Relevance of Constructivist Grounded Theory in Transgender Mental Health Research: A Methodological Review

History and Development of CGT

Grounded theory (GT) methodology is reportedly the most common methodological approach used in qualitative research (Chun Tie et al., 2019; Olshansky, 2014). It emerged around the 1960s as a seminal work of Barney Glaser and Anselm Strauss (1967). At its inception, the GT was developed to collect and analyze data in a systematic way to discover theory (Glaser & Holton, 2004). The processes of theoretical sensitivity, theoretical sampling, theoretical saturation, constant comparative method, coding process, memoing, and sorting are often employed to discover the theory (Charmaz, 2014b; Corbin & Strauss, 2008). Traditional GT is entrenched in positivist traditions largely due to ideas like rigor, agency, meaning, and action (Charmaz, 2008). The grounded theory has since transformed into several strands: the traditional GT linked with Glaser, the evolved GT linked with Strauss, Corbin, and Clarke as well, and the constructivist GT version of Charmaz (Charmaz, 2006; Sebeelo, 2022; Timonen et al., 2018).

Constructivist grounded theory was developed when the late Kathy Charmaz broke ranks with mentor Strauss as a move from the positivist traditions (Higginbottom & Lauridsen, 2014). CGT is geared toward constructing a theory that is grounded in the data and is co-constructed by researchers and participants in equal measure (Charmaz, 2006). The construction of a theory is done by adopting the methodological tactics of Glaser and Strauss’s classic statement but by combining relativity and reflexivity (Charmaz, 2011).

According to a journal commentary, CGT differs from other GT approaches by adopting a relativist epistemology, acknowledging research participants, and considering multiple perspectives and realities (Charmaz, 2017a). Furthermore, the author assert taking a reflexive approach to researcher background, values, actions, situations, relationships with participants, and representations and situating the research within history.

Epistemological Bases of CGT

All methodological approaches stem from “specific values, assumptions, and epistemologies,” with none deemed neutral, and as such, CGT has an epistemological basis (Charmaz, 2014b, p. 1076b). Furthermore, Charmaz (2017c) posits that methodological strategies are consequential from the researchers’ value positions and align with their assumptions. Consequently, it is crucial to look at various epistemological and philosophical viewpoints as they influence the data collection process and the researcher’s role (Charmaz & Thornberg, 2021). According to Mills et al. (2006, p. 9), grounded theory methodology is “relativist in ontology, epistemologically subjective and, thus, is situated within the constructivist paradigm.”

CGT also has different philosophical assumptions, which include a relativist ontology, constructivist epistemology, reflexivity, and pragmatism (Keane & Thornberg, 2024). Charmaz proposed a CGT methodology instituted on a relativist epistemology (Higginbottom & Lauridsen, 2014; Sebeelo, 2024). The arrays of relativist ontology allow people to share information and understand the phenomena of the research study (Schreiber & Tomm-Bonde, 2015). CGT acknowledges that reality is subjective and that the meanings people attach to their experiences can be interpreted (Breckenridge et al., 2012). The CGT recognizes various realities and seeks diverse perspectives; this epistemological position augurs well for transgender mental health research as the concept of transgenderism is fluid and evolving, and thus, there are many perspectives and experiences from the transgender community (Charmaz & Thornberg, 2021).

The CGT also assumes that there is co-construction of knowledge between researcher and participants, a view to be extensively discussed in the next section. Reflexivity is another key assumption that is pivotal in CGT and will be later addressed under the relevance of CGT to transgender mental health research.

In sum, because of the influence of pragmatism, CGT focuses on the practical implications of research and how it addresses real-world problems (Charmaz, 2014b). CGT helps generate a theory that is grounded in empirical data, hence suitable for practice, in this instance transgender mental healthcare practice.

Reflections on Co-Construction of the Theory

As highlighted by Polit and Beck (2022, p. 167), CGT emphasizes the need to co-construct the theory from the shared experiences of the researcher and participants. The purpose of grounded theory is to “construct middle-range theories from data” (Charmaz, 2012, p. 2). Although a substantive theory is constructed as an end result of the research process, it is not based on theoretical generalizations but is aimed at interpretive understanding (Charmaz, 2013). The interpretive understanding indicates that the researcher and participants collaborate to form the voice of transgender individuals in terms of mental healthcare support (Mills et al., 2006).

Previous research and experience with transgender individuals can assist with co-creation in the constructivist approach. As Carrol-Beight and Larsson (2018, p. 99) maintains, “familiarity aids in establishment of rapport and trust which consequently results in rich data being shared.” Charmaz (2014b, p. 17) further augments this by highlighting that researchers are part of the society and hence theories are constructed on the basis of “past and present involvements and interactions with people, perspectives, and research practices.”

