Bill and Tuna

Four Years On -- Time to Go Home

2012-01-29T15:17:00.000-08:00

I started this blog a bit over four years ago, as a way to keep my friends and family up to date on my big move from Providence to San Francisco. Then once I was here, I kept commenting on my "adventures" in the big city - until the city itself became routine.

Eventually, the blog morphed into a sort of running commentary on (mostly) gay health and various other topics that I enjoy thinking about.

And now, I've decided to move back East. Not immediately, but hopefully this year.

Probably not to Providence, but hopefully somewhere nearby.

Why? A big reason is that I've become an uncle, and my folks are moving back from Old England to New England, and it kills me to be this far removed from all that is going on back there.

So look forward to the travelogue in reverse. In the meantime, I'll probably keep commenting on various things I find intriguing - from gay men's health to vaccine policy to critiquing the 'health disparities' approach to dreaming of robotic farming.

p-Value Tyranny: Obesity Epidemic Still on the Rise, Despite What You Read in the Papers

2012-01-27T14:19:00.000-08:00

Four years ago, I showed my epidemiology class how misinterpreting p-values had lead to the headlines about how the obesity epidemic was leveling off in the US.

Two years ago, I wrote about essentially the same press release being issued, with new data and the same incorrect interpretation.

Then a week ago, the same headlines hit the airwaves - Obesity may have peaked was the optimistic line.

And I can predict with a high degree of certainty that you will see the same story in the second or third week of January, 2014.

There's nothing I like more than good public health news - strike that, there's one thing I like better: accurate good public health news. And I wish I could be so optimistic about the obesity epidemic in the US. Heck, I'd like to be more optimistic about my own obesity, but that's another story.

So what's going on here? Why do we get told, every two years, that the obesity epidemic is leveling off when the very data that these assertions are based on tell a very different story?

Every two years, the NHANES reports out the proportion of men and women in the US it finds to be obese. The NHANES is a very well-funded, very well conducted research study of the nation's health. The people in it are very well selected to be representative of the population. They are weighed very accurately; their height is measured precisely. And there are enough people in the study to say something definitive about the prevalence of obesity in the country.

But, there are not quite enough people in the study to say definitively whether the proportion of Americans who are obese has grown or stayed the same. The year-by-year growth in the proportion of people who are obese in the US has, according to these data, risen about 1% per year, which is a small change over two years, but a huge change over a decade or two.

So, when they compare the NHANES data from one year to the NHANES data from the year before, they find no significant differences. They then make the classic misinterpretation that "no significant difference" means "no difference" or "almost no difference", and out goes the press release stating that the obesity epidemic in the US may have peaked. And pundits opine on why the end of the growth in the obesity epidemic has arrived (or will shortly). But they all always overlook a much simpler interpretation. Every time these data come out, they are more consistent with that small year in, year out, growth rate than they are with slowing down the proportion of obese Americans.

"Obesity rates have increased since the 1976-1980 survey period. There was no significant change in obesity prevalence, however, between 2003-2004 and 2005-2006 for either men or women."

CL Ogden, MD Carroll, MA McDowell, KM Flegal. (Nov 2007). Obesity among adults in the United States--No statistically significant change since 2003-2004. NCHS Data Brief No. 1.

http://www.cdc.gov/nchs/data/databriefs/db01.pdf

"No statistically significant linear trends in ... high BMI were found over the time periods 1999-2000, 2001-2002, 2003-2004, 2005-2006, and 2007-2008 among girls and boys."

CL Ogden, MD Carroll, LR Curtin, MM Lamb, KM Flegal. (2010). Prevalence of high body mass index in US children and adolescents, 2007-2008. Journal of the American Medical Medical Association 303(3):242-249.

"The increases in the prevalence of obesity previously observed do not appear to be continuing at the same rate over the past 10 years, particularly for women and possibly for men".

KM Flegal, MD Carroll, CL Ogden, LR Curtin. (2010). Prevalence and trends in obesity among US adults, 1999-2008. Journal of the American Medical Association 303(3):235-241.

"There was no change in the prevalence of obesity among adults or children from 2007-2008 to 2009-2010."

CL Ogden, MD Carroll, BK Kit, KM Flegal. (Jan 2012). Prevalence of obesity in the United States, 2009-2010. NCHS Data Brief No. 82.

http://www.cdc.gov/nchs/data/databriefs/db82.pdf

Research Worth Reading (4) - trans health in Massachusetts

2011-12-23T10:15:00.001-08:00

Gunner Scott, Sewart Landers and pals have served up a very interesting paper in January's AJPH - the first time anyone anywhere has published anything peer-reviewed on a population-representative sample of transgender people.

In Massachusetts, the Behavioral Risk Factor Surveillance Study (BRFSS) has asked the adults it interviews "Do you consider yourself to be transgender?", and a whole lot of demographic and health-related questions.

Many studies in the past have sought out a transgender population to try to say something about the health of the group, but this is the first one to rely on a "random" sample, meaning calling people up at random; and that's probably the best way to be sure that you've got a study population that is fairly representative (at least of people with phones).

In addition to addressing trans health from a population perspective for the first time, this study is also the first to report simple basic demographics of the transgender population in the US as well, including the most basic one - how many transgender people are there?

The answer, in this study, is about 1 in 200 in Massachusetts, about 1 in 110 in a similar study from Vermont, and 1 in 170 in Boston. It is likely (for reasons I've discussed before) that these are overestimates, meaning that the true proportion is probably somewhat lower than that, but how much lower? That's hard to guess, it depends on how many nontrans people answer the wrong way because they are distracted or misunderstood the question. The only way to figure that out is to call back the people who said they were trans and ask them again.

The study is very interesting in that it validates some things trans health activists have known for years, but there isn't strong evidence to support all the health disparities that have been identified from "convenience" samples. Members of the trans population in this Massachusetts study were less likely to be employed, and more likely to be living in poverty than the nontrans population. The study also documented that 36% of the trans population were smokers, compared to 17% of the nontrans population. But markers of access to health care were not particularly different. The trans population was less quite a bit less likely to have health insurance (86%) than the nontrans population (94%), but this did not translate into not having a regular health care provider or not seeing a doctor because they couldn't afford it, and the trans population was even more likely to have had a checkup in the last 12 months (85%) than the nontrans population (75%).

Mental health measures did show some substantive differences: 70% of the trans population reported usually or always getting needed emotional support, but this was quite a bit lower than the 90% of nontrans people who got their emotional needs met; and 14% of the trans population reported being dissatisfied with their life, but only 6% of the nontrans population did.

The authors were very thoughtful about ways that these results might be misleading - for instance that trans people are probably less likely to be stably housed and have a telephone, so these figures may well present a rosier picture than a fully representative sample of trans people would be. And also, not knowing how many cis-gender (nontransgender) folks inadvertently classified themselves as trans, it is hard to know the degree to which true differences between the trans and cis populations are diluted by these inaccurately coded folks. Another possible source of bias might be people who have transitioned, but no longer consider themselves to be transgendered, although I suspect this is pretty unlikely to be a substantial part of the population, because the way the question in Massachusetts was asked, they made it clear that they meant "experience(d) a different gender identity from their sex at birth. For example, a person born into a male body, but who feels female or lives as a woman". But excluding people who no longer consider themselves to be trans would, probably, make the differences seem larger than they actually are. A similar bias would arise from trans people not feeling comfortable describing themselves as trans to a stranger on the phone.

Thanks Gunner & Stewart!

Redistricting - what's best for the gays?

2011-08-26T21:32:00.000-07:00

California has just undergone a major redistricting effort, by far the most public process in recent memory.

And LGBT groups chimed in on how the lines should be drawn.

I have read a few of the many articles on the topic, and it got me to thinking - how should we want the lines drawn?

The consensus seems to be that we should try to keep the gayborhoods together, keep them from being split up into multiple districts. I suspect that the idea is to maximize our political power. The only other reason I could think of was if the gayborhood itself would split up if there was a voting district line drawn down the middle. But, I don't think that the Castro would lose it's sense of identity if it were divided into two State Assembly districts...

So let's go with maximizing political power.

And here's the conclusion I came to: split us up!

The idea of concentrating political power by maximizing the concentration of a group within a single district is predicated on a couple assumptions, among these are:

a) the group has a large enough presence to dominate a given district, and

b) a high degree of segregation allows one to draw geographic boundaries that largely coincide with where the group lives.

There's probably more to it than that, but I would argue that neither or those is true of LGBT populations, in which case, a fresh look at the strategy may be in order.

There just aren't enough gay people, pretty much anywhere, to dominate the population. Outside of a few square blocks of real estate in central San Francisco and West Hollywood, we simply aren't anywhere near a majority of the population.

And, we're not highly segregated, assuming that same-sex couples in the Census are a good representation. Particularly lesbians, who are very evenly distributed across the country.

So perhaps we should consider another approach to maximizing political power: splitting the gayborhoods into as many districts as possible in order to maximize the number of political candidates who need to consider our needs. That, and do exactly what we have had to do to get anything done politically, build allies.

Have I convinced you?

Images taken from http://swdb.berkeley.edu/gis/gis2011/

Thoughts on the Behavioral Risk Factor SURVEILLANCE Study

2011-08-26T17:30:00.000-07:00

The Behavioral Risk Factor Surveillance System (BRFSS) is a telephone survey conducted every year. It's been growing and growing every year, and it gives a lot of people (including me) a data woodie every year in April when the annual data dump comes out.

Nominally, the survey is about "behavioral health", things like smoking & drinking, seatbelt use, exercise, diet, getting your cholesterol checked and a mammogram done. It has become a cornerstone of our data surveillance infrastructure - used to track progress against the Healthy People goals, and to reiterate endlessly repetitive health disparity analyses.

In 2010, 429,630 people responded to the survey. That's almost the population of Wyoming. Sure Wyoming is the least populated State, but do we really need to call that many people every year to look at trends in how often people smoke, use seat belts, and eat five fruits & veggies a day? Imagine talking to each and every resident of Kansas City, Missouri in one year, asking them some 75 questions about their personal behaviors. That's the scale of this thing.

Since 1988, there have been almost 5 million interviews - about the population of South Carolina, or the combined population of the 7 least populous States: Wyoming, Alaska, North & South Dakota, Delaware, Vermont & Montana.

And it has been growing at a rate of about 8-9% a year, which means that is has been doubling in size about every 7 years or so.

One of the ways that BRFSS is complicated is that it tries to have about the same number of responses from each State. Think Senate vs. House of Representatives. So whereas the response burden in New York, Illinois and California is a relatively manageable 1 in 2,000 or so residents getting called in any one year, in New Hampshire and Hawai'i, about 1 in 200 people have to answer this survey every year. And in Vermont, it's as low as 1 in 92 people! That means you Vermonters probably know several people who get surveyed this year, and given the survey growth rate, it will be almost impossible not to get interviewed at some point in your life.

The record goes to the Virgin Islands, though, where about 1 in 35 people get surveyed every year. We're going to know every detail about every resident of the Territory before long!

This raises a couple of issues for me. There's the inevitable risk of some hacker breaking into the State Health Department and snagging detailed information on tens of thousands of State residents linked to their phone numbers. Although that's a scary idea, it doesn't get me too exorcised, because there is probably very little value to that information - it is hard to imagine who would want to know about your dietary habits, or even drug use or sexual behavior.

Another issue is just the level of surveillance, or monitoring of the population. Gathering information from a small number of people to keep tabs on trends in the population as a whole makes sense, but it seems to me that BRFSS is getting out of control, moving towards a degree of surveillance that is quite intrusive on a high proportion of the population. I mean, at this rate, it might make more sense to just mass mail the survey to every State resident every five years or something like that.

But the biggest problem I have with BRFSS is only tangentially related to it's size. It's the fact that it asks really boring questions. How that's related to its size is that by becoming the largest health survey in the country by an order of magnitude, BRFSS is where lots of people will look for answers to what is causing our public health problems. It's the centrality of "behavioral health" that I've got a gripe with.

Let's take obesity as an example.

BRFSS can demonstrate in very great detail the growth in obesity rates over time, in very minute detail. But it can't tell us much of anything about why any individual or group is getting heavier. Partly that's because it's a prevalence survey, so there is no way to track individuals over time (talk about invasive surveillance). There is no way to know if an overweight person became overweight recently, or even if they have lost a lot of weight recently. But mostly it's because the questions are boring.

You would think that we'd have learned by now that asking people about their behaviors doesn't tell us much about behavior change. And even when we do learn something about behavior change, we have learned that such efforts are incredibly difficult, time-consuming and often barely effective, especially when they are administered at an individual level.

I won't pretend to know what's causing the growth in obesity rates, but I can assure you that the answer won't come from asking 2 million more people about their exercise habits and vegetable intake. If the answer lay there, we'd have licked the problem a long time ago.

One thing I guarantee that asking 2 million more people about their behaviors will accomplish is cementing in the minds of most public health researchers and practitioners that the answers to our public health issues lie in personal behaviors - and the corollary to that is that any health problems you have are because you have failed yourself. Is that the message we really want to send?

Health Disparities: Getting Worse or Getting Better?

2011-05-15T19:50:00.000-07:00

Yes. Both. Simultaneously. With the exact same data.

For my general rip on health disparities research, see the previous (lower) post.

So the other day, I heard someone say that in almost all cases, (racial) health disparities are getting worse, not better. Which, of course fits perfectly with the scare tactics that much of public health relies on these days. I think when we public health types hear that, we think it means we need more resources to address health disparities.

But in the back of your head, doesn't it also say: all the work that's been done on reducing health disparities has been an abject failure, nothing we do works, and it's disheartening to contemplate moving forward? Wouldn't it be an even more powerful motivator to garner resources to be able to say "Hey, look at this, things are getting better". If you were a funder, wouldn't you rather build on success?

But the numbers are the numbers, right?

Actually... depending on how you look at the numbers, whether things are getting better or worse is all a matter of perspective.

Arguably, the most important health indicator of them all is mortality.

So, I went to one of my favorite websites, wonder.cdc.gov, and looked up trends in mortality by race and ethnicity over the past few years, and then threw it into a graph.

When I look at that graph, there are a couple things that jump out - first that there are rather enormous disparities in mortality by race in the US. Second that Hispanics and Asian/Pacific Islanders have much lower mortality rates than Whites. (How often do you hear about that?) And third, death rates for all racial/ethnic groups are declining fairly rapidly.

It isn't immediately obvious from this graph whether the racial disparities are getting wider or narrower, the differences between these lines looks pretty similar over this 9 year period.

So, let's look at the disparity using the official method.

You pick the healthiest group, then divide the other racial/ethnic groups by that group to get the relative disparity. In this case, the healthiest group is the Asians and Pacific Islanders, so you get this graph:

It's pretty clear that relative to Asians and Pacific Islanders, the disparity is essentially unchanged for Hispanics, and has increased for Whites and Blacks.

But I find this way of looking at things strange.

It obscures the fact that Whites are the dominant group in the US, so I did the same analysis, but using Whites as the reference group.

When you hear the term "racial disparity", what is the reference group that springs to mind?

At any rate, this picture is a bit different. The Black:White relative disparity in mortality is actually declining slowly over time, while the relative health advantage of Hispanics and also Asians and Pacific Islanders is increasing over time.

But the interpretation of whether

health disparities are getting better or worse over time depends on something besides which racial group represents your baseline - it also matters whether you divide (the standard method) or subtract.

When you plot the difference between Asian and Pacific Islanders rather than the relative disparity, you actually get a different interpretation:

that the difference between Asians and Whites has not been changing much over time, but the disparity between Blacks and Asians has been improving, the exact opposite conclusion one would reach from looking at the relative disparity.

And when you use Whites as the reference group for the difference, these results are pretty similar:

The Black:White disparity is clearly diminishing over time, the health advantage of Hispanics has been increasing slowly, and there is no apparent change in the health advantage of Asians.

I don't want to bore you with the math that explains all this, but I guarantee I haven't done anything funny. It's just that when you subtract, most health disparities appear to be on the decline, but when you divide (which is the standard method), most of the health disparities appear to be increasing.

So both are true simultaneously. Which raises the question as to why dividing has become the standard? I have two explanations - one rooted in history, the other rooted in computerized estimation methods. Neither rooted in any logic the least bit related to health disparities.

The first reason has to do with the history of trying to figure out if smoking caused lung cancer. In post-war England, a couple doctors (Sir Austin Bradford Hill and Sir Richard Doll) did a series of studies to investigate whether smoking could be causally linked to lung cancer. Not surprising in retrospect, they saw that smoking had a big influence on the development of lung cancer. Whether you divide or subtract, lung cancer was clearly more common in smokers than non-smokers. But there was a pesky finding in relation to heart disease. When you subtract, it looks like smoking causes about as many heart attacks as it does lung cancer.

To their thinking, it made sense that smoking would affect the lungs, but why the heart? Fortunately, when you divide, rather than subtract, it looks like smoking has a huge influence on the risk of getting lung cancer, but is associated with only about a 20% increase in heart attacks.

From that, they concluded that dividing must be the right way to think about it.

But subtracting is just as valid mathematically. All these numbers say is that smoking causes about the same amount of heart attacks as it causes lung cancer, but because lung cancer is so rare in non-smokers, that makes a huge relative difference, while heart attacks are pretty common among non-smokers, so a small relative difference still adds up to a lot of heart attacks.

The other reason that public health types divide rather than subtract is that computers like to divide. Well, that's not really true, they don't care. But the complicated statistical methods that we ask computers to do almost all rely on dividing as the one and only way to compare two numbers. The statistical methods that rely on subtracting as much harder to implement, and are often impossible. So what I like to do is throw the complicated statistical methods out the window and calculate the differences using more labor-intensive methods.

All of which is by way of saying that next time you hear that health disparities are getting worse, take it with a grain of salt. It probably depends on how you do the numbers.

My Rip on Health Disparities Research

2011-05-15T19:21:00.000-07:00

A few days ago, I gave my final lecture in my epi class, partly an overview of social epidemiology, and partly a rip on health disparities research.

The short version:

Identifying and describing health disparities:

- is a great way to get grant money.

- seems like a great way to raise awareness-

--- in order to mobilize greater resources to address the problem &

--- in order to mobilize members of the 'target population' to take preventive action.

- can be demoralizing to the 'target population'.

- can induce feelings of helplessness in the 'target population'.

- can make ill health seem inevitable & expected in the 'target population',

--- potentially reducing the urgency for action.

- describes the result, not the causes-

--- if you believe genetics is the cause, the existence of health disparities supports that notion

--- if you believe lifestyle is the cause, the existence of health disparities supports that notion

--- if you believe racism is the cause, the existence of health disparities supports that notion.

- don't identify potential public health actions to address health disparities

Furthermore, the almost exclusive focus on adverse health disparities:

- is demoralizing to the 'target population'.

- enhances the sense of social distance between the 'target' and 'majority' populations.

- obscures the true picture of a mixture of adverse health disparities, health similarities and advantageous health disparities.

Ignoring advantageous health disparities

- blinds us to the possibility of understanding the mechanisms for these advantages

--- which could lead to more effective public health measures built upon those mechanisms to address the adverse health disparities

--- or could lead to building on those mechanisms to improve the health of populations other than the 'target population', including the 'majority' population.

Small-area variation in voting on Proposition 8

2011-04-17T07:43:00.000-07:00

I've been looking at how people voted on California's proposition 8 (the one in 2008 that restricted marriage to mixed-sex couples) at the voting district level for a project to try to characterize normative heterosexuality within small areas.

