added as a response option by itself. In other contexts, an Indigenous response option may be unnecessary and can be removed.We did not include a fill-in “other, please specify” response option for gender identity, as this can require a large amount of time devoted to recoding, and recoding may not reflect participant wishes. Moreover, recoding of some write-ins will not be clear or even possible (e.g. “human”). We believe that asking “which best fits” resolves some concerns in categorization. To provide greater flexibility for participants or to better understand current gender identities, we would suggest adding a separate open-ended question to follow Q2, wherein participants may write in their personal gender identities, rather than adding an “other” option to the item responses. The question stem could be “How do you personally identify your gender?” or something similar. Separating the question allows participants to categorize themselves in Q2, rather than to be categorized by researchers. Those who choose not to include an open-ended question for all respondents may want to consider including one for those who skip Q2.The lived gender item may be asked only of participants identified as trans by the broader gender identity definition, and this may be programmed into survey skip patterns. This question item is based on the multidimensional measure’s lived gender item, with one small change. While the item tested well, the language of “third gender” is an older term, and not one that any participant personally identified with. Here we just eliminated this term, as it was not needed for clarity. For surveys using proxy reporting, where the reporter will more likely know the lived gender of family or household members than their gender identity, a two-item version consisting of questions 1 and 3  may be a reasonable solution, though question 3 has not yet been evaluated with cisgender participants.Depending on the informational needs regarding sex and/or gender, additional questions on hormone use or surgeries may be included, and in most cases should be asked of cisgender as well as trans participants.SAS syntax for coding is presented in the supplemental materials . In addiBoth measure sets evaluated performed reasonably well, but with frequent problems identified. Consistent with other research on trans-inclusive survey measures for sex/gender, confusion on the part of cisgender participants was not found to be an issue, indicating little reason for concern with misclassification of this much larger group. In contrast, misclassification of trans respondents will likely be a concern with any single survey item attempting to be inclusive, as a substantial proportion of trans participants will indicate they are simply male or female in line with either their identity, lived gender, or birth-assigned sex. While a single sex/gender question with expanded options beyond male and female may provide greater flexibility for respondents than a male/female question, it will likely similarly fail to adequately identify trans survey respondents. Building on the two measures evaluated and issues identified for measure development, we propose a multidimensional measure of sex and gender for population surveys where data will be used for multiple aims. It includes two base questions on sex assigned at birth and gender identity, and a third item on lived gender asked only of the subset of participants whose gender identity differs from their sex assigned at birth. Additional dimensions of gender or sex  will be relevant for some surveys and can easily be added. Careful specification of sex and gender dimensions assessed, and of response options, can allow for health research which better reflects the diversity of sex and gender characteristics and their relationships to the health of populations.S1 File(PDF)Click here for additional data file.S2 File(PDF)Click here for additional data file.S3 File(PDF)Click here for additional data file.