“I’m a cross between Einstein and
Frankenstein.
And his brother Dr. Jekyl and Mr. Hyde.
Beware and proceed with caution.
And don’t jump the waters
For the ass you save may very well be your own.=
With me, messing with me at the wrong time is n=
ot
good.
Generally I am a good peaceful caring individua=
l
Who will not tolerate bullshit
from certain so-called educated holier than thou
bastards
Who are just control freaks.”
&nb=
sp; =
Poem
by R. Francine Bailey, 2002. =
Transgender is a relatively new term minted to consolidate the sometimes disparate group of people who share the experienc= e of an “appearance and behavior [that] do not conform to the cultural ‘norm’ for the gender into which they were born.”<= !--[if supportFields]>= ADDIN EN.CITE <EndNote><Cite><Author>Goodrum</Author><= Year>2002</Year><RecNum>120</RecNum><record><= rec-number>120</rec-number><ref-type name=3D"Electronic Source">12</ref-type><contributors><authors><a= uthor>Goodrum, A.J.</author></authors></contributors><titles><t= itle>Gender Identity 101: A transgender primer</title></titles><volume>2005</volume><num= ber>February 28</number><dates><year>2002</year><pub-dates>= ;<date>2003</date></pub-dates></dates><publisher= >Southern Arizona Gender Alliance</publisher><work-type>brochure</work-type><ur= ls><related-urls><url>http://www.sagatucson.org/downloads/GI= 101.pdf</url></related-urls></urls></record></Ci= te></EndNote>1 Transgender people have long experienced an unusual position in our society. Sought out by some, unknown by many, often portrayed as freaks, and all too vulnerable to discrimination’s most violent manifestations, people who flout traditional conventions of gender spark interesting responses from others.<= span style=3D'mso-spacerun:yes'> Unfortunately, many of these respo= nses are currently negative, which creates great stressors in a transgender person’s life. Too litt= le is known about how those stressors affect health; the field of transgender hea= lth research is nascent. Most art= icles published in peer-reviewed journals focus on the treatment and surgical advances available, and few dedicate themselves to a more epidemiological or personal study health status. The fact that females of transgender experience (i.e. natal males) a= re proving to be a population with high prevalence of HIV has spurred some groundbreaking research in this area. The current leading edge of epidemiological information about transgender people is embodied in a serie= s of needs assessments of local populations, most of which were conducted to estimate HIV risks and service needs. These needs assessments describe populations that experience severe discrimination, poverty, and concomitantly high rates of morbidity and mortality. While more needs assessments are being published in the peer-reviewed literature, this body = of work remains difficult to navigate since some key studies have only been published as reports. <= o:p>
The
health disparities experienced by transgender people are unlikely to be
biological in nature; there is no medical understanding of why one person is
gender normative and another is not.
Perhaps if or when this question is answered, the issue of biologica=
lly
derived differences in health manifestations can be researched. For now, almost all of the health
disparities experienced by transgender people appear to have a much more
prosaic root, in that they are causally linked to social determinants. Transgender people provide an
interesting avenue for studying social determinants particularly because the
population emerges out of every different social and economic stratum, maki=
ng
any congruence in health outcomes that much more unusual. Community-based needs assessments =
have
documented a series of health problems that are prevalent in transgender
populations. Taken together, =
these
data are intimidating, profiling a set of communities with record-setting
levels of HIV infection, violence, and suicidality. As Dr. R.E. Fullilove commented up=
on
reading a summary of these findings, “Giving this to someone to read =
is
like dropping bullets on concrete, you know there’s a big problem, but
you have no context in which to understand it.” Qualitative data in the needs
assessments and other research offers some explanatory information, but the
question persists: what mix of
social issues and influences provided the foundation for these health
outcomes? It was after experi=
ence
with this literature that I abandoned the idea of conducting another
quantitative study on transgender people for this dissertation. Researchers have amassed numbers
profiling the health of transgender people; the needed contextual informati=
on
about health disparities lies not in these numbers. This context can only be derived f=
rom
in-depth study of people’s experiences. To move the literature forward, we=
now
need information too rich to be captured from surveys, information that cha=
racterizes
the complicated social context that gives rise to these needs assessment
data.
