Category: Articles

The consequences of sampling bias

grvsmth

I wanted to go into a bit more detail about something I’ve mentioned before: that the use of non-representative samples can cause problems down the line. To illustrate this, I want to examine the claims of health disparities that Emilia Dunham lists in her Bay Windows article.

  1. Transgender people take more hormones and have have more surgeries than average.
  2. Transgender people smoke at a 30% prevalence rate, and use other substances to cope with the stress from discrimination.
  3. We’re more likely to suffer from depression and anxiety, and more likely to live with HIV.
  4. 61 – 64% of transgender people have been physically or sexually assaulted.
  5. 41% of transgender people have attempted suicide.
  6. All these percentages skyrocket for transgender people of color and low-income folks.
  7. A startling 1 in 5 transgender people have experienced complete refusal of services from healthcare providers.
  8. If transgender people aren’t referred to with correct names or pronouns or are treated with coldness, they may avoid the office.

Of these statements, only the last one is an existential statement. All the others are statements of prevalence or likelihood that are not generalizable without a representative sample. In my impression, some of them are more likely to be true of the entire transgender population than others. There are chains of causation from transgender actions to these disparities, and the chains are not all the same. Here are some possible causal chains. They are not the only possible ones, but they are the ones that seem likely to me.

First there are the inherent consequences of transgender actions: more hormones and surgery. If you’re only concerned with transpeople who choose to take hormones and undergo surgery, then of course this is true. But if you believe that not all transpeople choose hormones or surgery, and you don’t know how many do, then you have no way of knowing how great these disparities are.

Then there is harassment based on perceptible differences: physical and sexual assault. A lot of this has to do with passing – as one gender or another, not necessarily the one you prefer. The passing does not have to be total: a transperson can avoid a lot of harassment simply by avoiding being noticed. However, note that there is a feedback loop here regarding socioeconomic status: wealthier transpeople can afford higher quality hormones, surgery, hair removal or attachment, clothes, padding, cosmetics and training that can give them (us) a better chance of passing as the target gender.

There is also discrimination based on records or perceptible differences: refusal of healthcare service. There can also be housing, consumer and job discrimination, which can affect some of the factors below.

A transgender person has a number of potential reactions to the harassment or discrimination described above, including: avoidance of healthcare providers, depression, anxiety, substance abuse, suicide attempts. Out of fear of discovery, many transpeople engage in hidden sexual activities, where there is a greater risk of HIV infection.

Completing the vicious cycle I described above are the consequences of poverty, which may in turn result from discrimination: there is greater likelihood of harassment and discrimination (and the consequences that follow from that harassment and discrimination) and sex work (which increases the likelihood of HIV infection).

I know from personal experience, from friends’ anecdotes and from online reading that these disparities do not affect all transgender people. Some people do not choose hormones, some do not choose surgery. Some never take publicly visible transgender actions, and others pass well enough, so they are never harassed or discriminated against. Some are able to deal with the harassment or discrimination they experience without resorting to depression, anxiety or substance abuse, or attempting suicide (which is not a judgment against those who are unable). Some are able to avoid unprotected sex. Some are wealthy enough to avoid the consequences of poverty.

Here’s the problem with sampling: Dunham and other researchers have no way of knowing for sure whether they’ve oversampled from those who choose hormones and/or surgery; those who take publicly visible transgender actions; those who don’t pass enough of the time to avoid harassment or discrimination; those who already have tendencies towards depression, anxiety, substance abuse, suicide or casual sex, for unrelated reasons; and those who have lower incomes. After all, these are precisely the populations that public health researchers are more likely to come into contact with. Without representative samples, they can never prove that these disparities exist to the extent that they claim.

Now I want you to imagine that these researchers actually have been oversampling these higher-risk populations. On one level the consequences are minimal: if these are the populations with the greatest need, then it’s just another way to spend public health dollars on the people who need them the most. But on the image level and the credibility level, there are problems.

