The Future of Transgender Health Symposium Keynote

[This is the text of the keynote I delivered to the Future of Transgender Health Symposium on October 18, 2019 at Portland State University as part both the Portland State of Mind series, and the Public Health Portland Style series, and sponsored by the Oregon Health & Science University-Portland State University School of Public Health. Capitalized bold words were cued for me to stress vocally during the keynote.]

Welcome! Welcome.

I am profoundly honored to speak at this symposium on the Future of Transgender Health.

Welcome women.

Welcome men.

Welcome girls & boys, non-binary persons, agender persons, third gender persons.

Welcome cisgender, and transgender.

Welcome to those of you in transition… I think, in important senses, that is all of us.

Welcome two-spirit.

Welcome gender nonconforming.

Welcome to the playful, and to the somber.

Welcome the David Bowies, the unicorns, the critters, the artists formerly known as.

Welcome Good People.

I also thank and honor the land that PSU occupies in a history that carries colonization and the children of that colonization. I recognize and honor those who were sacrificed making possible our presence here today, and ask that you recognize and honor them also. I look around right now and wonder Where Are The Children Of Colonialism? If You Are Here, Know That I Welcome You As Your Authentic Selves.

I am Alexis Dinno.

I am a professor at the OHSU-PSU School of Public Health.

I am an epidemiologist — someone who studies the health of populations.

I am transgender.

I am transsexual.

I am androgynous, embracing my femininities and masculinities.

I am someone who was a boy, and then a young man, and then a woman who eventually took herself to graduate school.

I have some ideas about transgender health and the health of gender minorities. I have far more to learn.

This afternoon, we will be hearing from many good people with similarly rich and intersectional perspectives about the future of transgender population health and policy, community-based research involving transgender persons, and transgender experiences in the clinic.

We meet here today so that I, and the good people on the three panels to follow can share their perspectives about the good work currently being done to advance transgender health, to articulate optimism and vision for a healthier future for people in gender minorities, and to share some of the challenges we are currently grappling with in this work as we build that future, and to invite your participation at the close of the symposium in a questions and discussion session.

Before I jump in, I would like to offer a First Note on my own use of language: I use the word Transgender as a Very wide umbrella, encompassing all those who’s self-identities are out of alignment with the identity, roles and performative norms they were given by families of origin and the wider society when young, and who exercise their own agency in articulating those identities: that includes transsexuals and transvestites and drag performers, and gender fucks, gender punks, sissies, and bull-daggers and many other minority gender expressions and identities; Cisgender I use to mean ‘not transgender.’ In contrast I use the term Gender Nonconforming to describe individuals whose experience is at odds with performing received gender norms, and especially with respect to the gender binary, whether they reject gender altogether, reject gender as a binary, or as a static or context-free experience. Questions of gender, cisgender and transgender can arise in special ways for those of us who are intersex, and my own perspective on intersex is quite shallow, which I want to own up front. I use the word Transsexual not so much as identity, but as a convenient label for individuals who have opted to or who desire to express their gender using exogenous hormones or hormone suppressors and surgeries ranging from genital reassignment surgeries, to gonadectomies, to facial plastic surgery to feminize or masculinize features, to breast removal or augmentation, among many others.

Second Note on my use of language: we are all learning, all using language, and language is always changing.

Here I am speaking at the Future Of Transgender Health Symposium. Of course, in order to think about the future, we ought to understand where we are presently, and to situate where we are now, we want some perspective on the history of where we have been.

So a few thousand years ago in a treatise titled On Airs, Waters, Places, Hippocrates, the ancient Greek famous for inspiring variations of an oath taken by students of Western medicine as they graduate with their medical degrees — and, notably, for the maxim First, Do No Harm — wrote about a group of people who, were they alive today, might label themselves transgender or gender nonconforming. He wrote:

And, in addition to these, there are many eunuchs among the Scythians, who perform female work, and speak like women. Such persons are called Effeminates. The inhabitants of the country attribute the cause of their impotence to a god, and venerate and worship such persons, every one dreading that the like might befall himself; but to me it appears that such affections are just as much divine as all others are, and that no one disease is either more divine or more human than another, but that all are alike divine, for that each has its own nature, and that no one arises without a natural cause. But I will explain how I think that the affection takes its rise. From continued exercise on horseback they are seized with chronic defluxions in their joints owing to their legs always hanging down below their horses; they afterwards become lame and stiff at the hip-joint, such of them, at least, as are severely attacked with it. They treat themselves in this way: when the disease is commencing, they open the vein behind either ear, and when the blood flows, sleep, from feebleness, seizes them, and afterwards they awaken, some in good health and others not. To me it appears that the semen is altered by this treatment, for there are veins behind the ears which, if cut, induce impotence; now, these veins would appear to me to be cut. Such persons afterwards, when they go in to women and cannot have connection with them, at first do not think much about it, but remain quiet; but when, after making the attempt two, three, or more times, they succeed no better, fancying they have committed some offence against the god whom they blame for the affection, they put on female attire, reproach themselves for effeminacy, play the part of women, and perform the same work as women do.