Because this topic is in an arena that can be is unfamiliar to many, a general introduction to the concepts and terms used in the paper is provided here. <= o:p>
Prior to the 1990s, transsexuals and transvesti=
tes
were often grouped under the umbrella term “homosexual” by
outsiders. In recent years, t=
here
has been increasing attention to separating out the axis upon which gender
identity is measured from that of sexual orientation. Around 1990 a new word was introdu=
ced to
refer to the body of various people displaying gender variance,
“transgender.” It=
is
now commonly understood that the one can be transgender without being
homosexual, as transgender refers to ones own gender identity and homosexual
refers to the gender of one’s partner(s). It is acknowledged that a great de=
al of
overlap between the two groups exists, which explains the continued groupin=
g of
these related communities. In=
one
study, it was found that 89% of transgender respondents also identified as =
gay,
lesbian, or bisexual.2 =
In a
similar evolution of language, the term “homophobia”, or fear of
homosexuals, has gained widespread acceptance but is now being questioned in
some of its usages. Advocates
contend homophobia is not an accurate name for a phenomenon that is often a
result of visual impressions, instead of direct knowledge of a person’=
;s
sexual orientation. The word
“transphobia” has been coined to more accurately indicate fear =
of
transgender people. Some
transgender activists argue that transphobia and homophobia are manifestati=
ons
of the same concept, negative reactions to non-conformist gender presentati=
on.3 =
To more
accurately reflect the aggression and normalizing common in these reactions,
some have also gone further to abandon any “phobia” or fear-bas=
ed
term, instead labeling the systematic oppression of people who do not meet
societal gender roles as “genderism.”4, 5 =
Transgender individuals challenge the conventio=
nal
definitions of gender. Simila=
rly
intersex individuals, those born with atypical reproductive or sexual anato=
my,6 also challenge traditional gender paradigms.
Operational Definitions of Key Concepts<=
/b> &n=
bsp; =
;
The following definitions are commonly used in =
the
transgender community. For on=
e of
the concepts, the operational definition has been expanded in the context of
this study. If a reader is
otherwise conversant with these terms, I would recommend still reading the
operational definition of transitio=
n
for this reason.
“Transgender (or TG) refers to people whose appearance and
behavior do not conform to the cultural "norm" for the gender into
which they were born.”1
“Crossdressers (previously known as transvestites)
identify as, and are completely comfortable with, their physical gender at
birth, but will occasionally dress and take on the mannerisms of the opposi=
te
gender. Most crossdress=
ers
are heterosexual men.”1
“Drag
Performers dress and act l=
ike
the ‘opposite’ sex for the entertainment of an audience. For th=
em,
drag is a job - not an identity.”1
FTM stands
for female-to-male, it is applied to people who were assigned female at bir=
th
and are moving towards the male end of the gender continuum.
Gender
dysphoria is “the st=
ate,
as subjectively experienced, of incongruity between the genital anatomy and
gender identity. Transexualism is its extreme end.”11
Gender
expression – “=
External
manifestation of one's gender identity, usually expressed through
"masculine" or "feminine" behavior, clothing, haircut,
voice or body characteristics. Typically, transgender people seek to make t=
heir
gender expression match their gender identity, rather than their birth-assi=
gned
sex.”12
Gender
identity is the sense of w=
here
you belong on the spectrum of male to female.
Gender
oppression is the class of
behaviors that serve to reinforce societal norms about appropriate gender
behavior.
Gender
variant refers to behavior=
or
self-identity that does not conform to the cultural "norm" for the
sex assignment at birth.
Genderqueer, genderblenders, bi-gendered, andro=
gynes
and others “Not all
transgender people fit neatly into the above categories. For some, such
characterizations of gender and gender identity are more constraining than
liberating. Gender blenders may or may not identify as one or the other in a
binary gender system (i.e. either/or, male/female) and many times will assu=
me a
mixture of male and female dress and characteristics, combining elements of=
both.”1
Johns refers
to the clients of sex workers.
MTF stands
for male-to-female. It is app=
lied
to people who were assigned male at birth and are moving towards the female=
end
of the gender continuum.
Non-conformist
gender identity is one tha=
t does
not conform to a person’s birth sex.
Passing
refers to the state of bei=
ng
unidentifiable as gender variant or transgender.
“Sexual
orientation refers to whom=
you
love or have sex with.”1
Stealth
refers to being unidentifi=
able
as gender variant or transgender. This
word is usually associated with longer term immersion in a gender normative
community.