I’ve seen on the Web and on television that some people have a stereotype of “tranny” that combines all these factors: a drug-addicted, unpassable, mentally ill hooker with bad plastic surgery. Some people use that stereotype to justify harassment and discrimination against transgender people, and some family members fight against accepting their relative’s transgender feelings because they fear that this will be their fate. These kinds of unsupported survey results feed into those stereotypes.

What if at some point someone does succeed in doing a representative survey, and finds that the drug-addicted, cigarette-smoking sex workers are a small portion of the transgender population, and that the average transgender person is a drug- and disease-free, well-adjusted, successful computer technician making $60,000 a year? What if all the transgender health money was actually better spent on overlapping programs that would serve the needy population just as well? I think someone might feel cheated, and I think there might be a backlash.

There’s also the possibility that we might be missing out on some valuable information. What if we found that there were people who had the exact same background, and the exact same transgender feelings, but one group became drug-addicted HIV-positive hookers and the other became successful computer technicians? We could examine the populations and see what made the difference between health and sickness. It might not be the obvious solution.

This is why we need representative sampling, and this is why you need to comment on the proposal and tell that to Secretary Sebelius.

A critical opportunity in transgender research

grvsmth

The Department of Health and Human Services has just made a big announcement: they will begin collecting data on LGBT issues, including transgender issues. The goal is to document disparities in health care, as well as plain old disparities in health, so that they can be addressed in the future. The plan is to have two roundtables on “gender identity data collection” with “key experts” this summer and fall, and then the “Data Council” will present a strategy next spring.  The department will also collect public comment in various ways, one being through a website called regulations.gov, which is currently down.

If done right, this could be a tremendous help to understanding transgender issues.  “The first step is to make sure we are asking the right questions,” HHS Secretary Kathleen Sebelius told the Washington Post. “Sound data collection takes careful planning to ensure that accurate and actionable data is being recorded.”  As I’ve written before, current research on transgender feelings and actions is severely hampered by the lack of any kind of representative sample.  Just to give you a quick sense, here are ten very basic questions that nobody knows the answer to:

  • How many transgender people are there?
  • How common are the various transgender thoughts, feelings and beliefs?
  • How common are transgender actions like cross-dressing, body modifications, and “soft mods” like shaving?
  • How common are transgender name and pronoun changes?
  • How common are part-time cross-living and full time transition?
  • How often are sexual activities part of transgender activities?
  • How common are diseases and destructive habits among transgender populations?
  • How many transgender people are in long-term relationships?
  • How often are various subgroups targeted by violence and discrimination?
  • How satisfied are transsexuals twenty, thirty or forty years post-transition?

Unfortunately, transgender research is dominated by two camps, the pathologists who make unfounded generalizations based on case studies of their own patients, and the social service providers who make unfounded generalizations based on service recipients, Internet surveys and word of mouth.  Neither of them seem to have understood the idea that while convenience samples can provide the basis for many useful existential statements, prevalence statements based on unrepresentative samples are worthless.

At this point it looks like the roundtables will be heavily influenced by social service providers who only pay lip service to the limitations of their research.  The Plan says, “While HHS is in the beginning stages of developing data collection on gender identity, many researchers (e.g., Williams Institute at the University of California Los Angeles and the Center for Population Research in LGBT Health at the Fenway Institute) have been working on such data collection for several years.”  The Williams Institute produces reports like “Bias in the Workplace” (PDF), an important summary of numerous studies investigating workplace discrimination that repeatedly acknowledges that the studies are based on convenience samples – and then goes ahead and repeats percentage results as though they meant something.

The Fenway Institute employs transgender health advocate Emilia Dunham as a Program Associate, and she also hosted a webinar on the issue.  It seems quite likely that she will be one of the experts at the roundtables.  But in an otherwise solid article for Bay Windows presenting these changes at Health and Human Services, Dunham uncritically repeated several of these unsupported percentages.