There is a lot going on in the short passage I have just read, but I want to draw your attention to a few things. First, Hippocrates described gender variance as part of a Pathological Process, in effect equating this ancient gender minority as manifesting a disease, probably having something to do with the naughty bits. Second, Hippocrates tacitly Othered individuals occupying this particular gender minority, privileging assumed values of gender normative men “every one dreading that the like might befall himself.” Third, Hippocrates lands on the Identity of these gender minority individuals, and a label applied to them, but also he lands on Performativity and the social roles these individuals occupy. These points combine together to an absent expression of concern for the health of the individuals called Effeminates. Are the effeminates healthy? Do effeminates live as long as other Scythians? Do effeminates experience diseases in particular patterns relative to Scythians in the gender majority?

A few thousand years later we have professed similarly narrow ideas about gender and transgender, and by we I am explicitly including those epidemiologists and health care providers who have proven willing to treat transgender as a disease. Until only the past few years, health researchers and health care providers were all too happy to label transgender as a disease, as pathology, with articles published in the 20th century with titles like “Psychopathia Transsexualis,” and “The discrete syndromes of transvestism and transsexualism,” and only in this decade have both the World Health Organization’s International Classification of Diseases and the American Psychological Association’s Diagnostic and Statistical Manual ceased defining transgender as a mental disorder, recognizing that human gender identity and expression varies, and that those who transgress and transition genders are simply swimming in the deep end of the gender pool. Less than five years ago the National Institute of Minority Health and Health Disparities finally identified transgender and gender nonconforming individuals and populations as officially vulnerable classes worthy of specific funding to study as minorities in health.

An Aside: In the U.S. advocates for transgender health, including some transgender individuals, have often advocated for the diagnosis and labeling of transgender as a pathology, because, our private and greatly for-profit health care system prioritizes the concentration of wealth into a tiny minority at the expense of covering the maximum number of people with the greatest quality of health care. The logic of this advocacy has been that in our system, one strategy to providing access to transgender-specific care — including mental health care, endocrine care, and surgical care, etc. — is to make transgender a diagnosable disease requiring medically necessary treatment. On the other hand some of us recognize that, just as there can be a medical role for aspects of pregnancy, or birth control without pregnancy or a functioning reproductive system being pathological, so too can transgender itself simply be understood as a health-relevant condition, and we can advocate for the inclusion of transgender-specific care within our unjust system, and can also work to create a just system of true universal health care coverage.

Just as Hippocrates othered the Scythian Effeminates, many epidemiologists and care providers of the 20th and 21st centuries have likewise treated transgender individuals as a problematic Other for cisgender Real people, evident in the sizable body of research about cisgender men who are at risk of sexually transmitted infection via the vector of transgender sex partners. For example, if one searches for the terms Transgender, Transsexual, or Transvestite and Health or Disease in the GoogleScholar search engine, one finds 80,000 articles. One obtains almost 5.5 million articles when searching for Man, Men, or Male and Health or Disease, and almost 6 million searching instead the terms Woman, Women, or Female. If one then limits each of these results using the terms Prostitute or Prostitution a curious pattern emerges. As shown in this graph across the past eight decades, the probability of referencing prostitution among articles about men’s and women’s health (with an average of about 3%, peaking in the oughties), but articles about transgender health have referenced prostitution averaging over 30% across all articles, and this decade almost half of English language articles on transgender health reference prostitution. Like Hippocrates’, it seems many modern published researchers and clinicians are cleaving to a fascination with the naughty bits.

A graph of Probability A Health Article References Prostitution over the past 8 decades for Transgender vs Men vs Women.
A graph of Probability A Health Article References Prostitution over the past 8 decades for Transgender vs Men vs Women.

And as with Hippocrates, modern published epidemiologists and health care providers have been less focused on questions like Are transgender and gender nonconforming people healthy? Do transgender and gender nonconforming populations have comparable life expectancies to cisgender and gender conforming populations? Do transgender and gender nonconforming populations carry a different burden of disease than cisgender and gender conforming populations? Historically the answer to these questions has, beyond scattered data regarding transgender-specific care, been No Idea. No data. While a smattering of clinical case studies across the decades remarking upon a single or small number of cases of transgender health appears in this literature — typically describing a kind of disease, such as breast cancer, stroke, or heart attack in a Transsexual patient — there have been very few attempts to systematically measure and represent the specific health experiences of transgender and gender nonconforming populations.