These maps show voting behavior at the census tract level (census-defined neighborhoods of ~4,000 residents).

Yellow = 50% support
The darkest green = 35% or less
The brightest red = 65% or more
(white = fewer than 100 votes cast in that area - often airports, sometimes just very unpopulated)

San Francisco bay area.

Los Angeles area. It is surprising to me how polarized this issue was.

Nice camp, Google!

2011-04-15T09:51:00.000-07:00

I wonder how long it will take the religious right to figure out that today's Google doodle has a second meaning.
Brilliant use of camp, Google!

TBLG Data Geek Nirvana is Coming - Are We Ready?

2011-04-11T13:50:00.000-07:00

The year is 2015. An unprecedented amount of data is now available about the health, socioeconomic conditions, and familial relationships of bisexual-, lesbian-, and gay-identified Americans. We now have the opportunity to describe these populations in great detail.

Routine questions intended to allow people to identify as trans have been tested and deployed in a number of surveys, and our ability to describe the trans-identified populations of the United States is light-years ahead of where we were in the dark ages of 2011 when a tenuous estimate of the size of the trans-identified population was first reported from population-based surveys.

Although a fairly wide variety of national surveys had collected sexual orientation data since the mid-1990's, it was a haphazard process in which surveys would add a question on sexual orientation largely based on lobbying by lesbian and gay researchers with strong personal relationships with survey administrators. Not only that, but the idiosyncratic method meant that there was little, if any, co-ordination between surveys, and each one asked about sexual orientation in it's own slightly peculiar way, leading to much methodological navel-gazing, and debates about which results were different because of question wording vs. which differences were the result of population differences, or some other factor.

Then, in 2011, given a push from a prestigious Institute of Medicine report, the ground shifted.

Rather than the default position being that one had to justify adding questions about sexual orientation to a skeptical research committee, survey administrators would now feel pressure to justify _not_ including sexual orientation questions, and have to get creative about how to reliably assess transgender identity in general population studies.

Furthermore, a growing consensus about the precise wording used to assess sexual orientation and gender identity had developed, leading to a much greater ability to compare results across studies, and even to combine multiple studies together in order to overcome the problem of not having sufficient numbers of sexual and gender minority individuals, and also to enable analyses of ever more tightly defined sub-populations - such as elderly Asian-American lesbian and bisexual women, bisexuals in their 20's and those in their 50's, heterosexually-identified men who profess same-sex attraction but have not had sex with another man, and so on.

Not only that, but the National Institutes of Health had made substantial investments in supporting analyses of this data bonanza, and had also invested in programs designed to provide up-and-coming students of this field with mentoring and training to an unprecedented degree.

In short, TBLG data geek Nirvana had arrived!

Since that scenario, or one not far from it, is likely to be in our 5-10 year future, it is worth spending a bit of time getting past the salivating, and doing some serious critical thinking about some potential side effects, so that they can be anticipated and prepared for, rather than an unanticipated surprise and source of frustration.
And that's why I'm writing this piece. I'm as eager as the next TBLG researcher to get my hands on the tsunami of data headed our way. We all want to surf that wave, rather than get pummeled by it.

It's going to be great, and...
I want to think about the "and..." part for a minute.

I have been able to anticipate a few side effects of this coming wave, but I don't want to claim that I can see the future. Some of these may not happen. Undoubtedly other things I haven't considered will catch me by surprise.

The more research, the better.
Well, it depends on the research. See my previous posts for more on this. In short, it depends on what the goals of that research are. More than likely, we're going to see a huge expansion of rather thoughtless research. Specifically in terms of health research, we're going to see a lot more "health disparities" research oriented towards only adverse health disparities. We're going to see a lot of "intersectionality" research oriented towards showing cumulative disparity and adversity. Both of these approaches will miss the interesting exceptions: what health advantages do TBLG populations have? When does the assumption of cumulative adversity inherent to much intersectionality work fail to capture the points of resistance and resilience that provide opportunities for effective health promotion and community pride?

Who will be the gatekeepers?
"Nobody" is the short answer. Which we should welcome with open arms. Expanding access to data about TBLG people will be the inevitable result of this process of asking more questions. The thing to watch out for here is that people who have not in the past had any particular interest in TBLG populations will be chiming in for the first time, and making rookie mistakes in interpreting what they look for, what they find, and how they report it. The other phenomenon to wacth out for related to this is people who have had an interest in TBLG populations, but will now feel empowered to look at data across a variety of disciplines other than where they have spent most of their time to date. Of course that is to be welcomed and encouraged, but there will be bumps along the way.

A shift in prerogative
Survey administrators will feel the shift from having to justify adding sexual orientation and gender identity items to surveys to including these questions unless there is a strong reason not to. Similarly, people analyzing these surveys and studies will feel an expectation that they should at least try to see if there are differences across categories of sexual orientation.
And, when they do these exploratory analyses, a variety of possibilities may arise. They may see a disparity that it truly there and is significant in a statistical sense. Since the idea of disparity and deficit fits well with assumptions about the social order, these exploratory analyses are more likely to get published than health similarities or health advantages that are truly there and also significant in a statistical aspect (technically a similarity can't be significant, but the point is that if no difference is seen in a large sample, that is evidence of little difference). Disparites that are truly there, but not significant in a statistical sense may also be commented on, and disparities that are observed as statistically significant, but in reality aren't disparities at all are also likely to be reported out as adverse health disparities. The probability that a health advantage that is not significant would be reported is, I propose, vanishingly small.
As a result, we are likely to see reports of a wide variety of health disparities, many of which will be "real", and also many of which will be spurious findings that are less likely to be replicated in other groups of people. But we won't be able to tell which is which until replication studies are done. And the way science works, debunking a falsely significant finding that jibes with the overall assumption of TBLG people being deficient can take several, even dozens of failed attempts to reproduce that finding in other populations.
Conversely, findings that go against the notion of inherent deficit (health similarities and advantages) will be viewed as tentative, and may require dozens of significant findings before being viewed as worthy of comment.

The upshot of all that is that as we shift from analyses designed to examine TBLG health from a theoretically-oriented perspective to a time when routine, but atheoretical analysis of these populations become commonplace, we should expect to see a large increase in spurious findings of TBLG deficits.

How Come Queer Health Research Can Only See Unhealthy Queers?

2011-04-10T16:53:00.000-07:00

Recently, the prestigious Institute of Medicine came out with a tremendous compendium, The Health of Lesbian, Gay, Bisexual, and Transgender (LGBT) People: Building a Foundation for Better Understanding.
The goal of the book was to describe the state of knowledge on queer health, identify priorities for future health research, and make specific recommendations to the US National Institutes of Health.
And as far is goes, it does these tasks very well. The literature review is very thorough and will be useful for anyone writing a grant, among other things. The chapter on context is a great 30 minute romp through our nation's homophobic history.
The recommendations it makes are, in my opinion, a mixed bag, from laudable goals to some that I really can't get behind at all. All are the inevitable result of the mainstreaming of queer health research and bringing it into the NIH funding model.

If you've followed this blog in the past, you probably can guess that I don't think it goes far enough. I have to admit that I have not yet been able to read each and every sentence in the thing. It's huge. But I have read the executive summary, the intro and the recommendations, and I doubt that there is anything buried in the rest of the document that would alter my critique. (I hope I'm wrong, and look forward to being pleasantly surprised).
I also have to say that lots of this report makes for wonderful reading. If I had more time to devote to this, I would balance a lot of this criticism with things that the report does really well, like acknowledge that homophobia hurts straight people too.
I'm going to break my critique down into two sections. The first will address two broad deficiencies of the report: a failure to fully appreciate the health similarities and even advantages of TBLG people. What do we do well, for ourselves, one another, and for the society at large. A failure to understand the role of social context in the lives of queer populations except in a very limited and limiting way. Second, I'm going to tackle the recommendations one at a time..

Where's the Health?
Given that the report draws on the most frequently published research, it should have come as no surprise that the report concentrates heavily on health disparities in a very particular (and peculiar) sense. In virtually every case, "health disparities" means a health outcome (like depression, asthma, etc.) that we do worse on than heterosexuals. Very little attention is paid to those areas where we do about the same, and none (that I've found yet) of the things that we do better on than straights.
For example, gay men tend to have lower body mass index than straight men, but you won't find that anywhere in this document. Instead you'll find that lesbians are more likely to be heavy than heterosexual women repeated in at least three places, and a complete silence on the health advantage of gay men in this area.

Why focus only on adverse health disparities? As near as I can figure it, the rationale for focusing exclusively on adverse health disparities is that these fit nicely into the narrative that homophobia is bad, and homophobia affects TBLG people by making them less healthy in a variety of ways. Fair enough, but if homophobia is the thing making many of us sick, why not measure homophobia directly?

What's the danger of focusing exclusively on adverse health disparities?
1) It's not an accurate portrayal.
2) It's demoralizing - it reinforces the very effects of homophobia by making 'health' seem unattainable for queers.
3) It makes the radical religious nuts in this country smile from ear to ear - they love pulling out data about how unhealthy we are when they try to deny us various civil liberties (if not our existence entirely).
4) It doesn't explicitly differentiate whether these disparities are due to homophobia (as we would like to think), or whether they are due to some inherent, inborn insufficiency (as the nuts would like to think). Both interpretations are supported by these data.
5) We can't learn anything from the health advantages that we can build upon and use to improve the health of our communities if we can't call 'em when we seem 'em.
6) We can't really offer anything useful to other populations (heterosexuals, as well as other minority groups) as success strategies, if all we identify and talk about are what's adversely affecting us.
7) We can't learn how homophobia affects heterosexuals with this approach.

By analogy, the first century or so of research into health disparities affecting racial and ethnic minorities has largely fallen into the same trap, of spinning out a relentlessly monotonous string of adverse health disparities. These health disparities get interpreted by most of us as evidence that racism affects health adversely, and by bigots as evidence that they were right all along. Health disparities allow both interpretations.
A nearly exclusive focus on adverse health disparities has prevented us from seeing what it is that racial and ethnic minorities do well, what lessons can be learned to promote the health within these communities, and what lessons can be exported to the wider population as well?
For decades, epidemiologists have pondered and shrugged off the "Hispanic paradox", which is that many of the adverse health disparities one sees when comparing Blacks to Whites are not there when comparing Hispanics to Whites. And in many cases, (such as birth weight and longevity), Hispanics' health generally exceeds that of Whites in this country. Not looking into health similarities and advantages has really stalled both understanding the true nature of racism and how it operates in the US (it's a lot more complicated than 'being a minority'), and also being able to build on the record of strength that various communities have already demonstrated despite or perhaps because of living in a racially hostile social climate.

So, when this report focuses so exclusively on adverse health disparities, it really does us all a disservice. It's not an accurate picture of our health. It is demoralizing and depressing to read that litany. It supports our most adamant opponents' views of us. It doesn't get to the root cause. It doesn't show us what we've done well for ourselves, each other, or the communities (geographic, not identity-based) that we live in. It doesn't point (efficiently) to solutions. It doesn't address the degree to which cis-gender heterosexuals are affected by the same forces.

Social Context Involuted
I had the great honor to listen to a panel discuss the report at the 10th anniversary celebration for the Williams Institute on Friday. Stephen Russell was one of the panelists, and he really brought home the message that the report had been insufficiently curious about the role of social context in the document. I was practically giddy with excitement as he spoke, because I no longer felt like the lone curmudgeon in the room. Not that Stephen was a curmudgeon, not at all, I just was beginning to feel out of place as speaker after speaker lauded the report rather uncritically.

What do I mean by "insufficiently curious about the role of social context"? Well, I mean that the report does talk about the importance of social context, and much more so than the other documents of this type. One of the "cross-cutting perspectives" that the report recommends be used to understand TBLG health issues is:

A social ecological perspective--An individual's health is affected by community and social circumstances. LGBT health research should consider both the individual and the various contexts, including interpersonal relationships, in which the individual lives. (Summary, page S-6)

Not only that, they devote an entire chapter to describing the historical and social context of homophobia in these United States that is well worth reading.
Not only that, but also they have a terrific discussion of how stigma operates at various levels.

But, notice what happens in that definition of a social ecological perspective above - the definition sounds very inclusive of understanding how homophobia operates in the social environment, but the single specific context they mention is a highly individualized one "interpersonal relationships". Likewise, there are several points in the article which confuse "structural" with "institutional" or even "interpersonal" levels, where the interactions between patient and provider are characterized as "structural".

And when they get to the recommendations, this trick of collapsing social context down to the most proximal surroundings of a person happens every time the concept is mentioned. And nowhere in the recommendations is it suggested that a goal for understanding LGBT health should be to develop or use measures of heteronormativity and/or homophobia at any level beyond how it affects individuals in these very limited, proximal contexts.

I decided to do a bit of a quantitative analysis of this bias in the document (sorry my qual friends, I just don't know how to do your style well). I searched for the terms "stigma", "discrimination", "prejudice", "homophobia", "heterosexism", "heteronormativity", "homonegativity", and slight variations on these words.
The terms "stigma" (and "stigmatizing", etc.), "discrimintation" (and "discriminatory", etc.), and "prejudice" (and "prejudicial",etc.) occurred fairly often, including in the recommendations section. "Homophobia" and its kin occurred considerably less often, most often in the chapter on context, and the literature review, when other authors were being cited. It was completely absent from the recommendations, as were the other terms in my search list. About half of the occurrences of the term "homophobia" were in the titles of papers cited in the reference section.
OK, so they focused on "stigma" and "discrimination" in the parts of the document where they were proactively describing what they thought should be done in the future.
But every time these terms were mentioned in these sections, it was as though stigma and discrimination just happen to people, that there is no identified source. We should of course be measuring the experiences of discrimination and stigma that affect our health, but shouldn't we also try to identify those who do the discriminating? Those who perpetuate the stigmas?

Otherwise we run the risk of repeating what has been done in the "perceptions of racial discrimination" literature, where the source of that discrimination is rarely named (except in general terms like "at work" or "in health care"), and the use of the term "perceptions" invites the interpretation that this is somehow all in people's heads, that they are perceiving discriminatory acts whether or not they were intended to be discriminatory, and rarely delves into the pervasive issue of discriminatory actions that are not perceived as such (doesn't everyone get watched in those big mirrors when you're shopping?).

The Recommendations
The report has seven recommendations. Here's my take on them (wow that sounds egotistical. But it is egotistical, so I might was well own it instead of pretending that I represent a broad swath of TBLG opinion on these issues).
In general, these recommendations are written on behalf of people researching TBLG health, who are invested in the model of getting funding from the government to do so, written to the government agency that they seek to influence (and which itself seeks to be influenced).
As a result, they tend to look out for the interests of the researchers, even when these interests may conflict with those of many individuals in TBLG communities (although they are generally in concert), and they are intended to be appealing to a government funding agency that is notoriously shy about engaging in politically-charged areas.

The first recommendation is that "NIH should implement a research agenda designed to advance knowledge and understanding of LGBT health", which sounds pretty innocuous. What else should a group of researchers appealing to a government agency for more funding start out with. And who could object to more research?
I guess for me it comes down to what research are we getting more of? Demoralizing work on adverse health disparities (of which I would classify almost all the items listed in their specific recommendations in table 7-1, aside from the demographic items), or a richer exploration of health similarities and health advantages as well? Research that is highly individualized, dominated by the well-established methods of mass survey techniques, or research that starts with what we want to learn, then develops the methods most suitable to achieving those goals.
This part of my critique applies to the vast bulk of health research funded by the NIH, and isn't specific to TBLG health research at all.
More research, sure... but how about the right research?
There are lots of sub-recommendations under this one which I can't get into right now. Some of these have the potential to be great ("social influences on the lives of LGBT people"), and some leave me cold ("inequities in health care"), but that's for another day.

The second recommendation is that "Data on sexual orientation and gender identity should be
collected in federally funded surveys administered by the Department of
Health and Human Services and in other relevant federally funded surveys". More data = good... mostly. This one gets my unqualified support. The more surveys ask about us, the more we will be fairly represented. With sexual orientation, this is pretty easy, because the questions are there. Gender identity is a bit more difficult, because very little is known about how questions about gender identity perform in general population surveys. There are some dangers here, though. It is likely that the first few surveys that ask about gender identity will "get it wrong", but not in the way you're thinking - the biggest problem will be that a small number of people who have never given their gender a conscious second thought will answer the question incorrectly and be counted as transgender. As a result, a substantial proportion of the transgender-identified population will actually be inattentive or confused cis-gender folks, maybe even half or more.
But, as Gary Gates told me, if you don't have any questions on there, there won't be the incentive to fix them and make them more accurate.

The third recommendation "Data on sexual orientation and gender identity should be
collected in electronic health records" seems ill-advised to me. The research potential of asking these questions is phenomenal, but I'm not at all convinced that there are sufficient protections around this (or any) medical information to make it a standard field. And even when the information is protected sufficiently, there are many circumstances where being "out" on one's medical forms can be downright dangerous. I understand the potential for benefits in terms of getting more appropriate care, but that assumes that appropriate care is available, and that we even have a good sense of what appropriate care would consist of. I'm not convinced that we do know what TBLG appropriate care means in a broad enough set of circumstances to warrant having this information collected routinely on medical records. Should people who feel that it is important to their care have it recorded in their charts? Of course! But do we really want a young trans lesbian in Colorado Springs having that information on her record when she walks into see a provider she's never been to before?

The fourth recommendation is to "NIH should support the development and
standardization of sexual orientation and gender identity measures". Yes, of course. But at the same time, there is a risk that these standardized questions (much like the OMB directed race/ethnicity questions) will result in less curiosity about how people self-identify, and re-inforce the "normality" and reality of a small set of mutually exclusive categories. I still think it's a good recommendation. I just worry about cookie-cutter inclusion of the question in an un-thinking manner all over the place.

The fifth recommendation, that "NIH should support methodological research that
relates to LGBT health" is one I am fond of, but I think that is because I am really into methodology and want to see a certain set of methods (especially ecologic methods) built up, although most of it will probably be devoted to trying to turn various forms of "convenience" sampling into "probability" sampling. Boh-ring!

The sixth recommendation, "A comprehensive research training approach should be
created to strengthen LGBT health research at NIH" Sure, why not.

The seventh recommendation scares the pants off me. "NIH should encourage grant applicants to address explicitly the inclusion or exclusion of sexual and gender minorities in their samples". Sure there are abuses where TBLG people are inadvertently (and in some cases very intentionally) excluded from various research projects. But the discrimination we face in this regard is tiny compared to the historical discrimination against women and racial/ethnic minorities in particular in clinical trials. And a similar remedy for this past exclusion has had limited success and some strange side-effects (see Stephen Epstein's book Inclusion: The Politics of DIfference in Medical Research).
This formulation makes it sound like participating in health research is a civil right, and while exclusion from trials without a good basis should be discouraged, I'm not sure that adding another administrative check-box on the NIH grant forms will really achieve that goal, it may raise false hopes of being able to study TBLG folks in the vast majority of health studies. Perhaps most worrisome, by drawing attention to sexual orientation and gender identity as categories across which one should compare results, we are on the verge of being flooded with falsely positive chance findings that will crop up in various studies and which may or may not be able to be shoved back into the bottle with future research (as examples of this, I would cite the "gay gene" and "gay brain" studies, which, no matter how many times they have been subsequently disproven, still hang in the public imagination as valid). Another example of this (I can't remember if Epstein gets into it or if it came up after his book was published) was the spurious finding that an HIV vaccine candidate appeared not to work over-all, but did appear to work in a bizarre atheoretical grouping of African-American and Asian-American men. That finding was widely reported on, despite obviously being irrelevant to how the vaccine worked. It was a statistical fluke. And how often should we expect a statistical fluke? About 1 in 20 times. So if we start encouraging people to look at every possible health-related thing in every study, one in twenty statistical flukes is going to start adding up into an avalanche pretty darn quick.
In my opinion, if recommendation 7 is implemented, then a lot of researchers who have never given a second thought to TBLG issues are going to feel not only empowered to do these analyses, but encouraged to do them, and we're going to be up to our eyeballs in damage-control mode beating back spurious research results.