There is a very short list of Experts who I think should be on these Roundtables.  The strongest research into transgender issues has been qualitative research: listening, reading and introspection, finding existential statements but not making unsupported claims of prevalence.  I’ve said before that the best qualitative researcher in the transgender community is Helen Boyd, author of My Husband Betty.  At Helen’s recommendation I’ve also read a few things by Raven Kaldera that have been pretty good, particularly his post on female transvestites (which has somehow disappeared from his website).

There is only one person out there who has ever collected data from a representative sample of any transgender community, and that’s Niklas Långström of the Karolinska Institutet in Sweden.  He’s not focused on the transgender community, and he’s associated with the pathologist Kenneth Zucker (who is not someone we want involved), but he does know how to do a national survey, and it would be worth every penny for HHS to fly him over from Stockholm for the Roundtables.

If they can’t get Långström, then I want to be on that Roundtable.  I don’t have a degree in psychology or public health, but I did take an elementary course in statistics, and I learned what you have to do in order to make a generalization.  But what matters more than any qualification is that I care about doing this right.  If they can’t find anyone else who does, I want to be there.

Am I missing anyone? Are you doing quality quantitative research? Please let me know.

The closet corrodes your soul

grvsmth

I’ve talked before about the value of being out of the closet – the global political value.  But being out can be valuable in a more direct, immediate way.  It can save us from the closet.

When I first started cross-dressing, I knew that it was not acceptable.  I had heard so many people making fun of transvestites that I didn’t think that anyone would value or support me if I told them I was one.  For over a year I did my cross-dressing in secrecy and isolation.

One day my mother came into my room and said, “This closet is a mess!  I’ve given you so many chances to clean it up.  Now I’m going to do it.”

I said, “Okay, Mom, but just don’t open the top drawer.”

“What’s in the top drawer?”

“Just don’t look in it.”

“Angus, what’s in the top drawer?”

After a few more rounds of this, I told her.  Her response was not as bad as it could have been (the horror stories we’ve heard about teenagers being rejected by their parents, thrown out of the house, beaten, or even killed), but it was not encouraging.  I won’t go into too much detail, since she apologized for it many years ago, but she was ashamed, and worried that I might be gay.  She insisted that I go to therapy, which was probably a good idea, but I didn’t even mention cross-dressing to the first therapist.  The second one was helpful in various ways, but not with regards to this issue.

I avoided talking to my mom about cross-dressing after that, until I came out in general.  That meant that I was pretty much alone in the closet for another fourteen years.  And that time was hell.  I don’t know which was worse, the feeling of shame when I cross-dressed, or the feeling of relief when I purged.  Every time the topic came up in general conversations with anyone other than my mother I had to remain silent, afraid that I would be ostracized if anyone found out.  The chronic fear of being found out was a source of discomfort throughout my teen and college years.

Since I’ve come out, I know that there is a group of people that I can rely on, who have shown me that they support me no matter what I’m wearing.  I don’t need to feel ashamed around them.  Even if I don’t feel comfortable telling absolutely everyone, it’s still liberating to know that there are many people who don’t judge me for my gender expression.

Unfortunately, it took a long time for me to feel comfortable coming out.  I had to tell one person at a  time, until I knew that there were enough people who supported me.  This is why one of my goals is to encourage widespread, open, vocal support of non-conforming gender expression, so that the teenagers of tomorrow can live outside the closet.

A simple thing you can do for trans people is to say something supportive every time the topic comes up.  You can do this for gay men, lesbians, bisexuals, cyclists, or any disenfranchised group.  You might want to have a handy phrase or two ready ahead of time.  And if you can’t think of anything supportive to say, educate yourself!

The First Principle

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It’s been years since I wrote about principles of transgenderism.  It’s funny, when I think about it, how I was so deep into discussions of transgender issues at the time that I just wanted to get down the things that separated my thoughts from some of the prevailing ideas.  But now, I realize that I should add another principle that’s more important than the eight I listed, and I think it’s one that just about every transgender person would agree on.  It’s implied in all of my work in this area, but I want to come right out and say it:

No one deserves to be hurt or killed just because they’re transgender.