“Transexual
is “a person who has=
a
deep, core identity of the gender opposite to their born sex.”=
13
Transition
is commonly used to refer =
to a transexual
person’s change from presenting as one sex to the opposite one (e.g. a
natal female transitions into b=
eing
male). In this study, I
deliberately expand this definition to include the broader transgender
phenomena of reconciling ones public and private gender identity. (e.g. a natal female transitions into being genderqueer=
).
Transphobia
literally means fear of
transgender people, but is most commonly used to refer to actions or behavi=
ors
that are negative towards transgender people.
Community-based
studies of transgender populations have shown more risk behaviors and higher
prevalence of adverse health outcomes than in the general population. This is in accordance with the wid=
er
body of research on the health status of two groups that overlap the
transgender population, gay men and lesbians. If anything, the known resea=
rch on
transgender people indicates they have potentially a lower health status th=
an
people who are exclusively gay or lesbian (and not also transgender).14, 15 =
Barriers
to treatment are being better researched and documented for lesbian, gay,
bisexual, and transgender populations (LGBT). The primary barrier to care is the
discrimination that these groups face in the health care system and the
aversion to care that results.15 =
There has been an increased level of attention =
on
LGBT health in the last few years.
In 2000, the government issued an Institute of Medicine report on
lesbian health16 and convened a scientific meeting on the same
topic. In the most recent edi=
tion
of the government’s once-a-decade tome on heath planning, Healthy Peo=
ple
(2010), sexual orientation was added as a marker of populations that experi=
ence
health disparities.17 =
This is
an historic acknowledgement of the health problems that LGB communities
face. The growing acceptance =
of
sexual minorities as a population that experiences health disparities is of
benefit to LGBT research, as the legitimacy of health research on either LG=
B or
LGBT populations has been subject to political pressures. For example, in 2003 the New York Times reported that scien=
tists
were being warned to “cleanse” their National Institutes of Hea=
lth
abstracts of controversial words such as “gay” or
“transgender.”=
18
Following this, the Department of Health and Human Services compiled=
a
list of potentially objectionably NIH studies that were to receive addition=
al
scrutiny, many of which included LGB or T populations. The discovery that this list had b=
een compiled
by the notoriously conservative Traditional Values Coalition sparked Senator
Waxman’s response that this was a “witch hunt” and
“scientific McCarthyism.”=
19-2=
1 Documenting a history of this and similar anti=
-LGBT
federal policy decisions, the American Public Health Association passed a
resolution in 2004 urging Congress and federal agencies “to cease all
actions that unfairly jeopardize LGBT- and HIV-related research and service
delivery programs.” (p1.)22
Sometimes privatizing the results has been used=
to
distance federal agencies from LGBT results. In 2000 the Health Resources and
Services Administration commissioned a literature review of health research
related to LGBT populations.14 =
A year
later, they commissioned the largest single summary of LGBT health informat=
ion,
the LGBT Companion Document to Healthy People 2010.15 =
This
book compiles the best available evidence to explore HP2010 objectives and =
LGBT
communities in depth. After
consideration of the incoming conservative Presidential Administration, the
decision to publish it internally was changed, and it was instead given to =
the
Gay and Lesbian Medical Association to publish privately.
Often, the growing acceptance of research on LG=
B comes
at the expense of stripping off the more controversial T or transgender
populations, as was the case in Healthy People 2010. In 2004, the Centers for Disease C=
ontrol
announced to community leaders that they were expanding their Office of
Minority Health mission to include a focus on sexual minority populations.<=
/span>23 =
This is
arguably a great step forward for eliminating health disparities, but one t=
hat
stops short of identifying the disparate health issues of transgender
people. In early 2005, the he=
ad of
the Substance Abuse and Mental Health Services Administration threatened to
withhold agency participation, and possibly even funding, if organizers did=
not
comply with a “request” to remove the words “lesbian, gay,
bisexual and transgender” from a workshop title about LGBT teen
suicide. Agency representativ=
es
suggested they replace them with the transgender-exclusive phrase “se=
xual
orientation.”24 =
After a
strong response by concerned mental health professionals, the agency revers=
ed
this position and clarified that it is permissible for grantees to use the
previously objectionable terms in SAMHSA funded-presentations.25 =
This is
more consistent with their earlier publication of one of the only governmen=
tal
documents to address issues related to LGB and T health, the 2001 Provid=
er’s
Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and
Transgender Individuals.26 =
I am a contributor to two of the above-mentioned
documents, the literature review and the HP2010 Companion Document. My experience working on those doc=
uments
made clear to me the dearth of transgender health research. It also reinforced the need for re=
search
on the relationship between social determinants and this population. Particularly since these social
determinants might provide a much-needed framework for interpreting the
alarming statistics emerging from the community needs assessments. It was from this standpoint that I
proceeded to develop this study.