Blood

2010-10-23T17:36:00.000-07:00

Give Life. Give Blood.
Blood brothers.
"One drop" rule.
Blood on your hands.
What does blood mean to you?

Blood fascinates me. It tastes great, it feels great. It is vibrant and alive like nothing else.

The sweet gush of warm, salty liquer that erupted in my nose after a punk on Thayer Street clocked me 'cuz I said he'd look good in a dress, too. The blood is what made it come alive. I was afraid for my life, and not without reason. The blood, though, that's what told me "this is real". The pain told me too. But the blood, the blood made all of my senses jump into hyperdrive. At the same time, the blood was a secret joy in the midst of the pain.

I don't have a fetish around blood (though hats off if you do). I don't seek it out. But blood is a lovely thing.

And yet.
When I bleed, I'm very conscious to make sure that my blood doesn't come into anyone else's life. I hide the fact that I'm bleeding, and I clean up more carefully than I would, say, sweat or tears. Or for that matter, snot. Or cum.

And blood makes me queasy, too.
I don't think I could watch surgery on TV. Getting blood drawn makes me wince.

Blood has so many fascinating associations. It means so many different things. Often contradictory.

I wish I could talk about giving blood and what it means. But I can't. Not yet.

What does blood mean to you?

Make it Better!

2010-10-06T20:29:00.000-07:00

Here's the perfect antidote to the "There's nothing you can do now, so just wait until It Gets Better" campaign.
There's real hope in these messages.

What are some specific things you can suggest for queer and pre-queer youth to make it better? Right now?

It Gets Better

2010-09-26T15:26:00.000-07:00

Today I took a stand against gay youth suicide.
Sort of.
Don't get me wrong, I'm not in any way in favor of youth suicide, gay or otherwise.

I was inspired by the "It Gets Better" campaign, and when I heard that they were doing some shooting today within a few blocks of where I live, I decided to go over and lend a hand.
The most popular of the videos in this series presents Dan Savage and his partner Terry, with the aim of telling queer (or pre-queer) kids in high school that it may be rough now, but it gets better.

But I was also concerned about a couple of themes in this video that didn't sit well with me.

For one, I remember when people told me "don't worry, just wait. It gets better."
There is nothing more frustrating to a t(w)eenager than telling them to wait and sit on their hands. It makes it sound like everything it out of their control. All you have to do it wait - but waiting may be the one thing a young person cannot do well.
When people told me to wait and that "it gets better", I wrote them off as out of touch and out of options.

For another, I think it is potentially quite damaging to suggest that the best thing a queer (or pre-queer) kid can do is nothing, to sit back and wait for things to get better. What about coming out? What about taking a little bit of control over their lives? What about living authentically? I don't think that Savage and crew are suggesting that the best thing to do is nothing, but it's easy to read that message out of what they are saying.

Another thing that bugged me was the suggestion that the best thing you can do is tough it out, then leave everything behind and move to the big city. Well, the truth is, the big city sucks for a lot of people. I can't tell you how many people I've talked to living in San Francisco who moved here thinking that they would fall into the lap of a sweet landlady bearing magic brownies and get swept up into a fabulous and unstoppable social life, only to find that, just like everywhere else, you've got to build your social network from the ground up.
And when you don't have a solid grounding of who you are, the big city can chew you up and spit you out faster than you can say "doublemint".

OK, enough with the negativity!

So, I decided to go on over to the taping, and do my best to shift the message, a little bit. I wrote out a couple pages about what I wanted to say on my phone while walking over there, read & re-read it, and then shoved the phone in my pocket & spoke into the camera. I don't remember exactly what I said, but it was something like this:

Hi, I'm Bill. And you are awesome.

It will get better. It will. But that's not much help to you now.

There's a couple things you can do to make it better now.

One is that you can write, and read, about everything. Reading about history, how people have overcome amazing obstacles in the past.

And you can make things better now. For yourself and others.

To make things better, be yourself. When you are you, authentically you, then it doesn't matter what other people think or say.

And one more thing. 'It gets better' doesn't mean you have to leave everything you know and love behind and go to the big city. To be honest, the big city can be a pretty lousy place for young people.

But all across this country, from Portland Oregon to Portland Maine, from Austin Texas to Helena Montana, there are great queer communities. And when you do something to make things better, you make your home town better, too.

Things have been changing so fast in this country, all over the country.

So, it will get better. You can make it better.

I don't know if they will use it, or how they will edit it, but if it makes the cut, I'll post the video here.

More theory...
My thesis was about gay youth suicide. Well, actually, it was and it wasn't.
I was frustrated by seeing people amplify the statistics about gay youth suicide up into the scariest monster possible. Their intent was good - they wanted to draw attention to the plight of queer youth in order to do something to prevent suicide.
But, then the question is what do you do? Most of the boys who are struggling the hardest are not open about their sexuality, many may be completely unaware that they have a sexual orientation at all. Some of them don't want to be gay and are trying to find another way to be in the world.
So reaching out to queer youth is good for all kinds of reasons - but preventing suicide may be the least of them.
What is likely to be a lot more effective is changing the culture we live in so that it produces less stress in the first place.
So that's why I did my thesis about measuring heteronormativity in the social environment, and specific ways to improve the social environment (like passing gay rights laws), rather than trying to identify the individual-level risk factors that affect queer and pre-queer youth.

Legal Pot. Public Health. Queers.

2010-08-22T13:32:00.000-07:00

Pot is going to be legalized in California. No matter what your stance on the voter proposition, legal marijuana is coming, and Public Health will probably be in the mix in ways it has not been until now. I myself haven't decided how I will vote, but that's not the point. My point is that as marijuana slowly moves from the eagle eyes of law enforcement, public health is the natural next step for surveillance, monitoring, and control.

A couple weeks ago, I had a great conversation with a former (and future?) student about, among other things, what will happen once pot is legalized in California. He's been involved in the efforts to identify tobacco use as a health concern for gay men, lesbians, bisexuals and trans folks for many years, and we were wondering about how the activists who have built such a strong network around tobacco and smoking will react to legal joints in California.
Will the queer tobacco activists see themselves as primarily focused on tobacco (including smokeless tobacco like snuff & snus), or on smoking, which could potentially include pot, or both (which could possibly include vaporizers, brownies, etc.). Or will the idea of sounding like a negative Nancy on pot mean that we will just ignore the health consequences of smoking marijuana on queer folks?

Then, the other thing that got me thinking was looking into the environmental impacts of growing pot, because I'm looking for good material for my upcoming class on environmental health, and I figured that topic might engage some of the students.

At any rate, there are a lot of issues to think about there...
One can hope that the legalization of marijuana in California will lead to more environmental growing conditions - fewer diesel-powered generators, fewer diesel spills, less pesticides and more sustainable farming practices all around. But if there is an increased demand with no change in Federal enforcement efforts, there will still be a lot of pressure to grow pot in ways that are extremely damaging to the environment. What will the role of public health and environmental health be in developing policy and regulations? Will "organic" pot be certified by the same rules as USDA has developed for food?

For many years now, marijuana has been promoted as "medicinal". I'm sure it is for many people. But there are unintended consequences of promoting marijuana as medicine.
For one thing, a lot of people seem to be convinced that smoking marijuana is healthy, is good for you, even if you're not treating any health condition with it.
For another, a lot of people seem to think that smoking marijuana is just not dangerous compared to smoking tobacco.

If marijuana has been promoted as good for you, and now it becomes legal, it is complicated to modulate that message to be honest about ways in which it is not good for you, too.

So, where does public health come in on legal marijuana? We've gotten a pass because regulating marijuana has been the province of law enforcement. The "soft power" of Public Health has not been called on, and the research, as stunted at the field has been, is very polarized, with some researchers claiming that marijuana has virtually no down side, and others saying that marijuana smoke is more hazardous than tobacco smoke, and most researchers just not making much of it one way or another, because being illegal, it is assumed to be a bad thing anyway.

But that brings up another point - it is really hard to get any decent epidemiologic data on the health effects of smoking marijuana. On the one hand, the illegality of pot has led to the polarization above: the researchers are often so devoted to one side of the debate or the other that it is hard to trust their work. On the other, the illegality of pot makes asking questions about people's use a bit more ethically complicated, and also hard to trust people's self-reports of engaging in an illegal activity. And then on the third hand, there's the simple fact that most (but certainly not all) people who smoke marijuana also smoke tobacco, which makes teasing apart the effects of marijuana on health very tricky.

So where am I after thinking about all this?
Not much farther from where I began. I don't see myself likely to get very engaged in this debate. But, I will be interested to see what happens as the desire for society to somehow curb and contain the use of this substance moves from law enforcement to public health. And I will be curious to see how the message that "marijuana is medicine" gets tagged with the small print we're now familiar with from ads for pharmaceutical drugs, and tobacco products, for that matter. What will the Surgeon General's warning be? What will the breathless, low volume pitch-man sound like when rattling off the unpleasant side effects? And when will the large cohort studies needed to answer the fundamental health questions get funded?

invalid votes

2010-08-07T19:51:00.000-07:00

I've been thinking a lot about similar gender marriage lately. And its proponents.
I followed the prop8 trial very closely, even going to observe it two days. I watched every second of the proposition 8 trial re-enactment on YouTube. I've even listened to Family News in Focus to try to understand where the other side is coming from, and how they've interpreted the trial.

I've been absolutely mystified by the approach that the prop8 defendants (protectmarriage.com) took during the trial. It seemed like they opened up a shotgun on one foot, then the other, then still not satisfied, started gnawing off their hands. Their defense was really that incompetent. It can't be unintentional. They must have wanted to lose the case. But why?

I still don't have a good theory on that.

Were they just so cocky that they are going to win in the Supreme Court that they decided not to invest any resources in the trial? That doesn't make sense to me. Why sabotage their own trial if they thought they might have to defend it in the Supreme Court?

Were they hoping to portray the trial as a miscarriage of justice - in essence setting up Judge Walker to take on the unwitting role of an "activist judge"? That makes some sense to me, because they certainly have been making hay in their news broadcasts about how San Francisco justice is about to be foisted on the whole country. But how often (if ever) would they get the opportunity to get a new trial rather than have it appealed up to the 9th district? And is it worth losing the war in order to get a few bucks out of scaring people with the threat of having an activist judge force everyone in the country into a similar gender marriage?

In a related vein, maybe they really need a new front in this battle in order to keep donations up. Now that every state with a voter initiative process has had a marriage restriction amendment of some sort on the ballot, they need a new bogey man, and have found it in this trial. But that is just too conspiratorial for my taste. I believe that these people are earnest in their beliefs. I think that there are some people like Karl Rove who have done some truly cynical manipulation of them, but I think that the vast majority of them, the people giving money, even those running television ministries and organizations to "protect" marriage, are honest and heartfelt, if (from my perspective at any rate) misguided.

And that brings me around to the thought that I started out with when sitting down to write tonight. In the circles I travel, it is easy to be flip and dismissive about the millions of people who voted for proposition 8. I mean, what were they thinking, right?
In response to claims that one wacko judge in California had just over-ruled the entire voting public, I recently posted on FaceBook:

"Correction: one judge AND THE CONSTITUTION invalidated the votes of millions of Californians".

Hey, it's good for a laugh, but after posting that, I've been thinking, you know, invalidating the votes of millions of Californians is really no laughing matter. It's pretty serious business.
It was the right thing to do, but it's also unreasonable for our side to just think, OK, no biggie, now that's over and we're on the right path again. A lot of people did vote, and a lot did vote against us. And now they've just been told that their votes were wrong, unconstitutional, un-American.
It shouldn't be surprising if a lot of them resent having their votes invalidated, and there will probably be some who might be swayed to the right side of the issue, but will resist it just because they feel like their vote was stolen from them.

And that got me thinking about how should we go about acknowledging the hurt of having their votes taken away from them, and still trying to convince them that their position was wrong in the first place? Its thoughts like that that make me glad I'm not a political consultant. I mean, how can you square that circle?

day of decision

2010-08-07T19:31:00.001-07:00

This is moments after Judge Walker's decision was announced, before the "whoop" that you've probably heard on TV.

And this is after the "whoop", as the cameras were swinging around trying to find some "human interest".

Then, of course, there's the inhuman interest...

A procession towards City Hall to try to get a couple married. The judge's stay was ordered while these folks were en route.

I had a chat with this lovely couple, who were thrilled to share their special day.

Seth is beaming.

Internalized Homophobia - Why Measure it?

2010-06-20T19:15:00.000-07:00

Recently I saw an article that suggested that measuring internalized homophobia might be a waste of time.

I was intrigued. I have to admit, I've never been a big fan of internalized homophobia. Measuring it, I mean. But I never stopped to think out why the idea made me a bit queasy.

Maybe I should back up a bit. One of the leading theories about how homophobia affects people is that homophobia operates simultaneously at multiple levels: societally, institutionally, interpersonally, and internally.

Multiple levels of homophobia
At the societal level, homophobia (often called heteronormativity in this context), is the shared set of beliefs and assumptions about who ought to be porking whom. But more than that, it is a nexus of assumptions about what family structure and kinship should look like, about what gendered identities are possible and how they should be expressed. That's one reason why the debate over same sex marriage has been so contentious within the gay community - one the one hand it is about equality of opportunity, on the other, marriage is practically the very definition of heteronormative values.

Institutionally, homophobia can be expressed in official policy, or less official actions that intentionally treat sexual minorities differently than heterosexuals, or that result indirectly in the same effect.

Interpersonal homophobia is probably what most people think of when they hear "homophobia" - it's the disparaging words, the punch in the nose (then the gut, the groin, the kick when you're already on the ground, need I go on?). Interpersonal homophobia is the expression of prejudice from one person directed at another.

Internalized homophobia can mean a couple different things depending on who you're asking. Usually it refers to a form of self-loathing among gay men, lesbians, and bisexuals, the internal application of societal views on homosexuality on oneself. Sometimes people talk about internalized homophobia in anyone, including heterosexuals, as the result of internalizing the societal homophobia as being what one believes about homosexual and bisexual people.

So all these levels are in constant interaction with each other as well. A person is unlikely to let off a string of interpersonally homophobic slurs unless they have internalized societal views about homosexuality. They are unlikely to internalize these assumptions unless there is a shared ethos of homophobia in which that person lives, or grew up, and so on.

And all these can be in conflict with one another. For instance, one may live in a relatively non-homophobic society (like Rhode Island) with relatively few institutional policies that hinder people with same sex desire, but be in a more homophobic institution within this (such as a Catholic school), which nonetheless has a strong tradition of supporting individuals within the institution, and exposing them to very little interpersonal homophobia, so long as they maintain an internalized sense that their homosexuality is wrong.

So what's wrong with measuring internalized homophobia?
Based on the above, I obviously think that internalized homophobia is an important part of how homophobia/heteronormativity affect people. If nobody internalized homophobic assumptions, then it could not survive at a societal level either.
So why not measure it?

The article I read said that measures of internalized homophobia had very little predictive value for why some gay men get HIV and others don't. Not only that, but what predictive capacity it once had is rapidly diminishing. So, their argument was that it doesn't predict much, so measuring internalized homophobia may be a bit of a futile exercise.

But that wasn't entirely satisfying to me as a reason to avoid measuring it. So what if internalized homophobia has relatively little impact on HIV transmission - maybe it still plays a big role in some other health issue, like depression.

No, what I've decided bugs me about measuring internalized homophobia is the "internalized" part. I mean, describing "internalized homophobia" as a major health risk may in some sense be an important mechanism, but what sort of intervention does it lead to? How does one use that information to try to prevent disease, or better yet, promote health?

By describing "internalized homophobia" as a major health threat to sexual minority populations, the implication is that there are some of us who are in trouble (those of us who have internalized societal degradation as just), and others of us who are fine (we've coughed up the furball of societal hatred). Then what? Either the people who have internalized societal homophobia need some sort of intervention (which is paternalizing if that person is not actively seeking help), or they have some how brought these problems on themselves, failed to do what they need to do to take care of themselves.

The problem, as I see it, is that a focus on "internalized homophobia" focuses the potential for interventions internally, and doesn't take into account the full spectrum of the levels at which homophobia operates. Focusing on identifying and intervening with individuals who have internalized homophobia in no way explicitly challenges the broader social context within which these internalization processes occur.

-------------------------

Michael E. Newcomb, Brian Mustanski. (2009). Moderators of the relationship between internalized homophobia and risky sexual behavior in men who have sex with men: a meta-analysis. Archives of Sexual Behavior Epub aread of print 04 Nov 2009.

Michael W. Ross, B. R. Simon Rosser, Derek Smolenski. (2010). The importance of measuring internalized homophobia/homonegativity. Archives of Sexual Behavior Epub ahead of print 12 May 2010.

Transit ads to make your eyes sing.

2010-06-09T19:14:00.000-07:00

Like it or not, advertising is a big part of our visual environment.

San Francisco is a city that advertisers love to target. We are trendsetters, I suppose, so the ads often get quite aggressive in order to capture our jaded attentions.
I've seen pillars mounted with palm fronds (selling what, I can't remember), lavish inside views of the first class cabins of some upstart airline, all kinds of eye-catching stuff. And I have to admit, as much as I resent having my attention grabbed for profit, a lot of it is fun and playful.

But that's downtown. Up at Castro, your eyes are much more likely to be met by the sad empty face of a meth addict warning you not to follow in his footsteps.

The Castro is an international destination for gay men, and yet our visual environment is a long series of sad, unhappy, preachy, demeaning advertisements designed to remind us of how precarious our lives are, how we are one short step from misery and pain.
Well, at least until you emerge onto the street level, and your eyes are met with a series of bulges and slick colors designed to turn your money into alcohol.

So, when I came across these ads this morning on my way to work, I was happily surprised. I've seen these same ads on the BART, but in this context, they are obviously designed to appeal to a gay (male) audience, first by their location, and particularly because of the color scheme, the lollipop bright red-orange-yellow-green-blue-violet rainbow flag of smiling children, with a heavy dose of bubblegum pink tying it all together. These ads aren't cheap, the production values are high, and they spent a good bit of effort custom sizing everything for this particular space.

So I find myself wondering two really different things:
First, with the evangelical Right itching for a fight over adoption, why did adoptionSF.org decide to take the risk of catering to gay potential adoptive parents in such a blatant manner?

But the thing that's really got my head spinning is this. These ads are so different from any health-oriented ads I've seen in San Francisco. The first obvious difference is that they are up-beat. The second thing is that they are asserting quite forcefully that we have talents and capacities that are desperately needed.