Pretty obvious, huh?  Well, I guess it’s not so obvious to the bashers and killers.  But to me it’s the top priority in anything transgender-related.  We can make it Principle One and move all the others down, or make it the Zeroth Principle like Isaac Asimov.  Either way, I can’t think of anything more important.

The Value of Being Out

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Tonight I came across this interview about GLB issues with Barack Obama, and one passage in particular resonated with me:

A college professor of mine helped me to see the lives of LGBT people from a different perspective. He was the first openly gay professor that I had ever come in contact with, or openly gay person of authority that I had come in contact with. And he was just a terrific guy.  His comfort in his own skin and the friendship we developed helped to educate me on a number of these issues.

I, too, had an experience like that: a fellow student of mine who was willing to tell anyone and everyone that he was gay.  Steve wasn’t an authority figure (although I would meet plenty later), but still an example of pride and self-acceptance who inspired me to reexamine and discard my homophobia.  I had known many closet cases and “don’t ask, don’t tell” gay men, lesbians and bisexuals, and their own shame and fear had given me license to judge them.  I just couldn’t do that with Steve, and after a while I realized that I couldn’t do it with myself either.

This is the reason why I think we non-transition-track transgender people (transvestites, cross-dressers, etc.) should practice some verbal hygiene on the term “out” and stop using it to describe someone who cross-dresses in public settings that are still anonymous, and who doesn’t disclose their transgenderism to their family, friends, neighbors or co-workers.  Of course there’s such a thing as too much information, but there are times when people need to know that we’re transgender.

Clearly our next president benefited from the information he got from his professor, and more importantly, from his professor’s own self-acceptance and self-respect.  The gay and lesbian communities have benefited from Obama’s acceptance and respect.  If transvestites ever hope to be accepted and respected, we have to accept and respect ourselves, and be out of the closet.  And this kind of “out” has very little to do with clothes: we can be out to our friends and neighbors without them ever seeing us in a skirt, wig or maid costume.  All it takes is these three words, “I’m a transvestite.”  Could you say them to Barack Obama?  Could you say them, with pride, to a student who might some day be president?

Update. August 2009: I just discovered that Steve’s husband died tragically in March.  Steve wrote for Americablog about how some of his experiences afterwards highlighted the connection between being out, marriage equality and respect.  Last week, he wrote about how it related to his lexicography work.

James “Cora” Birk on Transition and Regret

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In the light of the recent news that sportswriter Mark Penner has detransitioned, I went back and looked at an earlier post on regret. I noticed that I had linked to Cora Birk’s writings on her partial transition and subsequent de-transition, but that they have since been removed from the site.

However, Birk’s columns are still available via the Internet Archive, and since the last one, especially, is particularly well-written, I would like to share some excerpts:

It is still (and always has been) true that I want to be female. However, somewhere along the way, I appear to have convinced myself that this desire was much more than a simple, harmless wish — that it was a yearning, that if I didn’t get what I wanted I couldn’t possibly go on. I’m not exactly sure when this happened, though I do suspect an intense psychological imprinting experience sometime in 1998.

[…]

I embraced transsexuality, I think, because I was extremely uncomfortable with the other terminology I was hearing. If I was merely a crossdresser of one kind or another, I was nothing more than a largely misunderstood pervert with an extensive makeup collection. But if I was transsexual… then I was validated. I could be helped. I could go on hormones and one day have sex reassignment, all under the protection of politically correct GLBT activists who would see my condition as something to be proud of. I could hold my head high in parades, and everyone around me would put aside their native discomfort with the situation and use all the right pronouns.

My take on this is that the decision about whether or not to transition would be a lot easier if we didn’t have to deal with rigid categories and arguments based on destiny.  Over at the Trans Group Blog, Helen, Julie and Marlena all allude to the question of whether Penner is “really a transsexual.”  To their great credit, they refuse to consider it, but their use still implies that they believe it’s a valid question, and that people who are “really” transsexuals should transition.

