“MSM” Revisited: Trans Inclusion in LGBT Medical Study

Recently, I’d blogged about a term that’s increasing in usage in HIV research and outreach: “MSM,” or “men who have sex with men.”  The term was originally invented because of a need to include not just sexually active gay men but also bisexuals and men who are not gay-identified but for whatever reason have casual or incidental sex with men.  It can also include gay- or bi-identified trans males, although they’re often overlooked in the study (or sometimes even thought not to exist).  And, of course, it’s often asserted that it includes or intends to include trans women.  I’d commented:

I get it that effective terminology must be given to identify target high-risk groups for the sake of study.  I get it that the terminology needs to be both simple and encompassing.  I get it that HIV is a serious issue and relevant to the trans community, though not all trans sub-groups are high-risk.  I get it that penile-anal intercourse (PAI) risk groups can include trans women….  What I don’t and will not get is the gay community’s insistence that transsexual women are “really men” and how it’s such a bother having to state otherwise in order to be inclusive.  To be fair, there are many folks in HIV study and advocacy who don’t feel or act that way, but the prevalence of MSM-exclusive study sure reinforces this impression.

As diverse as the trans umbrella is, where MSM really fails is primarily when female-identified or dual-identified trans people (usually transsexual women) are forced into one of those “M” designations (i.e. also encompassing straight-identified men who date trans women).  This is often justified by researchers through noting other cultures where trans women sometimes do identify themselves as “really a man,” because they have not yet had the freedom to develop a language with which to self-identify, and therefore accept the language and logic that is available to and used on them.  For something that was supposed to have been devised in order to respect different male identities and transcend constructions built around terms like “gay,” people sometimes wonder why it’s such a big deal when trans women are similarly not accommodated and their identities as not men are not respected.  Especially when this is the result:

This past Spring, I’d had one such study request forwarded to me by someone who was apparently on one of the mailing lists that I forward communications to.  A few days later, he wrote me, irate that I’d not forwarded it to my trans networks.  I’d pointed out (feigning ignorance) that while a few trans men might qualify and be interested, much of what was being discussed in his email didn’t really fit FTM configuration, or at least pre-surgical.  This resulted in a missive which started off with “you know what I mean” and launched into an accusation that I’d be “guilty of the murder of” every transsexual woman who perished from HIV who might have benefited from the study.  And yet, the survey was written so thoroughly to exclude those of female gender identity, I can’t see any way that any self-respecting trans woman would be able to sit through the whole thing without becoming thoroughly incensed at the obvious refusal to dignify her as who she is.

Additionally, many trans women never have sex with men, being either lesbian-identified or not sexually active.  And for a small few of us, HRT isn’t kind, and it becomes an either-or proposition where we really do have to choose between transition and sex.  So an assumption that all trans women belong in the study is as inaccurate as the assumption that all trans men don’t.

But the solution does get fuzzy.  I’m no longer convinced that any permutation of “MSM + …” works effectively at all (and I see in my original article some failures to look outside transsexual identities to the nuances pertaining to some other flavours of trans).  Possibly some terminology along the lines of PAI practices should be considered, but it’s obvious that the status quo needs to be replaced with something more appropriate.  And if that discussion needs to happen anywhere, it needs to start in the larger LGBT sphere.

This situation is also symptomatic of a fuzzy understanding of trans realities when it comes to inclusion in LGBT medical studies in general.  Trans brings along with it a host of medical questions that are often entirely overlooked in such studies.  Which is fine if the study is presented as a general overview that is not reflecting on trans-specific care or pretending that it encompasses all the issues of the included study groups.  I also get that adding all aspects of trans to a study that is aiming to look at primarily cisgender medical issues will confuse it beyond recognition.  However, too often, these studies use the fact that there is a “transgender” checkbox in the Sex question to claim that what is presented is comprehensive and targets all the LGBT medical issues that need to be addressed — which leads researchers and medical professionals to conclude that they do not have any need to look further.