Another Aside: I have mentioned Epidemiology a few times, and I have to tell you that when I am at a party, and someone who has just met me asks me about my employment and I say “I am an epidemiologist” the typical response is a bit of a vacant look, a pause, and then they say… “Skin?” To which I reply, “No, that would be an EpiDERMatologist.” So here is your crash course in epidemiology. Epidemiologists measure health and disease in populations. The number of Oregonians in 2019 who are HIV positive? How many new cases of type II diabetes were diagnosed in Multnomah County in 2018? Is There An Epidemiologist In The House? Because That’s Our Jam! Epidemiologists are also busy trying to answer questions like Why is California’s rate of new HIV cases almost three times higher than Oregon’s? And, How do state policies cause changes in state rates of suicide? Finally, epidemiologists answer questions like these Across Social Divides. How do the answers look for LatinX populations, and for other race/ethnic categories? Across categories of educational attainment, or income level? And so on. So when epidemiology answers these big questions, it is the science of keeping score on how we are doing as a society in terms of human well-being and the body count in terms of human mortality. When epidemiology does this year after year as routine business, we call that Public Health Surveillance.

There has been little to no public health surveillance of transgender populations in the United States. So those questions of population health and mortality cannot be answered with the precision we give to cisgender people (which we estimate is about 99.4% of the population). Passive public health surveillance results from the aggregates and vital statistics about births and deaths, causes of death, and the total number of diagnoses, prescriptions, and treatment codes reported by providers and payers across the whole state, for every state: stuff that the CDC collects and issues reports about. Because there is no consensus or common practice on how to represent transgender and gender nonconforming individuals, we generally cannot answer broad questions about gender minority population health with these kinds of data. Active public health surveillance enacts what epidemiologists call Population Studies, which do Not collect information on ostensibly all births, deaths, diagnoses, etc., but only on a much smaller Representative Sample. Some population studies have begun to attempt collecting data about transgender and gender nonconforming populations. Because we are a tiny minority, we often need to try very hard to specifically reach and represent transgender individuals for population studies, and this is expensive, challenging to do well, and does not happen often. The National Transgender Discrimination Survey is an example of this kind of study, albeit not one focused on health.

So where else can epidemiologists wanting to represent and understand transgender population health turn?

One recent strategy is to sleuth out transgender individuals who received physical or or mental health care specifically related to being transgender. For example, someone receiving a gender-dysphoria code alongside a hormone prescription code in a Veteran’s Health Administration, Medicaid, or Medicare database might be assumed to be transgender. There are several limits to these approaches. One comes from the fact that many providers may record codes specifically to hide transgender status — as when a previous primary care provider of mine coded my own hormone prescription as post-menopausal hormone replacement therapy — so we expect the total count of such people to understate the actual number of transgender individuals. Of course, not everyone who is transgender seeks gender-affirming medical or mental health care, and not everyone who does seek it receives it, so again such numbers must understate the true number of transgender people. Still, because these kinds of provider or payer data sets so often record details including the codes for diseases, injuries and treatments, sometimes for causes of death, they give us some kind of image, even if only seen through a glass darkly. From such studies we have learned what has long been anecdotally suspected, that transgender individuals have among the highest rates of suicide attempts, and suicide ideation, as compared to any other demographic, bringing a specific population health need into focus for both policy makers and for clinicians.

My own work in homicide rates of transgender individuals makes use of reports verified in the news media of murdered transgender individuals, which are then compiled into lists by the National Coalition of Anti-Violence Programs and the Transgender Day of Remembrance. This data source is also problematic, in that the number reported must almost certainly be an underestimate: coroners and medical examiners filling out death certificates do not have a box labeled “Was transgender,” and if they did have such a box, they would not necessarily know to check it from examining a corpse, and finally families of origin in the United States are well-documented to frequently erase their dead family members’ transgender identities when reporting. So we have to carefully examine and check our assumptions, and treat estimates as rough. The good news is that, contingent upon the data and the assumptions I have examined about under-counts, transgender individuals appear to have a Much lower rate of homicide than cisgender individuals overall. The details, however, make all the difference: this pattern reverses itself Sharply for young, black and Latina transgender women, who appear to be murdered at a much higher rate than their cisgender comparators. These kinds of insights can help us set priorities for a transgender health agenda.