Now, I don't know exactly what an ad campaign about gay men's health that was up-beat and urged us to exercise our talents and capacities would look like. But I'm hungry to see it.

The Census, Partiotism & Selfishness

2010-04-02T16:29:00.000-07:00

I remember filling out the 1980 Census.
I begged my dad to fill it out. I was excited to participate in this civic duty.
I guess I was a data nerd all the way back in Junior High.

As a nine year old on Independence Day in 1976, I was bursting with pride to the point of tears while riding my bike tricked out with blue and red streamers in our (no longer) small New Hampshire town.
The President made a compelling case for conserving energy, and I was eager to do my part for the country, shutting off un-needed lights, helping dad weatherize the house.

In short, I was fervently proud to be an American, and when the country asked for my help, I was only too eager to give to the common good.

Then the 1980's heralded in an age of selfish, individualist, suspicious governance that no longer asked for my help. Patriotism was recast as being against communists rather than for each other in this great nation.

I didn't get to fill out the 1990 Census, because I was off at college.

But when the 2000 Census came across my threshold in March, I was again eager to fill it out as a head of household for the first time. It was just the right thing to do.

The 2010 Census finds me under someone else's roof again, but we worked to together to make sure everyone was fairly represented.

Census and Distrust
It seems like this year, the Census has been politicized to a much greater degree than in the past. Rather than a simple civic duty, not filling out the Census has become a way to express distrust of government.
Certainly there are valid reasons to be distrustful of government, such as failing to protect the civil rights of minority populations, failing to ensure the provision of a basic level of social services to all our citizens, failing to protect us from pollution in our air, water, soil, and food, or failing to explore all reasonable options before engaging military solutions to political problems.

But the selfish rejection of government because you don't feel like paying taxes or whatever baffles me. It's so toxic to true Patriotism, which to me is all about pulling together in times of hardship, and helping each other out in times of plenty.

The Bus Ad
There's a bus ad circling the streets of San Francisco (and other metro areas as well) that says: "If we don't know how many PEOPLE we have, how do we know how many BUSES we need?"
This struck me as odd the first time I saw it. Anyone in San Francisco knows that the right answer to "How many buses do we need?" is "More". But bus lines are getting cut back instead while fares are jumping through the roof. There's no connection.

My gripe about the bus ad is not just that it offers a false promise (that buses will be provided in direct proportion to need), but more importantly, that it suggests that the best reason to fill out the Census is for selfish reasons - to make sure that you and your community get their share of buses, schools, hospitals, etc.

But isn't the best reason to fill out the census form that it's our civic duty? It's one of the most direct connections we as citizens have to our venerable Constitution. And the framers thought it so important that it's in the second section.
Article 1, Section 2:
The actual Enumeration shall be made within three Years after the first Meeting of the Congress of the United States, and within every subsequent Term of ten Years, in such Manner as they shall by Law direct.

What's wrong with appealing to our sense of civic pride, of patriotism, of doing our part?

New Word Game

2010-02-28T19:21:00.000-08:00

Rule #1. Put all 21 letters into a crossword-type format.
Rule #2. Take a snapshot of your result and send it to me, or type your result into the comment section, using underscores "_" to space the letters out.

Winning categories:
#1. Smallest perimeter (the shortest length of string that could be used to encircle the resulting crossword)
#2. Longest word
#3. Longest shortest word (i.e. if you use any 2 letter word, you lose, on the other hand, if all your words are at least 5 letters long, you're doing well).
#4. Shortest longest word (i.e. if your longest word is seven letters, eh, not so great. If your resulting puzzle shape is a diagonal series of two letter words, you're amazing. And you have too much time on your hands.)
#5. Least safe for work
#6. A five year old could read it (Simplest words possible)
#7. Most thematically related (all the words are fruits, colors, 'things you'd find in a wallet', verbs connoting motion, etc.)
#8. Make up your own category!

Use real English words. I will use Merriam-Webster's Original Scrabble Players Dictionary, 4th edition to verify. Honestly, it is a pretty far stretch on "real" English. I mean 'PTUI'? Really? That's a word? On the plus side, it has both British & American spellings.
Exception: this dictionary does not contain a lot of the juicy words for the LSFW winner (#5). I'm assuming it will be fairly easy to identify those unambiguously.

Here they are again, all upright and in alphabetical order.

Any suggestions for a better format for the digital/analog give and take for this game would be greatly appreciated. I'm hoping to turn this into a series.

And a big shout out to Aunt Sue for suggesting it!

HeLa reparations

2010-02-13T10:09:00.000-08:00

Henrietta Lacks made an incredible contribution to biomedical science, HeLa cells.
Her cervical cancer cells have a very unusual property: they can grow in the lab indefinitely. Because of this property, they have been produced by the ton for various lab experiments.

The ethically squeamish issue comes in that Henrietta was not asked for her contribution when she was treated for cervical cancer in 1951, and neither she nor her family was told about it until much later.

I used to work in a lab doing basic immunology. I never touched the "wet" stuff, so I don't really know, but as far as I can remember, our lab didn't use HeLa cells, at least while I was there. But, the knowledge base that we worked off of was certainly informed by work done on Henrietta Lacks's cells.

I owe some of my livelihood to Henrietta and the Lacks family. So I made a modest donation to the Henrietta Lacks Foundation. I made it on the basis of an appeal by the author of a book about Henrietta Lacks, her cells, her family, and the Johns Hopkins physicians who interacted with her and her family over the years. The author claimed that the donations would go towards providing educational opportunities and medical care for Henrietta Lacks descendents. But the incorporation papers suggest a much broader reach.

Seeing Healthy Gay Men

2010-02-07T16:42:00.000-08:00

I've been invited to take part in a panel discussion on Wednesday. Here's a preview of my talk. I'd love feedback on the flow, grammar, anything to make it roll off the tongue easier. I don't have a lot of time to deliver the talk, and I want to get some key ideas out there clearly.

SEEING HEALTHY GAY MEN
Introduce yourself to the person next to you, just your name. Hold their hand, and look right into their eyes, take a good deep look. Think about how healthy this person is. Through all of life's adversities, here is this healthy person in front of you.

What I've just asked you to do is very different from how I, as a public health researcher, look at gay men. To put it bluntly, in public health, we don't see healthy gay men.

First of all, we are not accustomed to look at health in anyone, queer or bland. We almost always look at sickness and death, and very rarely at health. Sickness is easier to measure than health. Sickness is seen as objective, while 'health' and 'well-being' are subjective states. Death is the most objective health outcome, and thus the most trustworthy object of study. So it's nothing special about gay men. We're not used to seeing anyone as healthy.

But there other reasons that public health, broadly written, is not used to seeing healthy gay men.

One of these is that a little over a hundred years ago, the fields of medicine (and later psychology) tried to exercise authority over homosexuality, to claim it as their turf, a claim widely supported by homosexuals at the time. It was a humane alternative to being regarded as the embodiment of sin, or being treated like a criminal.
Old habits die hard, and it has been hard to let go of these 'humane' impulses, despite the official depathologization of homosexuality in 1975.

Another reason that public health has a hard time seeing healthy gay men is that we actually have a lot invested in gay men being ill. That may sound strange at first, but think about it - citing health disparities is how we raise awareness about the health challenges facing us. Playing up health disparities is how we get money for programs. It's often how we make claims that legal protections are needed, how we describe ourselves in media stories to gather support.
So seeing healthy gay men risks upsetting the apple cart, derailing the gravy train, if you will.
And then there's the right wing. Not only are we a threat when we're sick, but if we're not sick, then we don't need "special" protections. We just can't win with those guys.

The last reason that public health has a hard time seeing healthy gay men that I want to raise is the perceived 'failure' of HIV prevention. While it would make sense to look at the relatively small number of new infections these days compared to the early 1980's and claim a great deal of success in HIV prevention, there is a tendency in public health circles to treat each and every new infection as a failure.
After all, we know a lot more about the biology and psychology of how HIV is transmitted. Hundreds of millions, probably billions of dollars have been spent on research and prevention efforts in the US, so even a single new infection represents some sort of failure in our prevention efforts.
Often implicit in our conversations about the 'failure' that each new infection implies is some blame directed at the man who got infected, and perhaps towards the man who infected him. Were these guys high? Careless? Selfish? Immature? Maybe they were just looking for love in a harsh world. Maybe they were possessed by the worst affliction a gay man can have in the eyes of public health: being a bug-chaser. All of these explanations imply that the infection was enabled by an individual weakness. So we are used to seeing gay men as sick, or at least as perpetually 'at risk'. And any attempt to break free from a life constantly 'at risk' must be a little crazy.

There may be other reasons that we public health types have trouble seeing gay men, but these are some of the big ones: 1) public health has a hard time seeing anyone as healthy, 2) the historical disciplinary claim of medicine and psychology implies that there is something inherently pathological about homosexuality, even though an explicit claim of pathology would be rejected in most circles. 3) seeing healthy gay men undercuts our ability to raise awareness within the community, and funds for services from public and private granting agencies, and 4) how else does one explain 'failures' in HIV prevention?

EVIDENCE OF HEALTHY GAY MEN
And so, a little over a year ago, when I came across evidence that gay men might well be healthier that straight men, I was dubious.
I was looking at data from the 2003/2005 California Health Interview Survey, the idea I had was to systematically go through the CHIS, documenting the disparity of each health outcome for gay and bisexual men relative to straight men, and for lesbians and bisexual women relative to straight women.
The first one on the list was pretty boring, at least from an epidemiologic standpoint: "in general, would you say your health is excellent, very good, good, fair, or poor?" Although this is by far the most common question on health surveys, analytically, we usually treat it like a throw-away question, basically a way to build rapport with the person on the other end of the phone before getting in to the more personal and revealing questions.
I expected to see what others before me had seen, that gay and bisexual men were more likely to report "poor" overall health. And they were in this dataset, too. But more striking was that gay men were also more likely to report being in excellent health. And that difference was larger.

But like I said, I was skeptical. Maybe it was a statistical fluke. I did what any sensible epidemiologist would do. I ignored it and moved on.

But, it stuck in the back of my mind.
When the 2007 data came on-line a short while later, I took another look, and the same pattern held. So now, I began to wonder if there might be something to it, these healthy gay men, not less healthy than straight men as everything had led me to expect, not equally healthy as straight men, but actually more likely to be healthy.
So then I began to look at other datasets. In most datasets, but not all, gay men were more likely to report excellent health.
I was still dubious.
Perhaps gay men were more likely to be in excellent health because they were younger, more educated, affluent. In most studies, men who say they are gay tend to be younger, more educated, affluent, and these things also tend to produce better health. So now I needed to find a dataset that was large enough to break people down by age and socioeconomic position.
I found two very large datasets, the Current Population Survey, and the Behavioral Risk Factor Surveillance System.
In both of these datasets, gay men were more likely to be in excellent health than straight men in all age groups, and within all levels of educational attainment. The BRFSS dataset was so large that I could stratify by both age and educational attainment simultaneously. Same result.
So now I knew it wasn't a fluke, it wasn't just because men who say they are gay to a stranger on the phone are just demographically healthier. Gay men were actually more likely to report being in excellent health.

Once I'd convinced myself that gay men are more likely to be in excellent health, that it was a 'real' finding, the next question is "Why?".
With all the HIV, STD's, alcohol abuse, drugs, depression and anxiety, even suicide documented in the literature, it still baffles the public health mind.
I'm going to leave the question "Why?" open, and move on instead to a related question: "So What?".
If gay men are more likely to be in excellent health, what are the implications of that?
One implication is that in the face of the long, oft-repeated litany of health-related faults, some gay men have found a way to thrive, arguably with no assistance from us in public health.
Perhaps we can learn from these healthy gay men. But that requires being able to see healthy gay men, and then to talk with them, and ask the right questions.
The salutogenic (health-creating) processes that these men have undertaken could be a blueprint for the rest of us, a novel approach to addressing the troublesome health disparities that gay men face.

Another implication is that gay men may well be doing some things 'right' that heterosexuals could do well to emulate. Perhaps the ways that we gay men have learned to structure our lives, with strong friendship networks, provides space for us to excel. Perhaps our more nuanced approach to monogamy and relationship structures gives us permission to be truer to ourselves and the ones we love. Pure speculation on my part, but if more of us are in excellent health despite all the social forces arrayed against us, we've got to be doing something right, and maybe if we knew what that something was, it would help society at large.

{I haven't quite figured out how to wrap it up yet}

Healthy Gay Men

2010-02-01T19:59:00.000-08:00

Reflections on Proposition 8 Trial

2010-01-22T17:29:00.000-08:00

I've had the privilege of sitting in for part of the proposition 8 trial (Perry v. Schwarzenegger), yesterday and this morning.
The trial has been incredibly interesting, although I have to say, the parts I sat in on were kind of slow.

I'm not a big fan of similar-gender marriage as a goal. And I'm dubious about the chances that this trial will succeed. But I have to say, it is doing an amazing job of revealing what the debate over similar-gender marriage is really all about: the prejudice that Evangelicals (and various allies) have against queers.

I'm convinced that this wouldn't be a big issue item on "the gay agenda" if the Evangelicals hadn't shoved it on us. An excellent book Courting Justice describes how individual queers have for decades (at least back to 1963, if not before) have tried to get some sort of official recognition of similar-gender marriage rights in the courts. But the issue didn't take off for the wider queer population.

Even after the Hawai'i decision in 1993, it still didn't take off. Even in 1998, when Alaska and Hawai'i were the first states to vote to restrict marriage, the wider gay community wouldn't touch marriage. A few people wanted it, but many of us thought of it as a badge of heterosexuality, a cowardly dodge from realizing one's full queer potential. A very bizarre "right" to demand.

But by 2000 there were the beginnings of a shift, and by 2004, it was absolutely clear we were being attacked with this thing, and we'd better start defending ourselves. Tell someone loud enough that they can't do something, and you know what they'll want to do next.

immutability, identity/behavior/desire
At any rate, here we are, many not excited about similar-gender marriage, but pissed off by being attacked as pedophiles, unfit parents, mentally deranged, sinful, and the certain cause for the ruin of Western Civilization.
In today's grueling 5+ hour cross-examination, Prop 8 lawyer Nielson badgered anti-prop 8 witness Gregory Herek with hundreds of variations on the same theme, trying to get him to say that homosexuality is neither definable nor immutable.
It is fairly clear that what the pro-prop 8 side was trying to do today is to make two claims. First, that homosexuality can't be clearly and unambiguously defined in the same way for all contexts, so homosexuals shouldn't be considered for equal protection under the U.S. constitution.
Second, that people's sexual orientation can change over time, and if so, which "class" a person fits in is ambiguous, making it impossible to consider equal protection under the U.S. constitution.

This seems like a pretty risky strategy on their part, since the exact same logic would lead one to conclude that religious affiliation should not be a basis for seeking equal protection. After all, one of the central tenets of Evangelical Christianity is that one's religious affiliation can change, and even ought to change in order to become 'saved'. Furthermore, it is not possible to define religious affiliation in clear and un-ambiguous terms.
Nielson hammered away at the themes of "identity, behavior, and desire" or words to that effect, as being multiple dimensions along which one could define sexual orientation, for research purposes.
Identity: "What do you call yourself?"
Behavior: "What have you done?"
Desire: "What do you want?"
A nearly-perfect analogy could be applied to religious affiliation, and the first two dimensions are routinely differentiated by sociologists studying religious affiliation. So should religious affiliation not be considered for equal protection because some people might define themselves as "Catholic", but not attend services, while others would decline to identify any particular denomination while attending services regularly?

Also, another category traditionally considered for equal protection would also fall apart under this logic, namely marital status. One's marital status can change over time (by becoming married, or becoming widowed, separated or divorced). Should it not be protected as a result? In this case, it is a change that is clearly under conscious choice (one certainly hopes that marriage doesn't happen by accident, or for unknown reasons).

The plaintiffs lawyers, for reasons I don't understand, haven't yet gone for the jugular on these points. Why not freely admit that sexual orientation changes over time, and is devilishly difficult to define in unambiguos terms? That doesn't seem to have much to do with whether a "class" of people should be protected from discrimination. Then come right back at 'em. Instead, the plantiff's witnesses have mentioned, from time to time, that ethnicity and race aren't easy to define either, and what "class" one "belongs" in can change over time. True, but the analogies between religious affiliation and sexual orientation seem more apt to me, and have the added advantage of putting it right back on their plate.

why get hung up on choice?
Another issue that Nielson fought over with Dr. Herek was the degree to which people's changing sexual orientation is under conscious control. Knowing what I know now, I would choose to be gay. But back in high school, when I was struggling to figure it out, I would have done anything to "choose" heterosexuality. It would have been easy. It would have made my parents happy. Heck, I even tried to be heterosexual - on my second "date" the girl laughed out loud when I said I thought it was a date, saying "But Bill, you're gay!" Sigh, I miss Rachelanna.

But back to the issue at hand, I think it's perhaps too easy to say that Evangelicals often believe homosexuality is a choice (conscious or otherwise) because their understanding of the Bible is that it is a sin, and that much like stealing, one may choose to "do" or not "do" no matter how strong the urge.

But I wonder if there isn't another reason that's just as strong. By enacting and re-enacting, and re-enacting, and re-enacting stories about "coming to the Lord", Evangelicals narrate to themselves and each other a story of conscious choice about a fundamental aspect of their being. I've listened to enough religious right radio to know that spontaneous conversion isn't nearly as common as stories of spontaneous conversion, which are ubiquitous.
Perhaps the belief that homosexuality is chosen reflects these continuously repeated narratives about choosing to be saved. Perhaps insisting that homosexuality is chosen despite all available evidence is really another means to re-inforce their own narrative of choice in matters religious.

In the past, I've pondered the fact that gay men tend to reinforce innate-ness and lack of choice in their coming-out stories. Mirroring the process above, when we tell and re-tell our stories to one another, these characteristics of innate, unchosen immutability become more and more central to our sense of self and identity. I think that's a lot of how I became gay, anyway.
I was Bill, then I became gay Bill. I didn't become gay out of being straight, I became gay out of unformed nothing-ness because it was the social construct available to me that best fit who I was, innately. In another setting, I might well have become celibate, or str8, or something like it, depending on what was available to me in the way of social role narratives.
Now that my gay identity is fully formed, I no longer need to tell coming-out stories to reinforce my sense of who I am, and rarely do. Part of that is that everyone who needs to know already knows, but mostly it's because I don't need to tell that story any more to know who I am.

Hate crime statistics
Yesterday, one of the prop 8 lawyers tried to run an event in the Oppression Olympics by comparing the number of crimes reported as being bias-motivated around sexual orientation to the number reported as being bias-motivated against Judaism.
I was shocked when the witness seemed to fall for it. He ended up giving a fairly reasonable response, but the premise that these numbers would be in any way comparable I find ludicrous.
As I covered at length in a previous post, the numbers of reported bias-motivated crimes appear to indicate, if anything, an environment that is relatively less hostile to queers.
Perhaps a minor point, but I was surprised that the plantiffs' lawyers didn't seem to latch on to it.