Let me put this out there: if we assume that there are “true transsexuals” and “false transsexuals” out there, isn’t it possible that there are “true transsexuals” who would turn out to be happier in their birth genders, and “false transsexuals” who would manage to be quite content after transition?

New Celebrity Detransitioner

grvsmth

I don’t have much to say about this now, but Sports by Brooks reports that sportswriter Mike Penner has detransitioned.  I have very little interest in spectator sports, so I’ve never heard of this guy.  Does that make me a true transgender?

Of course not; just kidding.  (Or rather, it has no bearing on the trueness of my transgenderism.)  Thanks to Kate at Deep Glamour for the link.

Magical Thinking

grvsmth

A year or two back I came across Sir James Frazer’s The Golden Bough, and was blown away by the theory underlying it.  I have to admit that I haven’t read much more of it yet than the first couple of chapters, but the rest, from what I can tell, is details about particular beliefs.  What fascinated me most was Frazer’s division of beliefs into four categories, based on what is being related to and how.  He makes a distinction between science and magic, as follows: “The fatal flaw of magic lies not in its general assumption of a sequence of events determined by law, but in its total misconception of the nature of the particular laws which govern that sequence.”  Science and magic are both rule-governed, but magic misunderstands the rules.  Religion, by contrast, is personal:

But if religion involves, first, a belief in superhuman beings who rule the world, and, second, an attempt to win their favour, it clearly assumes that the course of nature is to some extent elastic or variable, and that we can persuade or induce the mighty beings who control it to deflect, for our benefit, the current of events from the channel in which they would otherwise flow. Now this implied elasticity or variability of nature is directly opposed to the principles of magic as well as of science, both of which assume that the processes of nature are rigid and invariable in their operation, and that they can as little be turned from their course by persuasion and entreaty as by threats and intimidation. The distinction between the two conflicting views of the universe turns on their answer to the crucial question, Are the forces which govern the world conscious and personal, or unconscious and impersonal?

Things (rule-governed) People (relationships, prayer)
Empirical Science Society
Faith-based Magic Religion

Frazer does not really discuss the fourth quadrant of the chart, dealing with non-supernatural beings on a personal level, but it’s not very relevant to the main point, which is situating magic with respect to science and religion.

Glamor, Horror and the Trans Fatale

grvsmth

A couple of years ago I recommended to you Virginia Postrel for her insightful discussions of glamour, and argued that they’re relevant to transgenderism and transvestism.  Now Postrel has started a new blog focusing on glamour, as part of a new book she’s writing on the subject.  This is definitely good stuff.

Growing out of a discussion of whether a McCain presidential campaign ad aims to present Obama as the Antichrist, Postrel has a great post about the relationship between glamour and horror.  She writes:

While horror comes in different forms, some decidedly unglamorous (e.g., Alien, Saw), a lot of horror, including vampire tales, depends on glamour: What starts out as beautiful and alluring is revealed to be terrible and life-destroying–and by then it’s too late. Witness not only the vampire but the femme fatale, especially in her 19th-century form. Glamour promises escape and transformation; horror replaces escape with entrapment.

(With regard to gross-out “horror” movies like Saw and Friday the 13th, I’d say that they’re more appropriately called “terror movies.”  Sadly, that term has now been appropriated by the terrorism frame, but before that there were some insightful discussions of the contrast between terror and horror.)

This explanation of horror helps me to understand some of the various “trans fatale” movies (Dressed to Kill, Homicidal, M Butterfly): if the idea of the femme fatale plays off of men’s fears of unexpectedly strong women, then the trans fatale has the glamour of being beautiful and alluring, but are even more threatening because they can be imagined to possess the physical strength and aggression (and ability to rape) of men.

Going further, it seems connected to the “trans panic” that some men have claimed: they believed they were kissing a vulnerable woman, and on discovering that the person was male they were overwhelmed with the fear that they had been seduced and would be raped or killed.  This is often, horribly, used to justify beating and even killing the trans person.  Of course, a male who is small or slim enough to pass as a vulnerable woman usually has no more strength than a woman that size, and any trans woman on hormones probably doesn’t have much ability or desire to penetrate a man, but reality plays very little role in any of this.