The CGT method bolsters researchers to be closer to those that they wish to study (Charmaz, 2017c). Transgender individuals are of the view that transgender research should be hugely beneficial to them (Minalga et al., 2022). In ensuring this, it is pivotal to involve transgender individuals in research that seeks to address their issues. As argued by Hope et al. (2016, p. 362), “trans participants should be included broadly in research both by letting them identify themselves on appropriately worded demographic forms and by not excluding their participation in final samples because their numbers were insufficient to form a separate group in the analyses.”

The use of CGT is, therefore, crucial as it involves both transgender individuals and the researcher. Several studies have found that transgender people face marginalization and erasure; therefore, including them in the research process leads to empowerment through acknowledgment (Seelman et al., 2017; Thangthaeng et al., 2022). The realities of transgender individuals can be shared and understood when they are allowed to build their own understanding of the phenomenon being investigated. Gilbertson et al. (2019) indicate that the involvement in research by transgender individuals improved their positive outlook and sense of purpose as well as enhanced self-perception. Furthermore, psychosocial benefits can be annexed by the participants as they are helped in clarifying their understanding of their own, which can validate their identity (Mondragón Barrios et al., 2022).

It is because of their narratives and discourses on what entails being transgender that can enhance the research process. It is within the features of CGT that involvement and collaboration with transgender communities foster a research process that is inclusive and allows those involved in the phenomenon to participate. According to Bouman (2018), researchers should cooperate with transgender communities to ensure that proper language and terminology are utilized in research reporting. For example, the co-creation of knowledge with transgender individuals guarantees that the findings are consistent with their lived experiences and realities.

Can CGT Produce a Real Theory?

There have been several schools of thought that seem to suggest that CGT cannot generate a “real” theory. The criticism stems from the notion that theories need to be assessed through hypothesis testing, which unfortunately cannot be done for CGT because of its inductive method of inquiry that results in theory grounded in data (Charmaz, 2014a). Charmaz (2006, p. 125) defines interpretive theory as one that “assumes emergent, multiple realities; indeterminacy; facts and values as linked; truth as provisional; and social life as processual.”

The aim of GT from the beginning was never to be theory testing, but the emphasis was on theory development (Glaser & Strauss, 1967). The intent of the GT is to develop and construct theories grounded on data, although the end product, in some instances, may be model frameworks or conceptual schemas (Bryant, 2017).

Engward (2013) and Mills et al. (2006) accentuate that GT generates a theory that is constructed from the data that is provided by participants and interpreted by the researcher. As asserted by Charmaz (2012, p. 2), “grounded theory is a systematic method of analysing and collecting data to develop middle-range theories.” CGT encourages the use of theory from the outset of the study (Rieger, 2019). Furthermore, the process of theorizing in CGT needs to be in agreement with evidence and have the potential to be justified against it (Timonen et al., 2018).

Comparison of CGT and Other Qualitative Methods

CGT is one of the qualitative methods that address empirical data, which is similar to other approaches like phenomenology and inductive ethnography (Charmaz, 2014b). However, as Clarke et al. (2023) opines, there are features in the CGT methodology that are not unique to this methodology only but can fit with other qualitative methodologies. To this end, research elements like interviews, focus groups, sampling, coding, and data analysis are features of most qualitative methods (Moser & Korstjens, 2017). Gray (2023) proposes several distinct differences between phenomenology, ethnography, exploratory-descriptive qualitative, and grounded theory, as in Table 1.

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Table 1.

Comparisons of Qualitative Designs (Gray, 2023, p. 68).

Qualitative Design	Philosophical Orientation	Phenomena Under Study	Research Outcomes
Phenomenology	Phenomenology	Lived experience	Themes
Grounded theory	Social constructivism	Social processes	Theoretical explanation (substantive theory)
Ethnography	Anthropology	Culture	Values and ways of living in the culture
Exploratory-descriptive qualitative	Pragmatism	Problems	Understanding and practical solutions

In addition to the differences depicted in Table 1, coding, which is defined by Chun Tie et al. (2019) as a systematic route that identifies concepts in a data set, is different in CGT as the coding entails soliciting a more detailed understanding of the data collected through initial and subsequently focused coding (Charmaz, 2014b).

CGT also uses constant comparison, which is not utilized in other qualitative methods. Constant comparison entails looking for similarities and differences in codes, which consequently leads to advances in coding. The relevant concepts and categories are basically refined during this process (Polit & Beck, 2022).