I see the major problem as Representation. Epidemiologists simply tend not to represent transgender persons in basic epidemiologic research, and when we do, we often create more problems through our approach to representation. For example, the good people at the Williams Institute in Los Angeles — genuine strong allies of LGBT folks mind you — have published a Quote Best Practices UnQuote guide used by epidemiologists and clinicians, with a recommended measure of gender as Curent Gender Identity, How do you describe yourself? Check One Male, Female, Transgender, Do Not Identify As Female, Male, or Transgender.

This question enacts unjust representation of transgender people in several ways: First, it uses sex descriptors to represent gender, effectively conflating sex and gender, which is precisely hostile to transgender and gender nonconforming individuals who by definition manifest gender identities and performances at odds with gender as an essential expression of sex. Second, if a transgender person or gender nonconforming person identifies as male or female, then they must forego representing themselves as transgender or gender nonconforming. Third, if an individual identifies themselves as transgender, then they forego having their experiences represented among those of males and females.

NEWSFLASH! transgender people Are male and female and intersex.

NEWSFLASH! Transgender people Are masculine and feminine and neither and both. Transgender people Are men and women and gender nonconforming.

This question — Are you male, female, transgender, none of the above — also implicitly calls into question transgender individuals’ gender, and is therefore hostile. If the hostility of the question is not apparent to you, consider what is wrong in the following questions:

Are you (Check One): Male, Female, or Lesbian?

Are you (Check One): Male, Female, or Jewish?

Are you (Check One): Male, Female, or Cisgender?

If you need to know whether someone is transgender, simply ask: Are You Transgender Or Cisgender?

If you need to know someone’s gender identity, simply ask: Do You Identify As A Man, Woman, Both, Neither. Amplify the categories as needed.

If you need to know if someone has a vagina, testicles, prostate gland, etc., simply ask: Do You Have The Relevant Body Part?

If you need to know about someone’s sex chromosomes, then order the appropriate lab work, because most of us have never checked.

If you insist that each of these questions can or should be collapsed into a single overarching sex-gender-transgender question then you are Part Of The Problem Of Misrepresenting sex versus gender identity versus transgender identity.

How did the researchers get to such a place of poorly exercised compassion? Let me again turn to Language to tell a story about how This epidemiologist was trained. While I was a doctoral student at the Harvard School of Public Health, I took a required course — widely familiar to those in graduate Public Health degree programs — on theories about what drives individual health behavior: a course in which students are taught how to study why people don’t eat their veggies, why they don’t exercise, why they smoke and drink, and so forth. During the first week of the course the professor handed out a survey which included at the very top of the page several demographic questions. The very first of these simply said “Gender Colon Male Female.”

My hand immediately shot up — I wanted to make the point that “male” and “female” were sex descriptors, not gender descriptors… something I will return to in a moment — and to request a clarification. Instead of being invited to ask my question, the professor cut me off by hurriedly blurting “Write whatever you want!” I proceeded to make my comment, and to point out that the binary options were limited, and the professor responded with “You can write whatever you want.” In the subsequent lecture I pointed out that as far as I knew at least 3 out of the 21 students attending the course identified as transgender or gender non-binary. This experience, and variations on it, where individuals who are gender nonconforming and/or who are transgender, are asked to pretend to fit into a world where sex equals gender, and where SexGender is rigidly binary is all too familiar.

Many of you know of what I speak. In many places in the health professions, in the academy, and in our everyday lives, many of us understand that concepts like race, gender, caste, and sexual orientation are Quote Social Constructs End Quote. There is a broad currency to denying gender essentialism: Of Course sex does not equal gender! By disengaging sex from gender we allow that young males of our species do not have to eschew hot pink and may express empathy and kindness while being masculine… while still being Boys; we allow that adult females can simultaneously be dogged competitive weight lifters and authoritative medical doctors and may choose to not bear or rear children without jeopardizing their status as Women; we allow that human beings, regardless of their genitalia, hormonal flavors, chromosomal patterns can pursue their own expression, their own relationships: they can gender — as men, as women, as some mixture of both, or as neither — by occupying different spaces: knitting circles, boys clubs, bathrooms, names, pronouns. Divorcing gender from any imperative of sex productively liberates a human being’s potential.

I don’t think this is earth-shaking news to those of you who are present.

Health researchers and clinicians can and do likewise productively segregate sex from gender.