When transsexuals are factored in, there are numerous medical realities surrounding access to and cost of treatment, the fact that said treatment is part of a necessary course to righting one’s life, issues around hormone access and use, or access to surgeries or tests (i.e. obtaining a mammogram for someone with a penis, or finding a surgeon willing to perform a hysterectomy on a man).  Even outside the transsexual process, we find unique issues affecting genderqueer identification, or the existence of another DSM diagnosis intended for crossdressers (and which serves no useful purpose beyond stigmatization as well as the annexation of transsexuals): Transvestic Fetish.

Superficial inclusion can generate problems with survey questions like, “Have you ever been diagnosed with a mental illness?”   Is this supposed to include GID?  If so, isn’t that a bit like rubbing one’s nose in the fact that our little community still carries this stigma?  And if there is no means to elaborate, how are the people conducting the study ever going to know if the respondent is referring to GID (or TF), or to something else entirely?

Such surveys can often be accompanied by assumptions: the assumption that we’re sexually active; assumptions that we engage in risky sexual behaviour; sometimes assumptions that ones genitals dictate how they should be addressed; assumptions about who we’re attracted to and sexually active with; assumptions that we can see just any medical professional when we need to; assumptions that prejudice in the clinic could never take the form of being treated like we’re deluded or freakish by the doctor, medical staff and/or other staff; assumptions that we can access HRT, surgery and other forms of treatment without requiring letters of permission from someone who has psychoanalyzed us; assumptions that anyone with a trans history has to identify as trans(fill-in-the-blank), rather than as male or female.  It can also overlook issues entirely, such as that of changing one’s name on file, having it acknowledged by staff, and not having it create a crossed-wires situation were your lab tests from elsewhere don’t get where they’re supposed to.

And finally, there is an issue of relevance.  When trans-specific care isn’t in the study at all, what remains seems almost irrelevant or even foreign to trans participants.  It does seem a little humorous to me to be asked, for example, “Do you trust your medical provider enough to discuss issues with him or her that might out you as being LGBT?” when an adam’s apple (not to mention genitalia), medications, gender markers on identification or surgeries recorded on file all leave no doubt.

I don’t mean this to be entirely scathing — studies do vary, and I’m elaborating on the worst I’ve seen in order to open discussion on making them better overall.  While the MSM terminology is glaring, many other issues stem from cisgender privilege — not in the sense that cisgender people often complain about being accused of (i.e. wilful ignorance), but from the privileged standpoint of never having experienced these things, and therefore not realizing that they need to be addressed.

There is a concern that conducting separate studies can be seen as a license to not do trans population studies at all.  But because the medical situation can be significantly different for trans people, I wonder if these issues would be best handled as a trans-specific addendum?  And where language fails altogether — terms like MSM — there is a serious need for reassessment.

Readers’ thoughts on MSM and inclusion in general?

(Crossposted, and I don’t want any grief about it)

    • Thaniel
    • August 11th, 2010

    Very concise, good points! The pesky complicated realities of our trans/human lives so often get crushed by the binaries still firmly affixed in so many peoples’ heads. They have NO idea what we go through…because they don’t think to ask.

    • aformeroldfriend
    • August 11th, 2010

    This is where I diverge from the homo-sexuals
    We are not like them.
    Why should we be a part of their ghetto.

    I have a nice life in a straight world my sexual preference is nobody’s business just like 90% of the heterosexual community.

    Why should I be part of a bunch of men on men when I’m not a man at all.

    Same with you.

      • dentedbluemercedes
      • August 11th, 2010

      We’re different, yes, but I still see rights and overlapping issues as things that need to be fought for together. Strength in numbers.

      That’s a bit off-topic, though. There are certainly people in the trans community who are at risk, and we do need some mechanism to get accurate data and properly target outreach.

  1. As diverse as the trans umbrella is, where MSM really fails is primarily when female

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