Another unique feature that is different from other qualitative methods is theoretical sampling. Theoretical sampling is defined as a process that ensures that collected data is verified in order to build an emerging theory (Charmaz, 2014b; Polit & Beck, 2022). Theoretical sampling occurs after key concepts and categories have been established (Noble & Mitchell, 2016).

It is well documented that reflexivity is universal across the qualitative approaches, but it varies according to the characteristics of methodological approaches on account of different assumptions and the processes of the designs (Cena et al., 2024). While choosing a method is dependent on factors like theoretical, ontological, and epistemological assumptions and the desired outcomes of the study (Cena et al., 2024), arguably, CGT can be of utmost relevance in transgender mental health research, as will be discussed in the next section.

Relevance of CGT in Transgender Research

After having been historically left out of research, there has been an increase in conducting transgender research over the years (Staples et al., 2018; Sweileh, 2018). In a book review of an upcoming publication, one reviewer highlighted that CGT is the most inclusive of all the strands of GT (Keane & Thornberg, 2024) and thus could be used for transgender communities. The complexity of transgender identity cannot be underemphasized and hence should be explored and considered through this inclusive methodology (Darwin, 2020). CGT’s emphasis is on understanding participants’ lived experiences and how they construct meaning in relation to the phenomenon under study (Charmaz, 2006). It is well documented that CGT has re-invigorated the positive psychology landscape by enhancing the theoretical principles in relation to theory underpinnings, clinical practice, and future research (Charmaz, 2017a). It is within this context that the suitability of addressing transgender complexities that are shaped through interactions with CGT can be reiterated.

Tweed and Charmaz (2012) highlight that with CGT, the social structures and situations within the (transgender) community can be investigated since there is a focus on social processes. For example, transgender individuals seeking help for mental health services could be a basic social process (Westberg et al., 2020). Lindqvist and Forsberg (2023) also postulate that CGT addresses participants’ concerns and their perspectives related to the phenomenon being studied. In this regard, the CGT approach works well as Charmaz (2014a) and Sebeelo (2024) echo the fact that CGT can give voice to the marginalized and ostracized and as well explore under-researched and disregarded phenomena like transgender health. CGT necessitates that data be collected to allow those that might be unknown to be recognized (Charmaz & Belgrave, 2019). As an example, in a study conducted in Botswana, transgender individuals had to endure the challenges of people not knowing about transgender identities; hence, research on these phenomena is pivotal (Mangwegape et al., 2024).

As contended by Burns et al. (2022), constructivist research methodologies are helpful in putting into perspective the meanings behind several experience which leads to an informed and improved healthcare practice. Reay et al. (2016) also concurs that CGT methodology informs healthcare and research that seek to explain behaviors of individuals and evaluate interventions in social contexts. Data gathering in CGT allows health researchers to look beyond themselves and focus on the priorities of participants (Charmaz & Belgrave, 2019).

As (Charmaz & Thornberg, 2021, p. 305) posit, using GT makes it more open to learning about the experiences of the research participants. Furthermore, openness is the “willingness to understand the experiences of people who are different from you” (Charmaz & Thornberg, 2021, p. 322). Society is stuck in heteronormativity and genderism. Therefore, transgender people are seen differently (Staples et al., 2018); hence, employing CGT puts the researcher in a good position to comprehend them. There is a need for the researcher to listen attentively to the participants’ experiences and ensure reflexivity (Burns et al., 2022).

Charmaz (2017b, p. 39b) acknowledges that every researcher has “hidden preconceptions that stem from class, gender, race, age, health, and professional statuses.” For example, a researcher can harbor transphobic views that he/she may bring forth when interviewing participants. Furthermore, there may be power imbalances between the researcher and participant in cases where the participant has internalized stigma and looks down upon themself, which may hinder the interpretation of data or create biases. The remedy for this is within the CGT approach, as it allows for self-reflection and reflexivity by the researcher(s).

Researchers can lessen the risk of misrepresenting the opinions and ideas of research participants by critically examining their own biases and presumptions through reflexivity (Bobbink et al., 2024; Tebbe & Budge, 2016). Additionally, the process of researcher reflexivity is simply the acknowledgment that researchers have pre-conceived views, values, backgrounds, and perspectives that may influence the research process, which must be aired and addressed (Olmos-Vega et al., 2023). Charmaz and Belgrave (2019) assert that this “methodological self-consciousness involves a searching self-scrutiny beyond that in which qualitative researchers commonly engage.” In their study, Turner et al. (2022, p. e422) highlighted that “the reflexive nature of Charmaz’s CGT was appropriate,” hence their decision to choose the method. Reflexivity helps minimize transphobic assumptions that the researchers may have held. Several strategies that include keeping a record of researcher memos, field notes, and other written or recorded reflections during the research process can be carried out to ensure reflexivity (Olmos-Vega et al., 2023).

