Journal Club: Does Passing Improve Your Health?
A 2019 paper investigates the health effects of “passing” for trans people.
by Veronica Esposito
So-called passing privilege is a well-known issue in the transgender community. It’s generally taken that those who are generally believed to be cisgender have an overall easier experience than those who do not. But a 2019 paper asks some interesting questions about that and greatly complicates this picture.
Although segments of the transgender community have been shown to have health disadvantages compared to their cisgender counterparts, the devil’s in the details–specifically the details on which parts of the trans community carry those disparities. A fascinating 2019 paper by researcher Danya Lagos found an ingenious way to use the flaws in a health survey in order to investigate the complexities of this question more deeply.
This is partly a story about trans health, but also about how a creative research design turned a survey’s bug into a feature. And, most of all, it’s a story questioning received notions about layers of privilege within the trans community.
How did Lagos find a trans research project within a mundane health survey put out by the Centers for Disease Control? She found her data set in the yearly Behavioral Risk Factor Surveillance System (BRFSS). Created in 1984, the BRFSS is a program of the CDC that surveys some 400,000 American adults every year on various aspects of their health. It is a widely used pool of data for researchers, and it is believed to be the largest resource of its kind in the world.
Lagos examined the data of some 1,100 individuals who self-identified as transgender during the 2014 and 2015 iterations of the BRFSS. The data from the 2014 and 2015 BRFSSs is notable because in these two years the gender of participants were identified by the interviewer’s perception of the sound of respondents’ voices. (This was changed from 2016 onward, in which interviewers asked participants to state their gender.)
Participants in these years were also asked if they identified as “male-to-female” or “female-to-male “ transgender. The result of these two design features was a pool of data in which Lagos could determine how many trans respondents were “passing” according to the sound of their voices over the phone—per Lagos, only 22.1 percent of transgender women and 36.4 percent of transgender men passed based on the sound of their voice.
Passing, and its privileges, is of course a matter of much discussion among trans people. In her paper, Lagos defined “passing” as “successfully concealing that one is transgender and appearing to be cisgender.” She was curious to investigate its impacts on health, as Lagos noted that passing is widely believed to “contribute to a lower degree of marginalization for transgender people.” She was curious to know if the data bore this out or not. Lagos specifically examined the self-rated health of four categories of trans people: trans men who were correctly identified as men; trans men who were mis-identified as women; trans women who were mis-identified as men; and trans women who were correctly identified as women. Her fundamental question was whether or not passing conferred a health advantage.
In researching the degree to which passing came with health benefits, Lagos found results that were surprising to her: contrary to her hypothesis, she found that transgender women who passed over the phone were more likely to report lower self-rated health than those who didn’t. In fact, although there was some statistical overlap between trans women who did and did not pass, Lagos found that the former group’s self-rated health was lower to a statistically significant extent.
In an interesting reversal, Lagos found just the opposite for trans men: those who didn’t pass had significantly lower health ratings than trans men who did pass, and by a much greater degree than the gap among trans women. All of Lagos’s findings held even after adjusting for demographic and socioeconomic factors.
Essentially, the upshot of her research was that the two groups who were identified by others as women had lower self-rated health than the two groups who were identified by others as men—even though one of them passed for cisgender and the other didn’t.
As Lagos puts it, her research suggests “a significant penalty for expressions of femininity among both groups, even if gender misclassification is only particularly salient among transgender men.” She further found that other research had demonstrated a “pattern of devaluing and punishing femininity” among various groups—namely, groups of gay men, groups of children, and groups of adolescents. Lagos also reported that research generally finds a health disadvantage for cisgender women compared to cisgender men.
Lagos draws the following conclusion from her research:
These findings suggest gender misclassification may not always be associated with social disadvantages. However, there is a striking common thread between both groups: being perceived as a woman is associated with a distinct health disadvantage among both transgender men and transgender women.
Although Lagos notes that more research is needed to further validate and explore the implications of her findings, on the face of it this paper complicates notions over the the costs and benefits of passing to transgender women. It seems to tell us that the advantages of passing are more nuanced than generally believed, and at least in some cases there can be benefits to not passing. Of course, this was based solely on a given individual’s voice—if a passing voice were to be paired with a gender presentation not also deemed passing, there would be even more layers of complexity, indicating a potentially rich direction for future research.
As Lagos noted, there are further avenues of research that can fill out our picture of the questions opened up by this paper. The BRFSS does not include any information as to hormone use, and Lagos speculated that such data could add further nuance and details. As she puts it, “asking respondents about their histories with hormone use, and potentially measuring hormone levels, could help distinguish whether gender classification processes and hormone use are linked to within-group and between-group differences among transgender men and transgender women.” There are also interesting questions about the ethnicities of participants—in particular, Lagos found that Black respondents were nearly 30 percent more likely to be identified as female, and this was mostly concentrated among trans men. For Lagos, this opened up questions around unique forms of gender policing perpetrated against Black individuals, as well as the particular form of discrimination against Black women known as “misogynoir.”
At a time when the transgender community is experiencing a broadening of the ways that its members choose to be embodied and identified in society, there are ongoing debates about the desirability of assimilating into the larger cisgender population and what benefits do or do not come with it. Lagos’s research paper is an interesting data point in this conversation. More research along these lines could add a lot of nuance and complexity—not to mention some very useful data points—as a part of this important conversation.
Veronica Esposito (she/her) is a writer and therapist based in the Bay Area. She writes regularly for The Guardian, Xtra Magazine, and KQED, the NPR member station for Northern California, on the arts, mental health, and LGBTQ+ issues.