Since the early 1=
990s,
there has been an upsurgence of organizing and activism around the newly
created label of transgender. This
focus has forged a new understanding of the experiences of transgender
people. But the truth remains=
that
only a minority of LGB people and an even smaller minority of heterosexual
people have had any direct interaction with a transgender person. This lack of direct experience nec=
essarily
perpetuates the categorization of transgender people as alien to one’s
life. This is perhaps aggrava=
ted by
the sensationalist dramatization of transgender people on daytime talk show=
s. Without direct experience to round=
a
person’s perceptions, stereotypes remain valid informational markers
about a group of people, talk shows become key reference points, and even
well-intentioned people find themselves without tools to counter discrimina=
tory
stereotypes propagated by mass media.
This phenomena is classically associated with perpetuating a cycle of
stigma27. There
is a strong need for direct firsthand accounts of life from the perspective=
of
transgender people, without the dramatic stereotyping common in current med=
ia
depictions. This study is des=
igned
to help provide non-sensationalized direct experiential knowledge of a
difficult-to-access group of people, and will perhaps be useful to some for
that reason alone.
This study is add=
itionally
important because it provides data about the social factors that lead to
adverse health outcomes in populations with acknowledged high morbidity and
mortality. As has been stated=
, the
lack of data on these populations is a sincere problem. Additionally, existing data primar=
ily
capture information on health outcomes.&nb=
sp;
This study explores a different area, it plumbs into the different
potential causal factors that lead to these epidemiological outcomes. While this is one early study, lat=
er
researchers will no doubt have to further explore these causal factors to b=
uild
a foundation for interventions that change these outcomes.
This study has be=
en
conceived to augment the available research about transgender health
issues. It has been designed =
to
provide descriptive information on the key role social determinants play in
affecting the health status of transgender people.
This study has be=
en
organized to provide information on two key questions.
1. What social determinants have played an excepti=
onal
role in contributing to the health status of transgender people?
2. How do these social determinants conspire to im=
pact
health outcomes?
Since a portion o=
f the
data collection utilized life history interviews, there are many other
potential research questions that could be addressed with the resultant
information. For the purpose =
of
this study, the following secondary questions will also be addressed.
&nbs=
p; &=
nbsp;
i. &nb=
sp;
What is the
feasibility and acceptability of the proposed methodology in accessing the
target populations?
&nbs=
p; &=
nbsp;
ii. &n=
bsp;
What infor=
mation
can be gleaned about the interaction of demographic characteristics and
transgender status as this relates to health outcomes? (i.e. how do gender vector, race, =
and or
early childhood SES influence later experiences as a transgender person?)
Necessarily,
this study is delimited by several factors. First, the fieldwork for the study=
was
conducted primarily in the months of May through July, 2002, and written
through May 2005. Perspective=
s,
input, and supporting literature are bounded by what was available at this
time. Political interpretatio=
ns and
vocabulary are also affected by this timeframe. For example, there is currently ma=
rked
antipathy towards, yet acknowledged utility of the relatively new word R=
20;transgender.” As was mentioned in the for=
eword,
the convenient grouping of all gender variant people under this label is a
heuristic that assists researchers, but is not necessarily reflected in the
personal identities of the people it references. While an increasing number of peop=
le
easily adopt the label of transgender, some resoundingly do not.
Second,
as this study was intended to accomplish a specific goal, there are many wo=
rthy
research questions that simply fall outside the scope of this research.
Specifically,
the study does not attempt to explain causation in transgender status, i.e.
“why did this person become transgender?” Early childhood information may ap=
pear
to provide explanation for this question, but a study with that goal would =
have
been constructed very differently and subsequently yielded different data.<=
span
style=3D'mso-spacerun:yes'> The interviews in this study
purposefully do not probe very deeply into identity formation, key formative
events, or changing self-perception, all themes that would be important to
answering the question of “why transgender?”