History in the making
The most exciting thing about it, for me, was the feeling of being at the moment of "history in the making". This trial is big. In the league of the Scopes monkey trial, Bowers v. Hardwick, Lawrence v. Texas. It may not be Roe v. Wade or Brown v. Board of Education, but it's up there, a massive culmination of social forces distilled into one bundle (that this Supreme Court will likely fumble). It will be a major reference in the evolution of queer history, no matter the result.
When similar-gender marriages were first issued in Massachusetts, I went up to Boston and sat on the steps of City Hall, chatting with a handsome stranger. I was moved far more than I thought I would be.
When similar-gender marriages were re-legalized in California, I went to City Hall, and snapped hundreds of photos, mostly of a pair of handsome strangers getting hitched. I was moved to tears repeatedly that day.
I feel fortunate, to have been in the right place at the right time, to bear witness these momentous events.

Cool Word Trick

2010-01-17T12:01:00.000-08:00

Don't ask me how I know, because I don't know how, but copied work in a student's paper just jumps off the page. I usually detect it in under two seconds, and not because I'm looking for it, it just looks wrong immediately.

At first, when I was looking for the original source that a student copied from, I would guess what the most unique combination of words was, picking two or three multi-syllabic scientific-sounding words, and then do an internet search for them.
But I noticed a curious thing. In most cases, those unique words I was looking for often weren't particularly unique. But what did tend to be very unique was the "packaging" of banal words around them.

I've been shocked to find that, given about 5-6 words in sequence, it is almost always possible to find the one unique occurrence in the history of the English language that those particular words occurred in that particular order.

So now, I just type in the first 5-6 words of a sentence, no matter how banal and mundane the sentence structure sounds, and it almost always uniquely identifies the source. Neat trick, eh?
Try it at home. Grab a few words from anywhere nearby. Type them into your favorite web search. Watch the magic unfold.
See how many words you can get rid of, especially the words that sound most unique, and still have that one source pop up to the top of your list. (Hint: using quotes around the words to hold them in their original order makes it a lot easier.)

Somebody needs to write a paper about this phenomenon.

Obesity is NOT levelling off in the US

2010-01-14T08:54:00.000-08:00

If anything, we're getting fatter faster.

Over the past few days, I've been seeing and listening to reports in credible news sources, the New York Times and National Public Radio, repeating a claim by CDC researchers that the obesity epidemic in the U.S. is leveling off.

I was suspicious. I had heard essentially the same story two years ago and found that claim to be less than credible, so I decided to investigate more closely.

So here's the data as they present it - the red line that they want you to focus on represents the proportion of the adult population who are overweight, but not obese - you can see that in recent years it has turned down a bit. But the blue and green lines, which represent obese (but not extremely obese), and extremely obese have been increasing, with no sign of slowing down whatsoever.

I used exactly the same data, from the same table in their report to generate this graph.
You can see a little more clearly here (at least I think), that the proportion of people who are overweight, obese, or extremely obese has been increasing, not leveling off.

Taking a closer look at the last few years, the proportion of the population that was some degree of overweight in 1999-2000 was 69.5%. It increased 1.6% to 71.1% in 2001-2002, 0.3% to 71.4% in 2003-2004, and 2.1% to 73.5% in 2005-2006. So the latest two years of data show the largest increase in overweight in the U.S. population so far documented. (the steepness of the little lines between the bars on the graph tell the same story)

So how could the esteemed news agencies I mentioned at the top of the blog gotten the story completely wrong? Not only that, but they were able to find a plethora of obesity experts to proffer explanations and predictions based on the erroneous conclusion that the obesity epidemic in the U.S. is leveling off.

There were two fundamental misunderstandings, as far as I can excavate: first, almost everyone involved seems to have mis-understood the term "statistical significance", and second, there seems to have been a widespread (excuse the pun) misunderstanding of looking at changes in the middle of the weight distribution.

As to mis-understanding the term "statistical significance", here is the sentence from the original CDC report:
The NHANES 2005-2006 data for persons age 20 years and over suggest an increase, between the late 1980s and today, in obesity in the United States, with the estimated age-adjusted prevalence moving upward from a previous level of 23 percent in NHANES III (1988-94) to approximately 34 percent. The change between 2003-2004 and 2005-2006, however, was not statistically significant. {emphasis added}

This little phrase "not statistically significant" was mis-interpreted to mean "no change", that is, a leveling off, between the data collected in 2003/2004 and that collected in 2005/2006.
Interestingly enough, that exact same mis-interpretation was made when comparing the 2001/2002 data to the 2003/2004 data in this CDC report. Apparently, the last time they got it right was in comparing the 1988-1994 data to the 1999-2002 data, when they didn't invoke the problematic concept of statistical significance at all, in this CDC report.

But obesity rates didn't level off in their data - as I showed above - in fact it was the largest increase seen yet in this data set.

The other mis-interpretation seems to have arisen from how this report discussed being overweight as something distinct from being obese, and being obese as something distinct from being "extremely" obese. That is, when the broke up the overweight population into three sub-groups, the proportion of people who are "just" overweight has decreased in the last few years (the red line in the top graph)
Here's the offending sentence from the original report cited above:
Although the prevalence of obesity has more than doubled since 1980, the prevalence of overweight has remained stable over the same time period.

Which only makes sense if you completely ignore the fact that lots more people are becoming more than "just" overweight (i.e. obese), and many fewer people have been at a "normal" weight (the tan bars in my re-graphing). That is, they have pulled the middle of a rapidly shifting distribution out and claimed that it isn't changing, but that is misleading because the size of the weight distribution on either side of it is changing dramatically.

I'm afraid I may sound like some punctuation-correcting nag, nipping at the heels of our most esteemed news outlets for some petty transgression all the while making it sound like the English language is on the verge of collapse into a ruin of uninterpretable gibberish.

But this isn't a punctuation or spelling error. It's getting the story completely backwards.
And I don't really blame the NYT or NPR for screwing it up. They were, after all, following the lead of our most esteemed public health agency. They were able to find plenty of esteemed experts willing to line up and go on at length about the implications of this erroneous interpretation of the findings.

I trace it back to the deeply ingrained mis-training that scientists get about what the phrase "statistical significance" means. When the British eugenicists who were followers of Darwin coined the phrase "statistical significance" in the late 1800's, they intended it to mean (at least as far as I can interpret their meaning over 100 years later) something like "significant in a statistical sense only, and quite possibly not in any other sense". So to them the phrase "not statistically significant" wouldn't have had any particular meaning at all, perhaps a study that was "not statistically significant" wasn't looking at a big difference. Perhaps there was some sort of bias hiding a real difference. Perhaps there just wasn't enough of a sample size to reveal the real difference in a statistically striking manner.
At any rate, over the years and in order to simplify the concept of "statistical significance", it has been taught as "an unlikely probability of a finding arising from chance alone", and the phrase "not statistically significance" has increasing become mis-interpreted as meaning "no difference".

And that, my friends, is why you'll find that I seldom, if ever, use the phrase "statistical significance" - because in the end it doesn't really mean anything - it's only about the statistical interpretation of a dataset, which is only one small window for understanding and interpreting numbers.

After I Left AIDS - Part III (more thesis)

2009-12-17T20:12:00.000-08:00

I didn't want to study suicide.

Mainly because suicide is a bummer of a topic. It reminded me of unpleasant memories from adolescence. And whenever I talk about it, the first thing everyone does is get quiet - then they get concerned about my well-being. Which is nice and all, and I appreciate it, but after working on this stuff for a few years, I would forget the level of emotional charge the topic has, and get really excited about some finer point of data analysis, and come off sounding callous when really all I wanted to share was this exciting little piece of the puzzle.

On the other hand, epidemiologic studies of suicide go way back (to Durkheim in 1897, and before him Morselli in 1881), and unlike most health conditions associated with sexual orientation, suicide has been measured in a consistent way across the whole population for an extended period of time. So, in a sense I was stuck with it as the only health outcome that had both geographic and temporal scope, which is what I needed to look at normative heterosexuality.

So anyway, as I mentioned before, I wanted to look at how heteronormativity (a shared set of assumptions about sex, gender, and who ought to be having sex with whom) affected suicide rates.
At first, I wanted to find a data set where I could could compare gay men, lesbians, and bisexuals to heterosexuals. But the death certificates don't have that kind of information. And as I got to thinking about it, even if they did, how reliable could it be?
And that got me to thinking, maybe the sexual orientation of these people is really beside the point. Perhaps the stresses associated with dealing with assumptions of heterosexuality are greatest among people who don't identify as "gay" anyway.

So, the first study I did was to look at gay rights laws as a measure of heteronormativity, the idea being that in order to enact a gay rights law, politicians have to believe that public opinion is such that they'd be better off protecting sexual minorities from discrimination than not. The first gay rights laws were enacted in 1973, in San Diego and Austin, I believe. In 1981, Wisconsin was the first state to pass a gay rights law, and by 2003, most of the country's population lived in a jurisdiction with a gay rights law. (the gray map there has a nifty time-lapse).
I looked at three levels of gay rights protections, in order to get something like a dose-response curve - the red areas had no protections whatsoever, the green areas were protections for public sector workers only, and the blue areas had protections for both public sector and private sector workers.

And the results here are pretty compelling - at least for White males, particularly adolescents, young men, and the elderly.
Each color in this graph represents a different age group. So, among White males aged 15-19, suicide rates were 179 per million in areas with no gay rights protections, 155 in areas with protections limited to the public sector, and 131 in areas with protections for all workplaces. The only group without a step-wise dose-response was White men aged 45-64.

Among White women, the first thing to notice is that suicide is less frequent, and also doesn't increase among elderly white women, unlike men. The decline in suicide rates with increasing levels of gay rights protections is also not so pronounced, but there are declines in each of the age groups under 45.

Suicide is less common among Black men than White men in the US, but is still pretty high. And unlike White men, the peak incidence of suicide is in younger age groups. But what is strikingly different is that the highest suicide incidence among Black males is in areas with the highest levels of gay rights protections, which suggests to that public opinion among Black populations about homosexuality may not be strictly related to public opinion among White populations from the same area, and presumably the enactment of gay rights protections is, in most jurisdictions, reflective mostly of White public opinion. I'd love to do an analysis based on what might be a better measure of heteronormative assumptions in Black communities. Any ideas?

Among Black females, the incidence of suicide is lower than the other populations above, and like White females, declines among older women.
The differences between areas with and without gay rights protections are not large, but in general, suicide rates among Black women tend to be slightly higher in areas with gay rights protections. So these results also raise questions about whether gay rights laws are a good measure of heteronormativity for all populations. Or alternately, if the social forces leading to suicide are perhaps not identical among White and Black populations - perhaps heteronormative assumptions cause more distress in White populations, particularly among White males, while economic issues and racial discrimination play a larger role in Black populations.

Another consideration is that perhaps the stresses induced by heteronormativity are largely related to the performance of masculinity, which is why men turn violent against themselves under these pressures. Perhaps men under heteronormative pressures also direct violence outwards towards the women closest to them, and thus homicide, rather than suicide, might be a more strongly related outcome among women. That's foreshadowing to an analysis I'm thinking about doing next...

The patterns I noted are virtually unchanged after adjusting for a wide variety of potential confounders, namely population density, region of the country, unemployment rate, poverty rate, and measures of social isolation (proportion living alone, proportion who moved in the last five years).
Also, when I looked only at those areas that changed status (went from no protections to having gay rights protections), the same trends held up, so in order to explain these results, some other factor would have to be changing at the same times in the same places, which seems like too much of a coincidence to be possible.

The trends above are very similar when I looked at how people vote on the restriction of marriage to "one man and one woman" as a measure of heteronormativity, but as I mentioned before, the strong trend towards people being less likely to endorse a restrictive definition of marriage makes this measure a bit more complicated, so I'm trying to figure out how best to represent it.

After I Left AIDS - Part II (Thesis)

2009-12-13T11:59:00.000-08:00

So, after I left AIDS, I got thinking about how homophobia, as a societal norm, affects health. Not just queers' health, but how it also affects the health of the whole population.

In my last post, I talked a bit about my journey through thinking about health disparities, and how nobody seemed to be measuring the causes of these disparities. That leads directly to my doctoral thesis, which was about how to measure normative heterosexuality, and from there, estimating the impact of it on suicide. Not just on "gay" suicide, but suicide in the whole population, and also in various sub-populations defined by sex, age, and race/ethnicity.

So, following the lead of thinking about residential segregation by race/ethnicity, and income inequities, I began thinking about how to measure normative heterosexuality, the presumed cause of the health disparites that epidemiologists had begun to document with greater and greater precision.
How do you measure the degree to which a group of people (a large group of people) share a rigid set of beliefs about sex, gender, who ought to be having sex with whom, and how? My first thought was that the frequency of hate crimes directed against gay men would be a good measure. If this set of rigid beliefs dominated a social setting, then the informal "enforcement" of those beliefs would be enacted through the commission of bias-motivated crimes, presumably mostly by young men with "something to prove".

When I pulled the data down off the FBI's Uniform Crime Reporting (UCR) System, I quickly realized something was amiss. San Francisco had by far the highest number of anti-gay hate crimes in the country, and several Southern and Mountian states reported not a single one.

I've put more recent statistics by state in a table, based on numbers from 2004 to 2008, the five most recently reported. Basically the same trend holds - bias-motivated crime tends to be higher in places we think of as gay-friendly, and extremely low in the deep South. Then there are also strange jurisdictional oddities - Pennsylvania for example appears to have an extraordinarily low rate of bias-motivated violent crime.

The way I've come to understand this data is that it represents not the phenomenon of crime occurring, but rather on two phenomena: 1) how comfortable victims feel about reporting a bias-motivation to law enforcement, and 2) local law enforcement customs and legal constraints about recording and validating these reports. If it was just the first of these, then one could use the reporting of hate crime as a measure of homophobia at a societal level, that is the more hate crime reported in an area is evidence of how little homophobia there is there, as perverse as that sounds. But alas that second factor, particularly the bit about jurisdictional quirks in how different local law enforcement agencies deal with the reports that are made to them, really throws the whole thing off.

So, I couldn't use hate crime statistics. But maybe I could use the presence or absence of a law for reporting hate crime statistics that specifically included sexual orientation. Or, how about the presence or absence of a law prohibiting discrimination on the basis of sexual orientation?

So, the next thing I looked at was which states had gay rights laws, and when they were enacted. Various of the states have enacted gay rights laws over the years, the first being Wisconsin in 1981, a few more in the late 1980's, and a lot during the 1990's. Recently, state-by-state gains have slowed considerably, as gay activists have pressed for a national law (ENDA), or been distracted by the marriage thingy.
The point for my purposes is that the enactment of state-wide gay rights laws has been a pretty hotly-contested issue, debated for years within each state's legislature, rather than by a small cadre of legalistic judges, or the flash of public opinion of a referendum. As a result, the enactment of a gay rights law represents something of a local watershed, the point in time at which the balance of adverse consequences for elected officials switches from a net negative to a net positive.
So, looking at the enactment of gay rights laws seemed to hold promise, at least from a theoretical perspective, as a good measure of the broad social environment of a State in regards to the level of normative heterosexuality.

Another potential measure of normative heterosexuality to be considered is public opinion polling. The gay rights law thing seems a bit crude - a yes-or-no variable to measure something which I claimed varied by degree from one place to another, and one time to another within those places. Public opinion polling, on the other hand, offered the promise of a finely-tuned measure of normative heterosexuality. There are some relevant questions that have been asked the same way for decades. For instance, Paul Brewer has examined the time trends in how Americans feel about the "wrong"-ness of same-sex sex, which increased during the AIDS years, followed by a precipitous drop recently, the majority of Americans now saying it is not "always wrong" (small consolation that!).
So, public opinion polling looks like it might be a better "thermometer" to gauge how people feel about homosexuality. And there is longitudinal data to work with, so I could look at changes over time.
On the other hand, public opinion polls, by design, ask the smallest number of people possible in order to get accurate results. Thus a "large" national poll might have only 500 respondents. The GSS from which the data above is generated is a good bit larger than that, but still it is only a few thousand in any given year. A few thousand sounds like a lot of people, but what I needed to do was compare across places, not just time. So a few thousand breaks down into a few dozen in some states, and in others, fewer than ten. It would be a stretch to characterize the whole State of Connecticut based on how 15 randomly chosen people answered a question (for the record, I'm pulling that number out of thin air, but that's about what it comes down to).

So I was stuck with public opinion polling, too. Good temporal trends, but lousy in terms of geographic specificity.

A related idea was to look at how people voted on anti-gay referenda, such as the Briggs Initiative in California in 1978, Measure 8 in Oregon in 1988, and Colorado's Amendment 2 in 1992. These explicitly anti-gay referenda had the advantage of high geographic specificity, presumably accurate down to the precinct level, but represented a snap-shot in time. Also, they represented a small number of states, and the questions addressed in each one were quite different.

While I was working on my thesis, though, another opportunity to think about voter referenda came up. The issue of same-sex marriage cropped up. Although same-sex marriage has been contested in U.S. courts since 1970, it had never gotten much notice one way or the other - the Christian right didn't feel threatened by it, and most gay acitivists thought marriage was a non-starter politically, or at any rate a horrid reminder of heterosexuality run amok that should not be emulated.
But in 1998, Hawaii and Alaska voters chimed in on same-sex marriage, a few more did in the 2000 and 2002 elections, and then the 2004 election was swamped with voter initiatives to restrict marriage, in part a cynical manipulation by Republic Party operatives in order to keep their guy at the helm.

These referenda share the problem that opinion polling data have, in that they are a snap-shot in time (except for a few states which have had multiple referenda on this issue), but there were major advantages. For one thing, the question being asked was nearly identical in every state, some slight variation on whether legal recognition of marriage should be restricted to "one man and one woman". As an aside, no state has yet offered to restrict marriage to "one woman and one man" - something to consider when thinking about marriage as a forum for liberty and equity. And, the geographic scope was huge, with most states chiming in on the issue one way or another. The map I made here shows how different areas voted, from strongly in favor of restricting marriage (red) to being against restricting marriage (dark green).
On the whole, this map comports more or less with what one would expect, there's more red in the rural areas, more green in urban centers and on the Pacific coast, and there seems to be a trend towards more green in the Northeast. But there are some unexpected spots, too, such as South Dakota, which was substantially less in favor of restricting marriage than its neighbors Nebraska and North Dakota, And Arizona, which was the first state to reject restricting marriage in 2006 (alas, they went to the dark side in 2008).
So, there are some tricky issues to deal with in using this data. I haven't quite figured out how to make it comparable across time periods.

The final method I've thought of for measuring normative heterosexuality is using counts of same sex couples. The number of same sex couples was counted (albeit inadvertently) by the U.S. Census in 1990. For the 2000 Census, they did a better job of it, and the upcoming 2010 Census is expected to do better yet.
In any event, the number of people who identify themselves as married same-sex partners and un-married same-sex partners in the Census is probably mostly a factor of three forces: 1) How comfortable people in same-sex couples feel identifying themselves as such on the Census forms; 2) The degree of selective in-migration and out-migration of people in same-sex couples (or destined to join one), and 3) The degree of confusion by people in mixed-sex couples who inadvertently identify themselves as same sex partners.
The first two of these factors (net migration and comfort identifing as a same-sex couple) are related to what I want to measure - how accepting an area is of homosexuality. The third factor is a pain in the butt, not in a good way. I've discussed that issue at length before.

So, counting same-sex couples has two huge advantages: it uses the same methodology for the entire United States, and you can get comparable data down the the neighborhood level (census tracts). On the other hand, the data itself has some big caveats - it doesn't identify young people, single people, or couples living in separate residences, and it is essentially useless when considering older people (for reason 3 above). And although there will soon be three time points to compare, the methodology has changed in each Census, and it remains to be seen if the 2010 Census data will be comparable to the 2000 Census data (probably not, but for the reason that the methods are becoming more accurate).