According to Charmaz (2017a), GT promotes the transparency of previously invisible processes. In most societies, transgender issues are rarely discussed, with some questioning the legitimacy of the transgender identity (Skinner et al., 2024); hence, employing CGT will emphatically make it easy to dissect basic social processes related to transgender health and other issues. It is important to acknowledge that CGT allows researchers to advance critical questions during the research process, which enhances theoretical depth, ultimately revealing the “invisible” (Charmaz, 2017b); in the context of this article, accentuating what is not known about transgender individuals’ mental health issues.

Constructivist grounded theory aligns with dialogic engagements toward social justice (Duckles et al., 2019). As contended by Matthews and Salazar (2014), social justice encompasses studying hierarchies and inequities in relationships. Transgender individuals experience such inequities and are stigmatized (Lett et al., 2021); hence arguably, CGT may stimulate social action toward addressing those inequities. According to Charmaz (2017a), CGT “sparks new understandings of experiencing and redressing injustice”, thereby developing a theory directly from the words and experiences of transgender participants, and honors their voices and perspectives. In this way, a CGT approach is in alignment with the pursuit of social justice. It is pertinent to note that a dialogue with transgender individuals culminates in research results that are authentic and clearly representative of their feelings, thoughts, and experiences (Staples et al., 2018).

Schreiber and Tomm-Bonde (2015) pronounce that CGT is the only method that can work in tandem and has aesthetics of the philosophical concept of Ubuntu. Ubuntu is a sub-Saharan phenomenon that entails a value system that roots for weighty respect for all individuals and human dignity or humanness in some quarters (Schreiber & Tomm-Bonde, 2015). Thus, CGT can be employed in a variety of circumstances while preserving the human dignity that is essential for transgender research.

To substantiate the assertions that CGT is relevant for mental health research, Tweed and Charmaz (2012) highlight several studies that have been conducted on individuals perceived to be marginalized. Several other CGT studies have also been conducted for the purpose of illuminating the situations of people who are denied a public voice (Charmaz, 2014b; Charmaz, 2020).

As highlighted earlier in previous sections, transgender people are discriminated against and have barriers to health and well-being because of their gender non-conformity to the sex assigned at birth (Farvid et al., 2021). The adverse experiences of transphobia in society can ultimately lead to transgender individuals developing mental health disorders (Scandurra et al., 2018). According to White Hughto et al. (2015), the stigma of both mental disorders and transgender identity dissuades transgender people from revealing their gender identity. Concealment of identity can be seen as a social process that can be explored by CGT. As posited by Lane (2023), CGT has been seen to help in bringing perspective to stigma issues.

Specific to the transgender community, there have been several studies that have been conducted employing CGT (Austin, 2016; Burnes et al., 2016; Carroll-Beight & Larsson, 2018; Lindroth, 2016). The studies described transgender people’s experiences and expectations in healthcare and trauma experiences as transgender individuals, among others (Austin, 2016; Burnes et al., 2016; Carroll-Beight & Larsson, 2018; Lindroth, 2016). As noted by Saeed et al. (2018), transgender individuals have for many years not been listened to nor heard. Thus, CGT is suitable to address the plight of transgender individuals who are marginalized.

Strengths of CGT

There are several merits aligned to the use of CGT as a research methodology. The strength of CGT could be linked to its flexibility, which allows the researchers to easily adapt to the context of transgender individuals’ experiences that are ever-evolving (Charmaz, 2006). Gender identities and expressions continue to change on the basis of social, cultural, and political standpoints and as there is a need for amenability toward such (Callander et al., 2021). Because of CGT’s flexibility, CGT strategies can be modified to adapt and accommodate evolving perspectives in the social context of transgender individuals.

In CGT, data collection is done through several sources like field notes, interviews, and information from records and reports. This variety in data collection sources help enhance the strength of the GT as the data collected is rich (Charmaz, 2006, 2014b). Furthermore, the incorporation of a variety of data sources strengthens the validity of the CGT method (Leung, 2015).

The strengths of the CGT cannot be underemphasized as many scholars have assured for it. It is interesting to note that apart from transgender mental health research that the article has focused on, there have been other studies that sought to explore meanings in dire social processes like issues of normativity and deviance (Forsberg, 2022). To place this in context, in a study conducted on patients who had undergone pituitary adenoma surgery, Heckman et al. (2023) emphasized that CGT was an appropriate approach when compared to other methods since it allowed participants to explore the meanings of their situation, which led to the theory generation.