Deconstructing glamour with reality is actually an effective comedy technique, and this can explain why so many people find cross-dressing funny.  Since men have many of the traits that are considered unattractive in women (hairy, sweaty, big bellies), but more commonly and to a greater degree, a cross-dressed man can produce just enough cues to project the image of a glamorous woman (long wig, long legs, short skirt) before shattering that image with a hairy belly.  The humor is a bit broad for my taste, but it clearly works for many people, as shown by the enduring popularity of Benny Hill and Martin Lawrence.

The first pregnant man?

grvsmth

Sometimes trans dogma can be funny when it paints itself into a corner.  Here’s an example from the current news about Thomas Beatie.  Beatie is a transman who just gave birth to a baby girl.  This Metafilter thread claims that he’s “first legally transgendered man to become pregnant.”  This is just one of the many Bogus Transgender Firsts.

Back in 2004 there was a transwoman who claimed to be the first transgender delegate to the Democratic National Convention.  A little googling revealed that there was a trans Carter delegate in 1976, and possibly a trans delegate to the 1968 convention.  Ever since then I’ve been skeptical about Transgender Firsts.  Some transpeople, despite paying lip service to the idea that transpeople have been around forever, seem to think that history began some time around 1998.

Metafilter user Grapefruitmoon managed to assert the notion that Beatie is the First Pregnant Transgendered Man even while linking to an article in the London Telegraph that contradicted this claim.  A little bit of thought suggests that this Transgender First is highly unlikely.

We know that people have been cross-dressing and cross-living for thousands of years, and expressing feelings that could broadly be considered transgender for about as long.  Many transgender people claim them as spiritual forefathers and foremothers, even though if Henri III were alive today they’d probably bounce him out of the support group for not taking hormones.  If you want to claim that the Abbé de Choisy or Billy Tipton were trans, you’d guess that there have been transmen for as long as there have been men.

In the essentialist point of view, transgenderism begins in the womb, if not in the genes.  Along these lines, if you accept someone as transgender they are eternally transgender, whether they’ve had any body modifications or not.  This is always a source of laughs when people who were “heterosexual cross-dressers” last week all of a sudden become eternally transgender, provoking a desperate flurry of revisionism.  More to the point, if you accept the notion of Eternal Transgenderism, not only was Beatie a man his entire life, but so was everyone who can be corralled into the Transmen Through History exhibit.

Reading through some of the lives of pre-testosterone-injection transmen, it seems that most of them began to live as men quite young.  A cursory search doesn’t turn up any record of any of them having been pregnant, but there are plenty of transmen who are attracted to men, and plenty of others who’ve tried to conform and live as women for part of their lives.  There are also, shamefully, transmen who’ve been raped.  Whether or not it was something he desired or intended, it seems pretty likely that some transman must have become pregnant some time in the past.

I’d even venture to say that Beatie is probably not the first transman married to a woman who can’t bear children.  I could imagine a transman who passed as a man for years, married a woman who knew his secret, and then found himself in a situation like Beatie’s.  I can imagine this transman conceiving a child in one way or another, arranging to go on a trip somewhere with his wife, living as a woman for long enough to deliver a healthy baby, and returning as a happy father and mother.

Just because I can imagine something doesn’t mean it happened, and I don’t know of any documented case of a transman becoming pregnant before Beatie.  Maybe it never happened, but it’s irresponsible to keep claiming “firsts” without making any attempt to actually check whether something is the first.  Beatie was quite likely the first pregnant transgender man to be featured on Oprah, but history was old before Oprah.

Grapefruitmoon could possibly get around this by using the phrase “legally transgendered man.”  But I don’t know of any legal certification for transgenderism.  There’s clinical diagnosis, but I don’t know if Beatie has one.  Beatie has legally changed his gender, but before the era of birth certificates it was possible to do that by simply passing for long enough to establish an identity.

There is a word for what Grapefruitmoon meant: “first known.”  This provides some protection, at least.