Meeting people online

I’ve commented in the past about the focus  on sex, drugs and mental health in LGBT research. Indeed, it’s the title of this blog. One of the more depressing examples of this is in research on LGBT people’s use of the internet. Now, I expect it won’t come as a shock to you that quite a lot of LGBT people find relationships, friends and sexual partners online or via smartphone apps. When I volunteered on a LGBT switchboard, and in my subsequent membership of various LGBT and trans groups, one of the most common questions which gets asked is “where are good places to meet people?” If you live in a large city, you may have a choice of a few places to go in the real world, but if you’re in a rural area and can’t or don’t want to get to a bar or a club, the internet or an app is often your best bet.

I think it’s a good thing for people who want to meet people to be able to do so. The subsequent encounters don’t need to be committed, or involve binding promises, or only involve two people (though of course they can be all those things). They can be entirely about sex, or not involve sex at at all. Connections can be changeable, fluid and fun. But whatever you’re into it is a good thing for people to be able to find people who they want to socialise with in their preferred manner. Those kinds of connections have a massive impact on people’s mental health, on their wellbeing and ultimately their physical health too.

So what is the research agenda on LGBT use of the internet? As Grov et al point out, it’s basically “how many sexual partners gay and bi men have when they meet online”, and “do they wear a condom”. There’s nothing about the quality of the relationship (except insofar as that affects talking about safer sex or cuts down on multiple partners). As for lesbian and bi women, or trans people, forget it. Do we use the internet? How do we use the internet? Nobody knows. Nobody cares. Occasionally you might see a bit of research on how young LGBT people use the internet, but it tends to be focused on coming out and identity formation early on. The ongoing impact of the internet and socialising for LGBT lives is pretty much unexplored.

You might think that perhaps researchers should stay out of LGBT online socialising. There’s a couple of ways you could make that argument. You could say that researchers should stop poking into private matters about our lives and identity and let us be. Stop treating us as lab rats. Except that they don’t: the journals of sexology and sociology are filled with endless stuff about whether sexuality and gender identity is due to your genes, or how many older brothers you have, or neglectful parents, or sex hormones in the womb, or some bit of the brain being too small/large. There are loads of papers on identity formation, and coming out. Researchers are not staying out of this from respect for our privacy.

Another argument is that research and health speding should focus on proper, serious subjects that can either be used to make money or save people’s lives. Relationships and the internet seem like a slightly dubious area, with little public relevance. Well, we have an ageing population and a government committed to public sector cuts. The UK NHS and social care service is struggling, and realistically it’s going to end up dumping a lot of the responsibility for caring out into the community. It’s going to expect partners, children, friends, relatives and the voluntary sector to pick up even more of the slack than they already do in terms of supporting the elderly and the ill. There are already plenty of initiatives aimed at “empowering” carers, or providing them with respite, because getting carers to do the work is very cost-effective. But many of those initiatives have a lot of unspoken assumptions about who cares for who, and often don’t take into account some of the differences in LGBT social structures. Indeed, there are  many examples of studies looking at relationship status and later life health that apparently haven’t considered the possibility that heterosexuals might have important people in their lives who they aren’t married to. Even outside the issue of providing care, it is also pretty well-known that being lonely is terrible for all sorts of health conditions, mental and physical.   So putting a bit of money into understanding LGBT people’s relationships, and even into helping people make the connections that make them happy, seems like it might be pretty cost-effective.

It’s not just online issues that matter. LGBT groups up and down the country support many, many people by running coffee mornings and walking groups, moderating Facebook groups and internet forums, manning switchboards and undertaking advocacy. Many of them have no paid staff, and volunteers put their own time and money in until they burn out. Many of the things that would make a difference to those groups – enough money to produce publicity material, access to photocopiers, training for volunteers – could be provided by statutory bodies at marginal or no cost. But at the moment, there is very little research that says that social isolation in LGBT people is worth thinking about.

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Asking about gender identity.

Pet hates time.

