Relevance of the topic ‘transgender’ for the issue of postmortem identification

For a long time, large surveys aimed at general populations of states or regions did not contain questions regarding gender identity. Only recent surveys collect gender identity data more frequently and systematically [11]. Accordingly, only in the last two decades, an increasing number of studies has been published on the prevalence of transgender [11, 35]. Interpreting these data is sometimes difficult. The term ‘transgender’ is not completely uniformly defined. Since the definition of the term determines which groups are recorded as ‘transgender’ in surveys, the definition has an influence on the reported prevalences [11, 35]. Moreover, the context as well as the way how questions are asked influence the results [35]. Furthermore, the populations examined in studies often came from LGBTQIA + networks, maybe resulting in a greater prevalence of transgender people than in the general population [11].

We addressed these problems by focussing on the definition of ‘transgender’ proposed by Meerwijk and Sevelius (2017) [11] and on recent publications that present population-based data as described above.

Despite all methodological problems, the data cited appear to be very similar and suggest that one can expect prevalences of around 0.5% for opposite-sex identification and around 2–3% for a non-binary identification in the United States, the European Union and comparable societies. Another common finding is that there are higher rates of transgender individuals in younger populations. Meerwijk and Sevelius [11] suggest that the higher prevalence of transgender identities in younger populations is not due to an actual increase in the proportion of transgender identities, but it is due to people feeling more free to state that they identify as transgender.

Although it is empirically well documented that transgender people are likely to be overrepresented in suicides and in victims of homicides and consecutively in the group of unidentified deceased persons, the question of the prevalence of transgender individuals in the group of unidentified deceased cannot be answered with a specific number or percentage. Nevertheless, with the reported prevalences of around 0.5% for opposite-sex identification and around 2–3% for a non-binary identification (at least in the United States and the European Union), and under consideration of an assumed over-representation of transgender individuals in suicides and homicides, it can be concluded that the topic of transgender must have relevance for forensic practice.

Even if problems with the post-mortem identification of transgender people may only occur rarely (above all due to the availability of molecular genetic data in most cases), in these rare cases, optimal conditions for identification still need to be created. From our point of view, optimization of databases and recording as well as training and research are important goals in this context.

Optimization of databases and reporting

One cannot assume that the investigating authorities are always aware of the topic of ‘transgender’: Waldron and Schwencke (2018) reported that in 74 of 85 deaths of transgender individuals, the abandoned name and/or gender (corresponding to the biological sex) had been used to refer to victims during investigation. The authors point out that using the abandoned name and/or gender may hinder identification and slow down an investigation [33]. When collecting data on missing people, contact persons should specifically be asked about the gender identity of the missing person. The investigation authorities should check whether entries for name and/or gender in civil databases have been changed over the course of one's life. If this is the case, information about the new name and gender should be additionally used in the identification process.

Others have already pointed out that the way transgender people are recorded in missing persons and unidentified deceased persons databases is a relevant factor [10]. Palamenghi et al. (2023) assume that a transgender person should be recorded ‘under their self-identified gender’ as this ‘reflects their life identity and is typically the gender under which their disappearance would have been reported’ [10]. This is certainly not wrong, but from the authors’ point of view, listing exclusively the self-identified gender brings with it the risk of a mismatch with unidentified remains that have been classified according to the biological sex. So, entries in antemortem databases should clearly distinguish between ‘biological sex’ and ‘apparent sex’ / ‘lived gender identity’ (according to information of the contact persons). ln the German ‘VERMI/UTOT’ database there actually are options to enter the sex of a person documented by the registration office (or determined by DNA analysis) as well as the ‘apparent sex/gender’ of a missing person [9] making mismatches during the search less likely. This seems to be a reasonable approach even if the felt gender doesn’t always have to be consistent with the outer appearance. As pointed out above, in the future it will furthermore be crucial that the information regarding a change of gender entry is revealed by the registry office to prohibit delay or failure of identification.

The importance of a clear distinction between biological sex and apparent sex/gender also applies to the recording of postmortem data. Postmortem sex diagnosis should be clearly specified (for example ‘sex by morphological findings’ or ‘chromosomal sex’). Not only would this be helpful in the identification of transgender people, but also in other, rather rare constellations, like in cases of intersexuality where chromosomal sex is inconsistent with phenotypic sex (for example a XY-women with androgen insensitivity syndrome), or in which the phenotype is not classifiable as either female or male.

Training and research

The topic ‘biological sex and gender identity’ with its implications especially for the identification of unidentified deceased should be addressed in training and further education in the forensic field. The study of Tallman et al. (2021) impressively supports this claim by presenting survey data of forensic anthropologists; the authors critically explored the collective knowledge regarding the topic of ‘transgender’ in forensic practice and uncovered relevant gaps [8]. In general, forensic medical experts should be aware of this topic during the process of postmortem identification.

Knowledge regarding gender-affirming procedures and their detection in human remains is likely to be of particular importance. Transgender individuals have many medical options for a transition from male to female or female to male. These options include for example hormone replacement therapy (HRT), genital gender-confirmation surgery, facial feminization surgery (FFS) and facial masculinization surgery (FMS) [1, 8]. Consequences of HRT and surgical interventions can easily be determined if a corpse is well-preserved, but not in a state of skeletonization. The long-term effects of HRT on the skeleton are poorly understood [8, 10]. Based on current knowledge, reliable evidence of HRT cannot be expected when examining bones. Findings after many surgical interventions (as hairline lowering, brow lift, cheek enhancement or lip lift) will no longer be detectable in skeletal human remains. However, some FFS modifications may be detectable on the skull, especially in the glabellar region, at the mandibular or the zygomatic bones. In addition to osteosynthetic material, bone changes such as bone apposition areas can provide information [8]. Palamenghi et al. (2023) described such bone apposition areas as well as fragments of gelatinous material interpreted as residues of breast implants [10]. But even though the number of trans individuals undergoing surgical modifications grows [1], not all transgender individuals opt for surgical procedures. In a sample of 432 transgender people in Ontario [4], 30% were living their daily lives in their birth gender, 23% were living in their felt gender without medical interventions and 47% were living in their felt gender with at least some medical intervention. Only around one quarter of the MTFs (24%) and around one third of the FTMs (30%) had undergone transition-related surgical procedures. Knowledge regarding gender affirming procedures and their detection in human remains is important, so as not to overlook evidence of a transgender identity. At the same time, it is also important to be aware that the absence of such evidence does not speak against a transgender identity during lifetime.

In terms of research, working on the following scientific topics could optimize the way we deal with the challenges outlined above:

What is the prevalence of violence against transgender individuals?—Structured surveys, inclusion of gender identity in crime statistics.

What is the prevalence of transgender individuals within the group of unidentified deceased and of victims in cold cases?

What are the effects of new legal regulations like the German ‘Selbstbestimmungsgesetz’ on the process of postmortem identification?

Are there awareness and knowledge about the topic of ‘transgender’ in the context of postmortem identification? Do the investigating authorities as well as forensic medical experts consider the topic during their work? Do they need training?

What are the effects on HRT and gender affirming surgery on the skeleton?