The study also does not attempt to create a
classification status for different types of transgender people. This is a broad area of research t=
hat
needs to be addressed with greater resources than I had available in order =
to
yield any substantive conclusions.
Instead, study participants are crudely sorted into two categories:
people on the male-to-female gender vector (MTFs), and those on the
female-to-male gender vector (FTMs).
Vector information is supplemented with some information on
classification by self and other.
In noted instances, participants are defined more by commonality of
experience than by commonality of self-identification labels.
As stated in the =
research
questions, the study does explore which social constructs have played an
exceptional role in contributing to the health status of transgender people=
and
how they have affected health outcomes.&nb=
sp;
In addition to
delimitations, the design of the study necessarily creates some limitations=
on
the data produced. First, the
outreach plan was only able to reach people whose gender variance is public=
ly
known or acknowledged. This m=
ay not
seem too problematic on the face of it, but there is a issue of concern in =
the
transgender community, commonly called “going stealth”. People who have “gone
stealth” can live in the gender normative community without eliciting
curiosity or unwanted attention about gender, i.e. they “pass”
(usually as the opposite of the sex they were assigned at birth). They no longer associate themselve=
s with
a gender variant community, instead choosing to live submerged in a gender
normative world where few if any people will ever know of their transgender
history. There are potential =
advantages
and disadvantages to going stealth.
Since a person can obviously pass easily, they do not experience the
discrimination or hostility that can often accompany awareness of gender
variant status. Conversely, t=
his
person is often isolated from social support or social services that
acknowledge and validate the full depth of their experience. The significant other is often awa=
re of
the transgender history but without any further community contact, they are=
left
with little social precedent to normalize the situation. While a few people who had been st=
ealth
at some time were approached for this project, they ultimately were not abl=
e to
participate (one might have changed his mind about being interviewed, anoth=
er
just was not able to meet the timeframe).&=
nbsp;
It is acknowledged that the sampling methods employed were unable to
reach people who did not have any current connection with the gender variant
community.
Another study lim= itation is that this is not a population-based research project. The costs and difficulties inheren= t in conducting any population-based research on such a low-incidence marker as transgender status are prohibitive. As with many other low-incidence population groups, it is much more = likely that the bulk of knowledge obtained about transgender people will come thro= ugh non-probability studies, with a variety of innovative outreach methods being used to reach deep into the communities of interest and then gauge saturati= on28-30. This study does not attempt to approximate population-based findings, it instead intends to be illustrative. <= o:p>
This dissertation has been organized to be b= oth easy to read and clear in presentation of key items. I relied heavily on other disserta= tions to help accomplish this goal. The dissertation is organized in a classic style: introduction, literature revi= ew, methods, findings, and conclusion. In creating the document, I use a feminist writing style, eschewing dispassionate attempts at objectivity and locating myself in the work throu= gh the use of the pronoun “I”31. As much of the information related= to this topic is not common knowledge, more effort has been put into the introduction and literature review. Through this I hope to ground readers in key terms and operational concepts related to transgender communities. I also acknowledge that issues spe= cific to transgender people are of interest to a small segment of the academic communities. To broaden the interest in this work, I have considered how to use the data to focus on so= cial determinants that cross populations. For example, the findings focus more on social support than on the transgender-specific phenomena of “going stealth.”
One of the second=
ary
research questions in this study relates not to data collected but to metho=
ds;
“What is the feasibility and acceptability of the methodology propose=
d with
the target populations?” The
findings related to this question are presented in Chapter 3: Methods. The description of outreach activi=
ties
in that section has been covered in great detail specifically in response to
this research question.
The findings section begins with a short discussion about the pervasive role of discrimination and then outlines my conceptual framework, “compromised survivors.” This is followed by sections dedic= ated to elucidating the different elements of this framework, specifically the triumvirate of social determinants that emerged as characteristic of transgender health:
1. Stress
2. Social exclusion
3. Social support
In the last chapter I summarize the findings and stage the relative impact of these different factors. Through this lens, I further discu= ss and expand the framework of “compromised survivors”. In conclusion I present suggestion= s for future research as well as possible actions to improve the health of transg= ender people.
= ; &n= bsp; = ; &n= bsp; = ; &n= bsp; -