I hate the (generally well-meaning) belief in the UK that a good way of asking about trans identity for equality monitoring is to ask:

“Is your gender identity the same as the gender assigned at birth?” (Sometimes you see the reverse question, with “the same as” replaced with “different from”, but I’d take that as being conceptually equivalent, and I think it raises the same questions).

The belief is that that’s an inclusive and open question. It potentially allows for multiple ways in which current gender identity could differ from past gender identity. It doesn’t require anyone to specify either what their current identity is, or what it was in the past. It’s therefore felt to be non-binary friendly.

I have two major problems with it. The practical one is that it’s not familiar to most people outside the trans community, and it can be difficult to understand (in one testing session, people said the question was confusing, or it seemed like a ‘Star Trek’ question). If English isn’t your first language, or you’re not that confident with written documents, I think you might struggle with what you’re being asked. I have doubts about the analytical and statistical value of a question which aims to identify a small minority group when you know that a fair proportion of the majority don’t understand it.

But the real reason why I don’t like this question is a theoretical one. I know damn well that I’m supposed to say “no” to this question. I consider myself male now, but I was described as female at birth. That’s a pretty obvious difference. But my question is: who is it who can say yes? Is there anyone, anywhere who can honestly say “yes, my gender now is exactly the same as that assigned at birth”?

For a start, what do we mean by gender assigned at birth. Assigned by who? Society? Doctors? Midwives? Parents? If we take the actual, physical act of assigning gender, then I don’t actually know who it was who looked at me when I was born and said “It’s a girl”. However, I was born in a hospital in Slough, in 1985, during a fairly medicalised birth, so there’s a fair chance it was a doctor. Slough’s a pretty diverse town, with a lot of post-war immigration. Conceivably, the attending doctor could have been a feminist lesbian, a first-generation immigrant, a middle-aged middle-class white male consultant, or someone else entirely. I doubt any of those hypothetical gender-assigning doctors would have meant the same thing by “girl” or “female”, or that what any of them meant would be the same as what my parents meant (and indeed, I don’t think my parents have exactly the same concepts of female as each other). So if I wasn’t trans, how would I know whether my identity was the same as assigned at birth? The odds seem pretty high that it wouldn’t be.

Anyway, it’s not 1985 any more. Gender has moved on. Being a female in 2015 does not mean what it meant in 1985, so it seems pretty unlikely anyone, however conventional, would have a gender identity that remained “the same” in the intervening period.

What this question is really expecting us to understand is that all female/feminine gender identities should be considered “the same”, as should all male/masculine gender identities. Arnold Schwarzenegger’s gender identity is fundamentally the same as Bill Gates’; Ellen De Generes has the same gender identity as Queen Elizabeth II. Not similar, not falling within one general overall category, but “the same”. Moreover, it says that for people who aren’t trans, that sameness undergoes no change between birth and adulthood. I find it pretty difficult to reconcile that with anything in the last few decades of feminism, queer or trans theory. It also seems a conceptual framework which pays lip-service to non-binary gender identities while in fact missing the point.

To be clear, I am not suggesting that we do away with gender, sexuality or trans questions on forms and documents. Nor am I suggesting that those questions be turned into essay write-ins. There are pragmatic, political and social benefits to being able to identify the differences between different groups when we’re looking at things like health outcomes or job applications, and an endless fragmentation of identity terms won’t result in the types of analysis that identify inequality. We need some kind of categorisation. But I don’t think that’s a justification for a question which in fact goes beyond the standard male/female binary question by insisting that everyone within those categories has “the same” gender identity.

A common equality question about disability in the UK provides a short definition of disability under the Equality Act 2010, then asks if respondents feel it applies to them: Yes/No/Prefer not to say. That’s perfectly possible to statistically analyse. There are potentially some problems with the definition of transgender (or rather “gender reassignment”) in the Equality Act 2010, but the basic principle seems to me a straightforward and workable way of doing things. It also has the added (for me) advantage of not euphemising trans, by treating it as a dirty word we can’t ever refer to directly. Am I trans? Yes. Just ask.

Sex, Drugs and Mental Health

The LGBT health research and promotion agenda is not a balanced one. I’ve volunteered with a number of different LGBT groups, and we always had a pile of health promotion leaflets sent to us by local health promotion agencies and by charities.