So, in the end, I decided to pursue three measures of normative heterosexuality further:
1) The enactment of gay rights laws,
2) How people voted on referenda to restrict marriage to one man and one woman, and
3) The proportion of same-sex couples identified in the Census.

More to come...

After I Left AIDS - Part I

2009-12-09T08:14:00.000-08:00

About a month ago, I wrote about Why I Left AIDS, but didn't get around to what I'd moved into.

While I was working in gerontology, and started taking classes again in public health, I was trying to figure out what I wanted to do research on. I knew it wasn't HIV/AIDS, and most of the other health outcomes related to gay men (suicidality, depression, substance abuse) were kind of downers. The depression bit hit close to home, and the substance abuse felt completely foreign to me, so I didn't really know where to go.
At the time, in gerontology, I was working on a variety of measures of regional variation in social conditions to try to explain health disparities. We had noticed a big difference in the occurrence of pressure ulcers (bed sores) by racial identity. While it was interesting for me to crunch large datasets, and to work with colleagues to figure out a narrative that might explain the health disparity, documenting the disparity and theorizing about why it occurred seemed unsatisfying. I wanted to measure the cause, not just the effect.
I had also been a teaching assistant for the epidemiology class at Brown for many years at that point, and we always chose an article about the link between residential segregation along racial lines and some health outcome or another, usually birth weight or premature delivery. The idea was that racial segregation, the separation of people in space, reflected social segregation, or the history and current strength of racial hierarchical ideology.
So it was a natural connection to say, hey let's look at whether the health disparity in bed sores is larger in cities characterized by high levels of racial segregation than it is in cities where people are more evenly distributed.
Unfortunately, we never got around to writing that paper (I don't think we even got to the analysis stage before I moved on), but the point is, I spent long hours figuring out how to measure, in a quantitative sense, the racial segregation of where people live, and also the levels of economic disparity (gap between the rich and poor), and how these measures vary across the U.S.
Roughly at the same time, I began to think that I wasn't so interested in documenting the extent of health disparity there was between gay men and straight men, lesbians and straight women (and there was almost no literature on bisexuals, and even less on gender identity), I was interested in measuring what causes the health disparities that do exist.
At first, I tried to think about measuring homophobia in high schools. In my own life, high school was definitely the most homophobic environment I had survived, after all.
I figured that one way to do it was to ask a wide range of students who had graduated and gone on to college to rate their high school environment with regards to homophobia. Having gone to college, they would have at least one other environment to compare to, some perspective. And by asking them about the school environment, rather than their personal experience, then queer kids and straight kids would both have valuable and relevant insights and perceptions on the issue.
I developed a 20-some odd page questionnaire and tested it on maybe 40 or so Brown undergrads, queer, straight, and in-between. At that point, it was an exercise for a survey design class I was taking, so I wasn't particularly interested in scientifically important questions like inter-rater reliability, I had a much more mundane purpose - did recent high school graduates feel like these questions made sense? Were they salient? Were they getting at what I intended them to get at? and was I missing anything?
It was a great experience (for me, anyway). And the questions did make sense (most of them), they were on target (most of them), and there were a few things I had missed. I was convinced that it was worth taking it to the next stage.
I began thinking about how to use it. It was one thing if one could describe the social environment, it was another to use it to predict health or health behaviors. In conversation with a student (Marc), we had an idea - which was to measure the homophobia at a series of high schools where more than one student had died of self-inflicted injuries to high schools where no student had died of self-inflicted injuries in many years, and to measure the extent to which the school social environment was infused with homophobia in both sets of schools.
And here's an important point - whether the students were queer, straight, or in-between was not relevant to our plan. It wasn't going to be a study about who had killed themselves, but about what sort of environment drives people to the point of ending their lives.

So maybe you're seeing a thread here already - the vast majority of research literature on queer health is about documenting the bad things that queers (and usually gay men specifically) are at higher risk for. But I wanted to take a different tack - I wasn't so concerned with what the specific health outcomes were, but the cause of them, and specifically, the cause in the sense of the social environment.
And this opened up a new possibility - examining the influence of the perfusion of homophobia in social environments not just on queer people, but on the whole population, on straight people too.
My involvement with ActUp/RI was highly influential in getting me to think about homophobia as a health hazard, but in that context, I thought about it as the reason the government was letting gay men die without saying a word, literally. Or when words were spoken, they would be words of condemnation, threats of quarantine, of judicial prosecution for having an infections disease, of punishment for exposing the "general population" to a scourge that we deserved but they did not.
Instead, I was now thinking about homophobia as a threat to the whole population.

More to come...

Breast Cancer Screening Controversy

2009-12-07T07:38:00.000-08:00

I'm going to be teaching two sections of epidemiology this Spring, one for grad students, one for undergrads.
The grad student version I'm pretty confident about, but I want to change a few things, especially the cumulative paper that I ask the students to write throughout the semester.
The other thing I'm thinking about is pulling in the breast cancer screening controversy, which seems to have long legs, re-appearing in the news on a regular basis. I had been thinking about H1N1, but to be perfectly honest, it hasn't been able to attract my attention (not the way the 1918 war-fueled epidemic did anyway).
For the undergrads, I'm trying out a new textbook (new to me, anyway), which has more pictures. I haven't been able to find a good textbook for undergrad epi, and the worst are the ones that say that that is their target audience.

Anyway, back to breast cancer screening. I think it's a great issue to tussle with. It has a lot of emotionally laden content in addition to "the science". The science itself is complex and fascinating, and really engages all forms of epidemiologic study designs, from case-control studies to massive experimental trials, and concerns epidemiologists have about sources of error and misleading results.

Also, one of the pioneering epidemiologic researchers was Janet Lane-Claypon, who did a case-control study comparing 500 women with breast cancer to 500 women without breast cancer, and confirmed most of the risk factors that we now know have a large influence on the development of breast cancer, in 1926. I like having a historical focus in my class, and it bugs me that that means reading exclusively male writers in a class that's predominantly made up of women.
I'd also like to include more of the large corpus of early writing from Spanish language authors, but I'm not familiar enough with it, and the few pieces I have seen translated just wouldn't fit well into my curriculum. (Perhaps it's time to expand my curriculum, then!)

But back to screening. I myself didn't think much about breast cancer screening, until my mom got a positive mammogram. It pretty well freaked her, and me, out. Weeks of anxious anticipation were not erased after minor surgery removed what turned out to be perfectly benign calcified lumps. But still, what if it had been cancer, wouldn't it have been good to know earlier rather than later?
The more I've thought and read about it, the more I've come around to a different point of view - it probably wouldn't have been better to know about it earlier. I know that sounds harsh to anyone with breast cancer, and easy for me, given that it wasn't breast cancer. But I don't say it glibly. The unnecessary anxiety, the unnecessary (if minor) surgery, these are not benign side effects. They may be mild inconveniences compared to mastectomy, chemo and/or radiation. But really how many unnecessary side effects are we generating with screening mammograms compared to how many treatable breast cancers that get detected (and wouldn't be equally treatable after they grew a bit and became diagnosed by other means)? How many breast cancers are detected and treated with highly toxic and invasive methods that, left alone, would never have caused a problem? Those are complicated questions that are technically challenging to answer.
Then, there's also an issue of where we, as a society, spend money. I don't think that costs should be a determinant of what health care people get. In a previous post, I lampooned the idea of doing a cost-benefit analysis of vaccination against HPV. The more effective a vaccine campaign is, the less cost-effective it would be, so it's just silly to do a cost-benefit analysis in the first place.
But at the same time, one wonders if all the attention paid to promoting mammograms as the one thing you can do to prevent breast cancer has crowded out other means of preventing breast cancer. Methods that may be less sexy, and less under an individual's control. Why does preventing breast cancer have to be something each woman does for herself? What about pesticides and environmental pollutants that probably have a very small influence on any one woman's risk of getting breast cancer, but by increasing all women's risks somewhat, have a large societal impact? What about the disparities in the levels of these pollutants that often mimic disparities in class and race in this country? What about addressing the structural poverty and disenfranchisement that keeps women from having symptomatic breast cancers dealt with early on when it's more treatable? These methods at least give men something to do!

Why I Left AIDS

2009-11-10T20:30:00.000-08:00

I left AIDS in the mid-late 1990's.

I made a conscious decision to stop working on HIV/AIDS, and to stop referring to HIV/AIDS when talking about gay health.

In short, I was over AIDS.

I wanted to force myself into a new idiom, a new way of thinking. I had no idea what it would be, but I had come to the conclusion that continuing to work on HIV/AIDS would be detrimental to me personally, and might well not be helping anyone else either.

I wish I could say that I had some inspired moment, that I had some vision of the future of queer health, some goal in mind, some grand theory. But in truth I had none of those things. Gradually, I began to realize that working on HIV/AIDS felt increasingly distant from my personal experience I noticed that it was harder and harder to interest my friends to get active, it was even hard to know what to get active about.

But maybe I should start a little earlier.

I was a little fagling in 1987, a momentous year in queer history. In 1986, my freshman year of college it began to dawn on me that it was not a passing œdipal phase, that my attraction to other guys was not merely admiration of their physical form, to be replaced at some point in the future with an attraction to the voluptuous female form, marriage and children.
This was distressing to me, because my only image of an adult gay man was not what I wanted to become. Don't get me wrong, I didn't want to be "normal", I just didn't want to be lonely, depressed, and ridiculed for the rest of my life.
I quit the crew team, partly because I was not going to be competitive at the level required, but mostly because I just didn't see any possibility of being happy, healthy, and vibrant as a gay man.

I slowly began meeting other gay men, particularly Chris Bartlett and Stephen Gendin. Then in October 1987, Chris invited me to vanpool down to DC for a March on Washington. It totally blew my mind. For the first time in my life I saw happy, healthy, vibrant gay men. I kissed one of them, for about six hours, while driving around from one spectacularly lit patriot monument to another.

I came back to Providence transformed. I realized that I could do this gay thing after all.
My then (and current) roommate calls it my militant phase. I painted pink triangles on the back of my hands. I gave out "queer fries" at the snack bar to anyone who would publicly say they were gay or lesbian. I proselytized to anyone and everyone.

In early 1988, Stephen invited me to "come get arrested". I said "sure" and then it took me a week to ask "what for?" He told me it was about gay rights, and only during the civil disobedience training did I learn that it was really about AIDS, about trying to keep the Health Department from doing widespread mandatory HIV testing, and compiling a list of everyone who tested positive for some as yet to be determined intervention. I kinda freaked out. I had begun to come to terms with the gay thing, but I was scared to death of AIDS and didn't want anything to do with it.

But Stephen was inspirational, and I stuck with it, becoming one of six people arrested in H. Denman Scott's office on the fourth floor of the Health Department. I'm the one in the purple shirt with a green knapsack.

Thus began a long and industrious career with ActUp/RI.

We never needed to get arrested again, it just doesn't take much of a fuss to get on TV in Rhode Island. We disrupted Ed DiPrete's gubernatioral candidacy announcement, we protested the high price of AZT, we joined in national actions at CDC and FDA. I started writing a weekly summary called Bill's News Headlines, a 'zine about all things HIV/AIDS, with a few spicy pictures thrown in for interest.

Under the Reagan Administration, AIDS was largely ignored, until it wasn't. In the late 1980's all kinds of scary talk was coming down, including threats of quarantine. We had a clear and obvious enemy. Those of us young enough and pissed off enough rose up in anger and began a confrontational style of political action that the generation before us was too overwhelmed to undertake.
But when George the first took office, things began to lose traction. Many of our initial demands were being met (AIDS drugs cost less, mandatory testing and quarantine were mostly averted, some government resources began to flow into aid programs, some of the egregious ethical violations inherent to clinical trials of new medications were being abated). The newer issues we were grappling with (needle exchange, anonymous HIV testing) just weren't as sexy. We had a few more big demos (notably a big coalition bash at the Providence Journal, and a fun hootin' and hollerin' when Dan Quayle came to town), but things were starting to taper off. We started meeting with the Health Department, in addition to chastizing them. I even worked there on an internship one semester.
And by the time Clinton came along, all the air got let out of the balloon. Don't get me wrong, Clinton the first did as little as possible to advance the cause of people with HIV, and was arguably one of the worst presidents we've had on gay rights. But the community had had enough. It just wasn't possible to gather a crowd of pitchfork-wielding townspeople any more.

By this time, I was working in HIV/AIDS clinical research. Doing some statistical presentations of data from clinical trials, and medical record abstractions. I began keeping a list, for the medical researchers, of everyone that had been treated for HIV in Rhode Island, what major infections they had had, when they started treatment, etc. I felt pretty conflicted about that, and at the same time fascinated by the stories I was reading between the lines of lab reports and hospitalization records.

The job took me to an AmFAR conference in San Francisco. I fell in love with the city instantly, despite having an earthquake knock my hotel bed around the room my first night in town. I loved how it smelled. I loved the hills and the views. It seemed impossibly magical.

I vowed to move to San Francisco at the next opportunity, quit my job in HIV clinical research, and had all but bought the plane ticket when I got invited to take a job with the tuberculosis and HIV basic immunology lab at Brown. The pay was good, very good. And I figured, what the heck, I can do this for a couple years more, then go out to San Francisco. In the meantime, for several years I got in the habit of taking a month-long vacation in San Francisco every January, staying at the YMCA on Golden Gate & Leavenworth. Everything I needed to pack for a month fit in one bike messenger bag.

Well, I worked on that stuff for a few years, developed a mathematical algorithm for predicting amino acid sequences that would be likely to trigger an immune response, and had a lot of fun while doing it. Got to work with some very motivated and bright undergrads. Got to travel to a bunch of conferences. Even got a pat on the back from Tony Fauci at one point.

But at some point, I realized I needed a break from the frantic pace of HIV research.
HIV/AIDS was the most important thing in the world, or so it seemed. Everything was urgent. HIV/AIDS was an exception to every rule. But after the better part of ten years on the cutting edge, I got weary of being cut. I needed a break.

I began looking for another job, and quickly found it, in the much tamer field of gerontology. I got to work with incredibly bright, talented, and caring people. People who were interested in getting things done carefully, slowly, correctly, not living in a state of perpetual emergency. I had an amazing boss, who really helped me work much more effectively with other people (do you remember the 7 habits of highly defective people - I had probably 4 of them - I was not an easy person to manage).

So at first, I was just taking a break, not really thinking about HIV/AIDS, except about how futile it seemed to be to think about it.

At some point, though, I did make a conscious decision that I would not work on HIV/AIDS again. I wanted to force myself to think differently, to force myself to be more creative, to develop a new language and vocabulary, and whole new mindset.
As I was struggling to do that, I put together a forum at Brown about the Post-AIDS phenomenon. I invited Chris and Stephen as panelsits, after getting re-connected with Chris at the Boulder Gay Men's Health Summit, and also invited Justin Smith, a next-generation activist. It was a fantastic discussion, and there was plenty of passionate but respectful argument.
I made an analogy at the outset that Post-AIDS, in my mind didn't mean that AIDS was over, any more than Post-Modern means we are no longer modern. But the shock of modernity is largely over. The automobile has gone from being a bizzarre new sight on our city streets, crowding and running over pedestrians and cyclists, to being banal, a fact of life (though still running over pedestrians and cyclists - I've got the chronic pain to prove it - it's just banal and mundane now). Electric lights are no longer a showy extravance. It is not that modernity is done modernizing, but rather that the progressive development of wonderful, exciting, and dangerous new technologies is expected and welcomed.
My analogy to the term Post-AIDS was that the shock of AIDS was over, that we were now living in a world where AIDS is part of life, and that public health prevention efforts revolving around HIV as new, threatening, and catastrophic may have worked in the past, but would no longer work in the future. We needed to find new language, new ways of thinking about public health's role in prevention, because the tools of fear and hyperbole have run their course. We are in Post-AIDS now, but HIV prevention has yet to catch up to that reality.

Some ten years later, there are some exciting new developments on the gay health promotion front, such as Chicago's How are you Healthy? campaign, which is all about tying the three words "Gay. Sexy. Healthy." together in new and interesting combinations. The I Am Gay And... campaing in New York City is another one I like a lot. But these two are exceptions.
We're still bombarded with ad campaigns like this one, this one, this one, and this one that either play on fears and negative imagery, or treat us like we're just not knowledgeable enough to know what's good for us.

Well, I've wandered and rambled quite a bit here, and I'm not sure that I've adequately answered the original question - why I left AIDS. But it's a start.

I'm really curious about what some of the stories of the thousands of gay men who have left AIDS work - what did it feel like? What are you doing now instead? Do you, like me, feel conflicted about abandoning the AIDS work, even if what you're doing now is much more productive and forward-looking?

Quick Trip East

2009-11-04T07:36:00.001-08:00

Went back East for a week to see my parents. Here they are walking through a small orchard of apple trees planted a very long time ago (probably about 100 years or so) that I've been pruning. The apples used to taste awful but now they're pretty good. They are varieties that are not commercially viable (too small and bumpy), so you can't find them in stores, even specialty markets.
My mother says that one of them is called a "banana apple" which she recognizes from her father's farm in upstate New York. It's true, it's an apple with a faint whiff of banana as you bite into it.

Also stopped into Providence to try to do some work on my house. Got a bit frustrated because the windows I wanted to replace I have to special-order, so mostly I frittered around with some electrical work and painting instead.

I've come to the solid realization (yet again) that I need to work tirelessly towards getting a full-time teaching job. Not only do I love teaching (and I'm getting pretty good at it if I may say so), but I need to be connected to the land in Vermont that I've put so much time and effort into, and the best way to do that is to have the summers off.

HPV Vaccine for Boys? No (and Yes)

2009-10-21T20:29:00.000-07:00

The news about HPV vaccine for boys lately has been mighty confusing.

An FDA panel approved the use of an HPV vaccine in boys to prevent genital warts in September with a 7-0-1 vote.

Then an article came out in early October, sponsored by the CDC and others, suggesting that vaccinating boys to prevent cervical cancer in girls would not be cost-effective (more on that later).

And then today, a CDC advisory panel chose not to recommend HPV vaccination in boys. Apparently, the CDC-funded study weighed heavily in the committee's deliberations.

The upshot is that a doctor can write a prescription for HPV vaccination for a boy, but because it is not recommended, very few doctors will bring it up as an option, and no health insurance plan will pay for it.

Benefits of Vaccinating Boys Against HPV
1) The vaccine prevents getting genital warts. Sure, genital warts are mostly a minor nuisance, but tell that to someone who's had a few hundred warts cauterized up in his butt. Ouch!

2) The vaccine probably prevents anal cancer. No study is ever likely to prove that the vaccine prevents anal cancer. It is too rare, and takes too long to develop. But it doesn't take a genius to figure out that if the vaccine prevents getting the HPV strains that cause anal cancer, it will prevent anal cancers. Interestingly, this benefit is often dismissed as not a real problem, because most anal cancers occur in gay men (and nobody's son will grow up gay?).

3) The vaccine probably prevents a bunch of other, though rare, cancers - penis cancer (yes, there is such a thing), and cancers of the head and neck, primarily. Admittedly these are pretty rare. But if they can be prevented, why not?