And yet…

And yet. So many of us are still conflating sex and gender in our everyday lives by using the same language to refer to categories of sex and of gender. So here’s my ask — it’s (honestly) a humble ask, because I am going to ask you to change the way you speak and write in the everyday, which is a tall order: if you want to better walk the walk of separating sex and gender: use the words Male and Female exclusively to talk about Sex. As in: there’s no such thing as a Male or Female SHIRT. Ain’t no Fallopian tubes on those shoes. As in: there’s no such thing as Male or Female GENDER. At the same time use Gendered language — Masculine, Feminine, UnGendered, Androgynous, Man, Woman, Boy, Girl, non-binary, etc. — if you want to to talk about Gender. Woman isn’t a sex, neither are Man or nonconforming.

My next ask is Not a humble ask, but a demand of health researchers and health care providers, if you want to walk the walk and recognize that an individual’s sex and their gender are different concepts in your professional work, stop erecting linguistic roadblocks that force the patient in front of you, your study participant, your professional colleague and the inheritors of your published legacy to try and figure out what the hell you mean by “Gender Colon Male Female,” because I do not think that even the author of such language has much of a coherent idea about what such conflation of sex and gender actually means. We can do better. We ought do better. We must do better.

And here is a good moment for me to say that this touches me quite personally… touches my heart. I cringe every time I get asked that idiotic question, and the variations on it by health professionals who seem So terrified of simply asking the question Are you transgender or cisgender? I am So frustrated that health researchers who I admire set their sites So Damn Low. In 2001 the American Journal of Public Health — essentially the journal of record… the New York Times of the public health profession — published its first issue dedicated entirely to LGB and Ostensibly T health. Aside from an article by the luminous transgender revolutionary communist Les Feinberg, who was not a public health professional, very few of the issue’s articles mentioned Transgender. One of the few contributors who did, Ilan H. Meyer, who has done much fantastic work in the service of queer health, so I stress that Dr. Meyer is a real ally, wrote QuoteTransgender’ refers to such a variety of individuals, from intersexed newborns [Aside WTF?!] to heterosexually identified transvestite men, that Any Discussion Of Transgender People As A Group Would Distort The Group’s Diversity. UnQuote. To this day I have tremendous difficulty as a scientist wrapping my head around the despairing ‘Gosh, studying transgender is hard! So let’s not bother! ELL OH ELL’ attitude on display by a fellow scientist as to what public health could offer transgender populations so that there is a hand wave at simply not bothering to study us. By the way, the examples Dr. Meyer references can be distinguished by the separate questions I mentioned a moment ago: one about sex, one about gender, and one about transgender.

So much of the image I portray about our past — where we have been — as researchers and clinical providers has been pretty grim for gender minorities. I should pause and say that I recognize, honor, and continue to learn about the history of genuine advocates for transgender health in the research and care professions, including those present with us. They have done good work, and built foundations upon which the past and emerging successes in understanding and serving transgender health rest. I want to briefly mention by name Jenn Burleton and the folks at TransActive who have lead the way Globally in advocacy and education in the service of transgender and gender nonconforming children. I want to mention OHSU’s Transgender Health Program which serves the needs of transgender patients under the magnificent leadership of Amy Penkin. I want to recognize than many in the health professions are struggling to represent transgender, and it is beginning to happen. My students in the School of Public Health, I think the majority of which are Not transgender or gender nonconforming, are manifesting a Vibrant interest in inclusion, and specific interests in gender minority work. The changes at the National Institute of Minority Health and Health Disparities mean that new research has been funded and is in process. And I recognize that not only OHSU, but several of the local health care centers, such as Outside In, Northwest Primary Care, and Legacy have been active in serving the needs of transgender patients. And of course, gender minorities exist in all societies, and health professionals in many nations are rising to the challenge and making good work.

So the future is bright, especially as momentum grows to implement third sex and third gender policies on government IDs as we have done in Oregon, transgender anti-discrimination laws in housing, and the workplace, and the growing representation of transgender folks in society at large. The future is bright, as the Oregon Transgender Health Research Group, which began earlier this year, brings researchers, clinicians and community members together to share perspectives, passions and plans in the advancement of gender minority health. The future is bright as Lewis & Clarke and Jenn Burleton establishes the TransActive Gender Project to provide future educators training and expertise in addressing the needs of transgender children.

Gender minorities are also vitally important to all our futures. I believe that the harmful societal disease that is Patriarchy will resolve when the rigid SexGender binary categories are fractured, recombined, given new meanings, and when it is widely understood that the categories Transgender and Cisgender themselves construct just another binary, that all of us have self-identities which are more or less at variance with those norms and identities we have received.

As I prepare to hand over the mic, I leave you with two thoughts:

All transgender people are beautiful” which I pass along to you from author Charlie Jane Anders.

And at last The Future Is Fluid!