Probably 80% were targeted towards gay and bisexual male sexual health. We might have a couple on cervical screening and breast checking for women, and a few on alcohol, smoking and substance misuse. We might have a couple of more general ones about mental health or coming out. More recently, there’s started to be more publications targeted at trans people, usually focused on medical transitioning. Very, very recently there have also been some sexual health publications for trans people. And that was about it.

That health promotion literature more or less reflects the state of current LGBT health research. It’s also often reflected in the funding available: one of the groups I volunteered with provided general support to the LGBT community on a wide variety of issues, but it got its funding on the basis of HIV prevention. There’s often also funding for supporting young LGBT people with issues such as coming out, but it typically stops at 18, or 25 if you’re lucky.

But let’s just think about what’s missing in that. The LGBT Public Health Outcomes Framework collects together what evidence exists on LGBT health issues. Here;s a few little excerpts:

  • “There are no data on cancer incidence, diagnosis, treatment, survival, morbidity and mortality among LGB&T populations.”
  • “… it is reasonable to assume that there will be inequalities in [preventable mortality] affecting the LGB&T community.”
  • “… it is reasonable to extrapolate that [the LGBT] community will be potentially more at risk of excess winter deaths.”
  • “There is no evidence in relation to lesbian and bisexual women, or trans individuals [with regard diabetes]”

There’s also little or no evidence on heart disease, liver disease, dementia or respiratory disease.

HIV is a serious disease. Suicide is tragic. But most of us are going to die of things like cancer, heart disease and lung disease. Many of us are going to live for many years with conditions like dementia and diabetes. Those are diseases where prevention, survival and quality of life are clearly linked to issues like economic exclusion, social support and trusting your doctor enough to tell them if you think there’s a problem. It’s scarcely a big leap to say that being LGBT is probably relevant. But at the moment, the best we can say is “it is reasonable to assume” that LGBT people may be dying early of diseases that could be prevented. That isn’t good enough

Undoubtedly part of the reason for this is timescale. Mental health, substance abuse and HIV are issues where an intervention can potentially have a measurable effect here and now, and sometimes you can point to the difference made in a specific case. It’s easy to make a financial and moral case for researching that. Whether an intervention has actually prevented heart disease might require thirty years of population data to work out, and even then you might still struggle to disentangle it from wider social trends. But social isolation among older LGBT people is something where it would be pretty easy to carry out an intervention which has an immediate measurable impact, and which would tend to be beneficial for a wide number of health indicators. Ageing, social support and health are huge issues for the NHS right now. Why is there so little out there on older LGBT people.

Another issue is the old “it’s too embarrassing to ask” one. Of course not everyone wants to talk about their identity and everyone should always have the right not to say, but there still seems to be an assumption that simply including the question on an equal opportunities form will lead to patients fainting in shock or storming out of the waiting room in disgust.

It’s hard not to feel that the hidden issue under some of this is due to the interaction between age, sexuality, and gender. The health issues which get highlighted in the LGBT community are those which stand a fair chance of affecting younger people, and especially young men. Ill health, or even death, among the young is shocking. And if someone commits suicide due to hateful bullying, or dies young of AIDS, the cause is clear. It’s harder to work up activist passion about the fact that one group on average gets a chronic disease associated with age a year or two earlier than another. Plus there’s still a sense that our society doesn’t really want to think about older people as having sexual and gender identities, other than very limited stereotypes of grandma and grandpa.

The optimistic view says perhaps it’s just because we’re in a transitional phase. Perhaps now there’s greater equality all these issues will work themselves through, and by the time my generation reaches retirement no-one will be embarrassed to discuss sexual or gender diversity, and there will be few inequalities to identify anyway. Perhaps so. But if we are in a transitional phase, that’s because of the activism and campaigning by the LGBT people who are older now. It doesn’t seem fair to ignore their wellbeing, here and now, while we lie back in the expectation of a glorious future. And if we aren’t in a transitional phase, if the problems aren’t all fixed, we’re going to really regret not acting when we become the older people.