4) Vaccinating boys prevents cervical cancer. Huh? But only people with a cervix (born female) can get cervical cancer. OK, but how are they getting HPV? From "Immaculate Infection"? No, from men and boys (for the most part). So, vaccinating boys is crucial to having a successful strategy for reducing the prevalence of these HPV strains in the population, thereby reducing the chances that a woman or girl will get infected, either because she didn't get the vaccine, or because it didn't work.

Lousy Vaccine Policy
The problem with contemporary U.S. vaccine policy is two-fold. Vaccination policy is strictly limited to worrying about individual risks and benefits, and vaccination policy is couched in terms of cost-efficacy, a framework that doesn't make sense.

Individual Benefits Only
So first, the individualized approach to vaccination strategy assumes that nobody else benefits from you getting vaccinated. So, if there is not an immediate benefit to you, don't get vaccinated. Because the individual, albeit miniscule, risk to you outweighs any potential benefit to others. And since men can't get cervical cancer, it is irrelevant that men and boys can infect women and girls with the virus that does cause cervical cancer in them.
That's not how vaccination policy has always been done. Smallpox vaccines were given to lots of people who had a next to zero risk of getting it, because the risk to society of having smallpox come back was too high. Same with polio. Today's vaccines are a lot safer than those vaccines were. The shift came with the HBV vaccine, when individualized risk-assessment was used to guide vaccinations, a policy that largely failed for the first two decades, and thousands of Americans are paying the price with HBV infections they didn't need to get, because a safe and effective vaccine was bottled up in a bureacracy of risk-assessment.

Cost-Efficacy. You're Worth $50,000 a Year.
Second, cost-efficacy is the wrong framework for evaluating vaccination strategy. For one thing, it is fairly arbitrary to say that a year of healthy life is worth $50,000, but not $100,000. By that logic, it wouldn't make sense to treat many forms of cancer, or advanced HIV infection, etc. Because if your treatment costs more than $100,000 in a year (which is not hard to do if you get surgery, chemo and radiation therapies), it exceeds the 'value' of your life for that year.
But that's exactly the logic of the CDC-funded article I linked to above. At $50,000 per year of healthy life saved, vaccinating girls is worth it. But at a little bit higher than $90,000 per year of healthy life saved, vaccinating boys isn't.
The study was also funded by the American Cancer Society, which recommends cancer screening programs that cost many times higher than that, and some of which (mammograms in women under 50, PSA tests), may well cause more human health harm than good, so could not be considered cost-effective at $10 billion per year of healthy life.

More fundamentally, cost-efficacy ignores any societal benefits acheived through reducing the prevalence of HPV infections. There is no space in the calculation for the benefits to society from reducing one's exposure to HPV because fewer people in the population have it. By the logic of cost-efficacy, if the vaccination strategy were somewhat effective, and reduced the prevalence of HPV infections by half, then the cost of a year of healthy life saved would rise to $100,000, and this logic would dictate that we should stop vaccinating girls at that point if the vaccinations are successful.
If we had pursued that strategy with smallpox and polio, we would have vaccinated people when the prevalence was high, but as soon as it got down to an acceptable annual cost to just let people get sick, we would have stopped the vaccinations, and we would not have eradicated smallpox from the Earth, or polio from almost everywhere.

Gloomy Predictions for HIV Vaccination Strategy
All the signs point to these forms of illogic being applied to the HIV vaccine, when it becomes available. First, vaccinations will be targetted only to "high risk" individuals, meaning that doctors won't think to ask if you want it, insurers will not pay for it, and you'll be hard-pressed to find it in-stock anywhere, meaning that you'll need to visit your doctor to get the prescription, go to a pharmacy to pick it up, and make another trip to the doctor's office to have it administered. Second, the logic of cost-efficacy will almost certainly exclude recommending any HIV vaccine - which will be expensive, require multiple shots, and be only partially effective (maybe 1/4 to 1/2 of people would be protected).
Getting a vaccine that works, my friend, is the easy part of this battle.

So forget what's recommended. If you can afford to get your boys vaccinated for HPV, please do it. For them, and for the girls.

Environmental Success Stories

2009-10-04T17:21:00.000-07:00

Global warming. Air pollution. The ozone hole. Nuclear winter. Acid rain. Deforestation. Pesticides. Extinction. Industrial waste.

Poisons are everywhere, undetectable, and have unknown risks.

Everything you hear about the environment leaves you feeling threatened and helpless. Not only that, but usually you are personally culpable unless you spend a huge amount of money buying your share of the problem away with (insert environmentally chic and expensive food/clothing/transportation/lifestyle item here).
A pretty insurmountable trio of adjectives, threatened, helpless, and culpable.

Believe it or not, there are actually a lot of environmental success stories. Successes that are the direct result of the political action engendered by making us feel threatened, helpless and culpable.

Acid Rain
When I was a kid, everybody talked about acid rain, how it was killing the fish in the lakes, burning the trees. And it did. And it does still, but to a much lesser extent. Did anyone tell you that acid rain has gotten much better? That your outrage led to actions that severely curtailed the emission of the pollutants responsible for acid rain? That progress has been made even faster than what Congress anticipated?
Clap yourself on the back. We did it. Or, more correctly, we're doing it. Keep up the good work!

Air Pollution
You never hear about it, but the air is easier to breathe. Not everywhere, but in most cities, particularly in California and the Northeast, air quality has been getting better and better, thanks to some of the same measures that were taken for acid rain, but mostly because cars and trucks have become less polluting.

Deforestation
Deforestation is a huge problem worldwide. But not everywhere!
New England used to be about 80% de-forested. Now it is about 80% re-forested. Those new trees are a lot smaller than the old trees that got cut down. And the demand for wood in New England is largely met by exporting the problem to other parts of the world.
And yet, New England is rapidly re-growing a valuable renewable resource.
And nobody talks about what a huge success that is. How can we learn from what happened in New England and export that success as well?

The Ozone Hole
The ozone hole was first recognized in the 1970's, and by 1978, the main agents responsible were banned in most countries. We changed the propellants used in spray cans, and the refrigerants used in refrigerators. And although the ozone hole hasn't been shrinking, it has stopped growing quickly, and is expected to recover over the next few decades.
Problem caused. Alarm raised. Problem addressed. Let the healing begin.

Lead Poisoning
A huge success story is lead poisoning in children. You've probably heard about kids getting poisoned from lead paint. Too much lead causes brain changes that are not good. It's still a big issue in areas with older housing stock (but rapid progress is being made).
Not too long ago, virtually every child had potentially toxic levels of lead in their body, due to the lead additives used in gasoline that we all breathed in. That's gone now. And there's a huge generational shift in blood lead levels.

And there's more. The Nashua River used to stink to high heaven, it's banks were scorched clean. Now you can eat the fish you catch there. Bays have gotten cleaner. Alternatives to pesticides are gaining ground. Eagles are laying eggs that hatch. Wild areas are being protected. And so on and so on.

I remind myself of these stories now and again because I think feeling threatened, helpless and culpable is a pretty big waste of time.
I'd like to think that there's a way to motivate the public to address the serious environmental threats facing us that doesn't resort to backing us into that uncomfortable corner. And can we celebrate the successes, for once?

When faced with the newer threats - like global warming - and the old threats - like nuclear waste - I take heart in the fact that we've been able to make real progress on a lot of fronts in the past. I don't necessarily think that there's a technological fix to every problem, that there's a progressive inevitability to cleaning up after ourselves. But I also don't think we're living in a world that is on the verge of total collapse, either. And I vehemently disagree with the stance that the only real solution is to reduce the human population. We may cause the problems, but we're also the ones to fix them.
I think we can make a difference. We already have. Let's keep doing it.

redefinitions

2009-08-29T12:23:00.000-07:00

retreat. v. Seconds on dessert. I had a light supper, so I retreated myself with ice cream.

revenue. v. To move an event from its original location. The unexpected douwnpour caused us to revenue the wedding ceremony.

predate. n. The period of time before a date when you can think about nothing else.

distance. adj. Holding both sides of an argument simultaneously. The senator distanced himself on the Health Care debate, hoping that whichever way it went, he'd be able to declare a victory.

promote. adj. Supportive of the political aspirations of dust particles.

reveal. v. Milk feeding the calf of a cow that never left its own mother's teat.

prevent. adj. The hot clammy slap in the face you get coming home to an apartment that's been shut up on a hot muggy day.

represent. v. see retreat above.

propound. n. (Br.) see anti-euro.

Research Worth Reading (3)

2009-08-23T08:16:00.000-07:00

There's a myth out there that gay men are self-obsessed and narcissistic, and I for one don't buy it.
David Nimmons, in Chapter 3 of his book Soul Beneath the Skin claims that on the contrary, gay men are actually more likely to get involved in volunteerism and altruistic behaviors, in part basing that on the enormous outpouring of volunteer time and energy devoted to AIDS service organizations.

Well, this is the first quantitative random sample analysis that really tries to get to the issue of whether gay men (and lesbians) are more or less altruistic than straight people. And that goal is what makes it 'research worth reading', in my opinion.
This is one of the few analyses that examines assets, rather than risks; one of a very small number of quantitative analyses to do so. So regardless of the results, regardless of the methodologic challenges, this is an important read in terms of thinking about the health of sexual minority populations.

Self-reported altruistic and reciprocal behavior among homosexually and heterosexu

ally experienced adults: implications for HIV/AIDS service organizations.

Susan D. Cochran, Vickie Mays, Heather Corliss, Tom W. Smith, Joseph Turner

AIDS Care 21(6):675-682. June, 2009

The authors used data already collected as part of the General Social Survey (GSS), a random-dialed telephone survey of the US population conducted annully since the 1960's, a staple dataset for the social sciences.
They looked at four potential measures of altruism across groups of people defined by whether they reported ever having had sex with someone of the same sex, or whether they reported only mixed-sex sexual relationships. The sample size of the GSS is fairly large (they combined 2 years to get 2,031 people), but the number of men and women reporting same sex partners in their lifetimes was pretty small (68 men and 51 women), so they elected not to divide that group farther, but lumped together men who were homosexually active and bisexually active together, and the same for the women.

The GSS asked a 7-item scale intended to measure empathic concern (other-oriented feelings), a 4-item altruistic feelings scale (similar idea, as far as I can tell), a set of 11 altruistic behaviors (things that one does for others that have no self-serving interest, like giving directions to a stranger, even at some risk to one's self, such as donating blood), and 4 reciprocal behaviors (things that one does for another, but do have self-serving aspects as well, like helping someone you know find a job, or lending a friend a considerable amount of money).

They found that gay/bi men (at least in terms of reported sexual behavior) were very similar on all of these measures, in terms of the average. Of course, the average is just the average, it doesn't really say much about the distribution of individuals in the population, meaning there might be a bunch of gay/bi men who are much more altruistic (for example: helped 7 people find jobs, not just one) but that wouldn't be reflected in the average.

The lesbian/bi women were also very similar across all four measures of empathy and altruism.

So, the results are pretty vanilla. Looks like we're about as caring and other-centered as everyone else.

Blood donations
One interesting side note is that they found lots of people in GSS reporting having given blood recently, over 20% of exclusively hetero men, and almost as many of the gay/bi men. That's similar to what I saw in the same dataset and reported on here.
I suspect that there's something wrong with that variable, not because it shows lots of men with same sex sexual behavior giving blood, but because it shows many many more people of all stripes giving blood than actually do.
I don't know what the problem in GSS is about blood donation. Maybe a lot of people are interpreting it to mean gave blood ever in their lives, rather than just in the last year. Maybe a lot of people are interpreting having given a tube of blood for medical tests as having given blood. I don't know.
But at any rate, there are more credible results on blood donation in the National Health and Nutrition Examination Survey, which I reported on here.

Study limitations
The General Social Survey (GSS) is an amazing dataset. They ask tons of questions, and repeat a lot of them year after year. But, it is also very general, and not necessarily designed for whatever analysis you or I might have in mind, so when re-purposing it, it is important to hold in mind that the results may not be what they seem for a variety of reasons.
As is typical for epidemiologists, I'll break them down into three large categories: errors in assessing sexual orientation; errors in assessing altruism; and other factors that may be associated with both sexual orientation and altruism.

errors in assessing sexual orientation
The GSS is a telephone survey, and it is a really long survey. And not everyone pays close attention the whole time they are on the phone. As a result, some people inadvertently give answers that don't actually represent their reality, and in very rare cases, the interviewer records something other than what the respondent said.
All that would be well and good if a little bit of error here and there gets swapped from one group to another, but it gets problematic when one group is much smaller than the other (like sexual minorities). In this sample, 5% of the women and 6.6% of the men reported at least one sexual partner of the same sex in their lifetimes (since age 18). It's possible that maybe 4% of the women and 5% of the men really did have same sex partners, and the other 1-1.5% represent people who were inattentive or miscoded for some reason (this is purely hypothetical, there's no way to know what the error rate really is). So, if that were the case, then gay/bi men and lesbian/bi women would look more like straight people than they should, because a bunch of the people we think are gay/bi/lesbian really aren't (Scout's Law of Fake Queers).
The GSS actually has more opportunity than most datasets to check on this kind of error, because at different points they ask about sexual partners ever in one's lifetime, in the last five years, and in the last year. And there's always people who say they have had no sex in the last five years, but they have in the last year. No way to tell which of those is correct, but they can't both be true, so you can get a sense of the error rate that way. I haven't done that analysis myself, but it could be done.
Another way to check is to see whether the queers identified in this study look like queers identified in other studies. Most demographic studies have found that people who describe themselves as LBG, or who report same sex partners, tend to be slightly younger, more highly educated, and especially less likely to be married. In this study, they were somewhat younger (much younger for the women), but not more highly educated. The LGB people identified in this study were less likely to report being married, but still about 30% reported being married, which is pretty high.
For those reasons, I'm a bit skeptical that the GSS sample has really accurately described the LGB population, I suspect that there's a fair amount of 'slop' from the heteros mixed in with us.

errors in assessing altruism
Another potential source of error is if altruism is not measured accurately. This is an area I'm much less familiar with, in part because I just don't trust scales. The known inaccuracy of the blood donation question gives me some cause to interpret this study cautiously, but that could be a problem mainly with that one question for whatever reason, and not reflect systemically on the other measures in the study.

other factors associated with sexual orientation and altruism
I don't know enough about how altruism is distributed in the population. They separated the population by sex, and that's probably the biggie. There weren't enough people to do stratified analyses across any other variable (like age, educational attainment), but they did do a mathematically smoothed model to try to partially adjust for these factors simultaneously, and found no big difference from the overall results.

Full disclosure: Susan Cochran, the lead author on this study, was also the external reader for my dissertation. She and I have never discussed this paper, though. I don't think seeing her name on the paper made me especially more likely to choose it, I was hooked by the word 'altruism' before I saw that she was associated with it. I do think that knowing that she and Vickie write good research is why I asked her to be my external reader.

2009-08-20T13:39:00.000-07:00

Patricio gives a very moving account of his experiences at the Chicago LGBTI Health Summit here.

Social Network Theory in HIV Prevention, the Role of Metaphor and Scope

2009-08-19T19:30:00.000-07:00

With the realization that social context plays a large role in HIV transmission in addition to personal behaviors, some people have turned to social network theory to help explain why HIV infection happens the ways it does, and to whom it does.
In turn, researchers, health promoters and activists have been struggling with (and arguing about) the implications for social network theory-based analyses on how to inform public health practice (for an example, check this out).
This post comes out mainly of a series of conversations with Michael Scarce & Peter Keogh, with my own special twist.

Wrong toolbox?
I'm going to argue that there is a profound disconnect between thinking about what social context means and how to design public health strategies that address social contextual factors, and social network theory as an approach for understanding the interpersonal dynamics of disease transmission.

Social network theory
From what I can gather, social network theory is about describing the linkages between people, and in the disease transmission context, using those linkages to help explain why a disease moves in the way that it does.

Social networks are often invoked to explain why rates of HIV infection are different in different demographic identified groups, despite similar occurrences of personal behaviors across these groups. But usually the evidence for that interpretation is the observation that the groups have different rates of HIV infection, a circular logic. I'm not aware of anyone having done the kind of individual mapping necessary to show how (over the span of decades, with constantly changing linkages) these communities came to have different HIV infection rates.

The metaphor of a social network as a map of nodes and lines, in this case describing who is friends with whom in a 4th grade class in the 1930's, has a remarkable similarity to the 'web of causation' models elaborated in epidemiology, especially since WWII.

Epidemiology's 'web of causation'
The metaphoric imagery of the web of causation is so vivid that a web to show linkages between causes and effects for any specific study is rarely actually drawn out. Usually, someone trained in public health sees one in their textbook at some point, then that's it. For illustrative purposes, here's an example from a 1966 US Government report. If you can reduce hyperlipidemia by reducing fat in a population's diet, or increasing physical exercise, this will reduce atherosclerosis, which in turn will reduce the clinical manifestations of heart attacks and strokes. The power of the 'web' among public health folks is that interrupting any of the pathways between causes, intermediaries, and finally disease outcomes can have a large impact on public health.

The similarity of these metaphorical representations I think is partly at fault for the way interventions based on the invocation of social network theory sound so strange.

When someone from Public Health sees a network of nodes connected by lines, our gut reaction is to start thinking about how to break them, so in this case, that translates into breaking social networks apart in order to limit disease transmission.

In the specific case of HIV prevention, this could mean, for instance, trying to interrupt HIV transmission by limiting the sexual vectors between younger and older men, since older men are more likely to have HIV.

But in a social network, the lines represent the substance, the sociality, of social networks. They are the sources of information, of resources, of resilience, not just vector lines across which bits of infectious protoplasm are transmitted.

So, any program designed to tear these networks apart, or prevent them from forming, seems counter-productive. Ripping the heart out of the communication of ideas and resources, the means men have to get support from one another, just to interrupt sexual connections between younger and older men is an exchange that even Faust would have been hesitant to make.

A kinder, gentler form of social engineering designed to limit social network growth has been proposed, the idea being to present young men with neutral and unbiased information about higher HIV infection rates among older men than younger men, the implication being that they should choose to associate only with other younger men.
The impact is the same, even if the intent is somewhat more benevolent. No matter how you dress it up in neutral language, the message that "older guys represent a sexual danger to you, young man, so avoid them" comes through loud and clear.

So, the invocation of social network theory, and it's strong metaphorical resemblance to the 'web of causation' probably has played a role in the development of such bizarre and counter-productive ideas for addressing the social contextual factors that influence HIV transmission.

Lace, Macrame, or Felt?
Perhaps we need a new metaphor to describe social networks. At the Chicago LGBTI Health Summit, Marshall (Feldman?) described the network of social relations in San Francisco as 'lace', its fragility due to the high turnover of people in this transitory town. This metaphor may be more useful for us public health types - why would you cut lace? If anything, wouldn't it be better to bolster the lace with new connections, tougher and stronger connections.

Perhaps the goal of health promotion would be to turn lace into macrame, the knitting craze that filled American houses with hanging plants in the 1970's. But there's something too vertical and hierarchical about macrame for my taste as a metaphorical substitution.
Someone suggested that felt, made by mashing fibers together, rather than weaving or knitting them, might be a good metaphor, it invokes the idea of the strands having multiple points of contact with one another, not fixed into a pre-arranged shape, and the tighter the felt, the more points of connection between the fibers, the more difficult it is to rip apart.

At any rate, using fabric as a metaphor pushes one to think about strengthening ties, not rending them apart.

Social networks as units of analysis
Another way to think about using social network theory is to design studies and interventions around the idea that social networks are discrete entities. This may be plausible when describing the strictly sexual links that have been used to trace STD transmission among heterosexuals, whose sexual networks tend to be dyadic, or only slightly more extensive than that. But the idea of discrete, separable social networks quickly falls apart when thinking about social ties other than strictly sexual ones, or even "purely" sexual networks in the vibrant sexual culture that gay men have fought so hard to create.
Despite this practical limitation, one could theoretically think about how to design a study using an individual's perceptions of their social network as the unit of analysis, and ask which types of social networks are more successful than others at help that individual avoid HIV, or avoid exposing others in the context of secondary prevention.
Doing this sort of research would imply that interventions should be designed to intervene in social networks that are identified as being dysfunctional. How to do that without simultaneously stigamtizing the very groups one is trying to assist seems difficult to me. In simpler terms, "Hi, we're here becuase we think your friends might let you down, so we want to help you make new friends" could be taken as very offensive to people who have a lot invested in their social networks, no matter how dysfunsctional social science research deems that style of network to be.

Broadening scope
So, perhaps the main problem isn't one of metaphor, but of scope. Rather than focus on the ties that bind individuals together within discrete social networks, a more fruitful way to think about the role of intentionally altering social contexts might be to go a bit broader, and engage the structural forces of gender hierarchy, material deprivation, and racial ideologies that work a broad social level. These forces certainly get reflected within social networks of friends and family, but their source, and the means for addressing them require a broader focus; on laws, policy, and public opinion. It requires engaging the total population, not just the relatively small population that is 'at risk' for whatever reasons.
With this broader focus, lobbying, grassroots organizing, school-based anti-bullying campaigns, and social marketing campaigns designed to address stigma become practical, efficient ways to think about intervening in the realm of social context to reduce HIV infection rates.

Throw out the tools if they aren't working
Don't get fooled by the work 'social' in social network theory. Social network theory may be a good way for infectious disease epidemiologists to understand disease spread through a time- and space-limited population (such as measles through the Faroe islands), but it's probably not a good guide when thinking about how to address the social contextual factors that influence HIV infection spread.

Get some new tools instead.

Hurricane Bill: Why I Touched You in Chicago

2009-08-19T10:15:00.000-07:00

OK, so nobody asked me why I was going around giving shoulder massages in Chicago. At least I don't remember anyone asking why.
And that's part of the beauty of it. It's not about talking.

But in case you're curious, and want to waste valuable head space with an answer, here's why.

I need it.
I've got a bad back, and sitting in a chair all day just kills me. So I've gotta get up and walk around. Touching your shoulders gave me something to do.

I want it.
I enjoy touching people. I'm a bit of a touch top, to be honest. If you get anything out of it, hooray for you, but that's not what it's really about for me.

I need it.
For me, it's easy to feel misunderstood, and it's easy to be critical. I've got a lifetime of training in feeling misunderstood, and an education that stressed critical thinking to the n^th degree.
So even in the midst of a bunch of passionate queers getting together, for the purpose of critiquing our own and others work in promoting health, being critical and feeling misunderstood (or un-heard) came quickly and easily to me.
That's not how I wanted to spend my time with y'all though, so in discussions with a few other critical and easily misunderstood people, I decided to take some responsibility for feeling that way, both to get myself out of the mire, and also to subtly shift dynamics that I was afraid might lead others into a similar state.

I decided to concentrate on touch.
Intimate touch.
Public touch.
Touch that is not spoken about, just experienced.
Touch that is not sexual, but could be flirtatious, and could have sexual overtones.
Touch that has no pretense of healing, but may nonetheless be healing.

In short, touch that is designed to get us out of our heads a bit, and into each others lives.

Being together without touch is isolating
Chairs in a room, aligned in rows, with talking heads at the front reading words off of Power Point slides is about the most isolating and alienating sort of group experience I can imagine, and yet, somehow that has become the norm for academic and professional meetings, even how classes are taught, and it takes a great deal of resistance for us to create other forums and formats for the sort of group experiences we want and need to share ideas and inspiration from one another.

My intention
So to break though that isolation, I hoped that by touching you, in public, it would create some sort of intimate experience. Not only between you and I, but between me and the room, and between you and the room. Most of all, I hoped it would liberate you to touch other people in the rooms, hallways, and other Summit spaces, public and private, and everywhere in between. And as I said above, a main motivation was to move me from a critical space to a communal space.

Consent
I did not ask if you wanted it. I intentionally asked only "May I?" if I asked at all. For many of you, "May I?" and a nod of assent were the first and only words we exchanged during the entire weekend. That's kind of wild, thinking back on it.
I understand and expect that for some people, my touch may have been somewhat less than welcome; perhaps because intimate touch of any sort implies sexual expectations; perhaps because intimate touch triggers a bit of a traumatic response; perhaps because inter-racial touch and inter-generational touch have incredibly complex sets of meanings, especially when done in public. And what the heck does it mean for a gay man to touch a lesbian intimately in public?
I accept that my method of seeking consent may have left some people feeling less than comfortable, and am happy to take responsibility for that. It was, after all, an intentional approach I took. And I took the risks of having a somewhat ambiguous (if intentional) approach to consent to serve what I felt a greater goal, to create a common experience that wasn't in our heads, that was in our bodies.
What would it have meant to do a more complex ritual around consent? Having been a victim of hate crime myself, I have struggled long and hard with what it means to continue to perceive myself as a victim. And I have concluded that it is really unhealthy for me to live with that status, that identity. If my consent procedure had encouraged a victimhood status in someone else, that would be contrary to my goals in creating a communal experience.
Had I touched only the people I knew, that would have been contrary to that goal. Had I sought a special level of consent from people of a different racial background from mine, from people considerably older or younger than me, that would in a sense have reinforced a bunch of stereotypes about racial and age related sexual objectification. Did I as a middle-aged White guy have a position in the room that 'allowed' me to act in a way that seemed to ignore these racial and age dynamics that another person in the room may not have been able to 'get away with'? You bet, and it pains me that that's the case. I sure don't have a fix for that one. But I hope you'll understand what my intention was, and why I tried to address chiefly the issue of intimate public touch as a matter of breaking down barriers and creating more of a communal environment where we were invested in one another.

So, how was it for you?

Chicago LGBTI Health Summit

2009-08-19T08:18:00.001-07:00

So many things to possibly blog about. Any suggestions?

Maybe...

Lace, crochet, ribbons, and cross-stitching to describe social networks: mixing fabrics is banned in Leviticus, but is mixing metaphors allowed?

Social network interventions: Why inquiry into what makes a social network fuctional or not is a counter-productive question.

Observations on Scout's Law of Fake Queers, and how we've already gotten in trouble because of it.

Why Identifying 'Research Worth Reading' is So Dang Difficult.

Hurricane Bill: Why I Was Touching Your Shoulders at the Summit.

How NOT to Recruit Research Subjects

2009-07-26T21:44:00.000-07:00

I went to a coffee hut tonight to work on a paper I'm writing, and while waiting for the bathroom, this ad caught my eye.

Powerful graphic, but where have I seen that before?

Try Birmingham, Alabama, 1963.

Please tell me it's unintentional. But how could it be? Is there any other setting where fire hoses get used for anything but putting out fires?

Addendum: There's an interesting back and forth on FaceBook about this ad here.

Let Your Fingers Do the Walking

2009-07-16T08:33:00.000-07:00

About ten years ago, I looked back through the San Francisco Yellow Pages, to look at the evolution of ads for the gay baths in relation to the emergence of the HIV epidemic.
I was surprised to find how far they went back - this ad from 1950 certainly is evocative!
Somehow, I don't think the fellow on the table has lumbago or neuritis on his mind.
More to come...

2009-07-07T08:19:00.000-07:00

thanks for a lovely birthday!

Walking the Dog

2009-07-03T15:01:00.001-07:00

Found myself sitting in front of my computer doing not much of anything this morning, while the day turned beautiful outside.

So, I grabbed Tuna & we walked down to Civic Center to deposit checks (Yee haw!).
On the way back, we walked past the place we moved to a year ago August, the Fox Plaza tower, and Tuna started pulling towards the door.
So, we went in, walked through, and out the other side. On the other side, she sniffed out her dog walker David, and they had a grand old time sharing stories. A few steps later, we ran into Bonita's owner who was also thrilled to see Tuna. Then, a run around Alamo Square for kicks, and now I'm ready for a nap.

I wonder what it's like for her?

Picked up this cute little painting on the way - seemed thematically related to my work on air pollution. Bought it for $10 and a couple Oakland ferry passes, from this artist.

Counting Same Sex Couples in the Census

2009-06-19T07:38:00.000-07:00

Potentially great news - the Obama administration, hoping to score some points with gay and lesbian voters after a series of profound let-downs, has instructed the Census to try to count married same sex couples.

I fully support making the effort to count married similar gender couples. Not counting them smacks of denying their existence, which is untenable. But, it's going to take more than jiggering the software to simply acknowledge married similar gender couples in the Census. It's going to require re-interviews, which is going to require funding and a plan.

And that's because of a simple statistical fact.

Most married same-sex couples on the Census are not married same-sex couples.

Huh? Understanding that statement takes a bit of background, don't worry, it won't be painful...

The census form is a piece of paper that gets mailed to most people's homes, or gets filled out in a number of other ways by census enumerators (people who go door to door and from underpass to underpass looking to try to count as many people as possible). But most of the time, the census form is filled out by whoever is living at home.

That piece of paper then gets scanned into a computer and tabulated, counted with a few other hundreds of millions of pieces of paper.

And every once in a while, there is an error.
Some of those errors come from the process of scanning it in, but most come during the process of filling out the piece of paper.
But let's take another step back in the process. Getting counted as a married same-sex couple relies on three pieces of information: 1) the reported sex of the householder, 2) the relationship of the householder to "person 2", and 3) the reported sex of "person 2".

For example, if the householder checked herself off as Female, her relationship to "person 2" as Husband or wife and the sex of "person 2" as Female, then they would be considered a same-sex married couple.
So far, all well and good.
But the problem comes in that sometimes (usually pretty rarely), someone makes an error somewhere along the line - and it's not the same-sex married couples we have to worry about here - it's the married mixed-sex couples.
Let's say a small minority (say one quarter of one percent) of married mixed-sex couples are confused by the form, or are inattentive. Perhaps the person filling out the form starts with "person 2" out as her husband, but then her daughter calls in from the other room, and when she comes back to the form, she's thinking about her daughter and fills in Female. An innocent enough mistake. There are a thousand other scenarios where someone could get confused, inattentive, or just mark the box incorrectly.

There are a lot of married mixed-sex couples in this country, in the 2000 Census, there were a bit over 70 million of them. So, if only one quarter of one percent of the 70 million made an error filling out the form there would be 175,000 couples miscounted as same-sex married couples.
Assuming that all the legally married same-sex couples identified themselves correctly, it still wouldn't come anywhere near that large a number. So, the number of apparent married same-sex couples would be much larger than it really is, and most of these would, in fact, be erroneously classified mixed-sex couples.

That's why when you look at Census numbers, there seem to be a lot more same-sex married couples than we know actually got married, and married same-sex couples look a lot like married mixed-sex couples. That's because most of them are married mixed-sex couples, incorrectly classified. In fact, the married same-sex couples tend to be older, which is completely the opposite of what every demographic study of lesbian and gay people has found. That makes sense, considering that elderly people are probably somewhat more likely to make errors when filling out the form.

So, what's the fix?
Well, the only way to resolve who really is a same-sex couple and who is not would be to go back and ask them.
It would be a lot more accurate, and it's not hard to do. But it does take a small commitment of funds and personnel to get back in touch with the couple of hundred thousand people who will call themselves same-sex married couples on the 2010 Census.

For an example of how well it works, consider the work done by Susan Cochran and Vickie Mays at UCLA. They had a bunch of in-depth questions that they wanted to ask about the health of same-gender-loving people identified in the California Health Interview Survey, so they planned a follow-up conversation with anyone who identified themselves as gay, lesbian, or bisexual, or who reported having sex with someone of the same sex.
Lo and behold, when they called these people back, a surprisingly large number of them were completely baffled - they were not gay, lesbian, or bisexual, nor had they had sex with someone of the same sex - somewhere during the interview, a small error had been made, and a very small proportion of the heterosexual majority had become a sizeable percentage of the sexual minority population inadvertently.
The largest group where these errors had occurred was among the elderly, so many that in future runs of the CHIS, they decided not to even ask anyone over 70 about their sexual orientation.

In conclusion, I'm not trying to throw a wet blanket on counting same-sex couples - just the opposite - I want to count them accurately. And an accurate count means going back to weed out the sizeable number of erroneously classified heterosexually married couples.

Make your voice on the issue heard! Support the NGLTF's petition.

Word Game - 1st Winner

2009-06-16T08:21:00.000-07:00

hat bat pat pack mass ball

We have our first word contest winner!

Daniel added hat and bat to the list. I had thought of bat, but passed over hat initially, so now there's at least 14 words with this property...

Who's next?

Word Game - New Clue

2009-06-14T12:13:00.000-07:00

mass ball pack pat

These four words share an unusual property (and there are at least 9 others that do as well, but I had to use wiktionary to confirm some of them).

fand is not a word, but if it were a word, it would also share this property.

When you figure it out, think up two more words that share this property, and send me the answers.

Several of you have noted that the 'a' in these words is a short vowel. The property has nothing to do with how the words are pronounced (directly, anyway), but it does matter how they are spelled.

You've almost got it!

Word Game Contest

2009-06-12T07:49:00.000-07:00

pack pat mass ball

What do these four words have in common?

If you've got it, find two more words with this unusual (but easy to describe) property, and reply with just those two words.

Another clue - I'm pretty sure that there's no two-letter words that have this property, although an comes very close. I also haven't yet found any five-letter or longer words with this property, although there's no reason there shouldn't be (theoretically).

And thanks Nick for another shot, tot and roast. Now I've got another puzzle, to figure out what ball, pat, pack, tot and roast have in common. Hmmmm.

PS: I've now found 9 other words with this property (13 total), but some depend on some pretty obscure dictionary entries.

Word Game Contest

2009-06-11T08:13:00.000-07:00

New clue!

ball pat pack

What unusual characteristic do these three words share?
To answer, give two more words that share the same unusual property (but not your rationale, if you know it, the words you pick will make it clear we're thinking the same thing.

Thanks Nick for guessing qualm and drat, not what I was looking for, but I'm curious what the common thread you saw was, now I have my own word puzzle to work on!

PS: I've found 6 more words myself, but there must be more than that...

Word Game Contest

2009-06-10T09:36:00.000-07:00

ball pat

These two words share an interesting and unusual property.

That property can be explained in one simple sentence that any graduate of elementary school would understand.

To win the contest, tell me two other words that share this same property. Do not say what you think that property is.

Do not put anything else in your comment other than two words, or it will be deleted.

The winners will get the fabulous prize of satisfaction. Guaranteed.

Badminton. Board Game Night. Making Jam.

2009-06-09T14:10:00.001-07:00

These are a few of my favorite things.

Making Jam
I've been making jam for years. I don't even especially like jam. But I like making it. In huge quantities.
This year, I paid attention to the prices on fruit, and I've been buying in bulk towards the end of the season. Started with two crates of strawberries. Next was 18 pounds of cherries. Looking forward to blackberry season, but I'd prefer to pick those myself from the wild (even if the 'wild' means from the large number of blackberry stands in our local public parks). Maybe I'll grab a bunch of grapes from my back yard in Providence this Fall, too. Unfortunately, I'm going to miss raspberry season in Vermont. Oh well.
Michael and I put together a few gallons of jam from the strawberries and cherries the other night, and I've been scratching my head trying to figure out how to get rid of it all now.

Still, my all-time favorite jam was the 'Horseneck Beach" jam Marc and I made a few years back. For reasons I don't understand, it was a banner year for beach plums, I'd never noticed them before, and haven't ever caught them in season like that since. We stuffed bags full of beach plums, and also rose hips because they were also especially ripe.
As raw fruit, neither beach plums nor rose hips are especially appealing. The plums are more stone than fruit, and taste sour. The hips have a narrow flesh protected by sharp hairs surrounding a seed pod that has a nasty tendency to pop open and fill your mouth with phthhhh.

But, throw 'em though a Foley food mill, and double their weight with sugar, and you've got a mighty fine jam on your hands.

Board Game Night
About a month ago, my roomies invited me to the board game night around the corner, at a coffee hut called On the Corner. We basically played our own game of Catan there, even though it's open tables, and had a good time.
I've been going back every Wednesday, played a few more games of Catan, and been introduced to a bunch of new games as well.
I've enjoyed meeting strangers - there's something relaxing about having this shared activity of playing a board game together. It's interactive, without being forced or too intimate too quickly.
I seem to have made a habit of it, we'll see how this thing pans out...

Badminton
I've been playing badminton at the Y for the better part of a year now, and it's great exercise. Lots of running around, and it's a real challenge for my hand-eye coordination, which was never very good, and there's a lot more strategy than I've been able to grasp yet. But I always have a good night playing badminton, and it's a bit of a community, so it's nice to be interested in other people & have them interested in me.

Prop8 observations

2009-05-26T11:20:00.000-07:00

Stopped by at history in the making on my commute this AM. Got to SF City Hall moments after the Supreme Court upheld Prop8 to restrict marriage.

I was surprised by how subdued the crowds were, given all the awesome organizing that happened after the vote itself in November.

It was an interesting contrast to the day that the Supreme Court decided to allow similar gender marriages about a year ago, when the crowd numbered less than a dozen. That day, I happened to be walking my dog outside the Supreme Court when that decision was made.

One quick observation: it occurred to me that this isn't really about wanting marriage - it's much more about being told that there is something specific we can't do. It's been fascinating watching queers slowly evolve towards being in favor of marriage after so many decades of resisting it.

Commuting getting better

2009-05-20T11:07:00.001-07:00

So, the bike is too short, that's true.
But, I can't describe how wonderful it feels to be biking again.

Floating through the city, skimming along the streets

Timing my strokes to the count-down on the stoplights

Seeing smelling hearing the vibrancy all around me

Coming home sweaty and smiling

Falling asleep during the first TV episode

Waking re-freshed

Isn't that what it's all about?

First Commute on New Bike

2009-05-15T12:20:00.000-07:00

Riding a fixie is definitely different. I like it, but different. I have some sore muscles on my inner thigh that I've never felt before, so they must be related to the pedal braking.
I'm not confident about my braking skills yet, so I was taking it all pretty slow. I think I'll need a rear handbrake as well in order to feel more confident.

I also am realizing that the frame is just too short. I need to swap up to a larger frame.

Bill's New Fixie!

2009-05-13T22:29:00.000-07:00

I am so happy to be back in the saddle again.
If you know me, you know I'm attached to my bike.
So having my bike stolen in December was a crushing blow. It did force me to get familiar with the MUNI transit system, for which I am grateful, but all and all, five months without a bike was an eternity.

So, I went on craigslist and found this awesome '84 Peugeot converted to a fixie. It's my first fixed-gear bike, at least first since I was a wee one, and the ride is really different, it's going to take some getting used to.
It's really smooth, this bike is in fantastic shape, the weight is just right (steel frame). I can't wait until a week from now when I've got the hang of slipping in and out of the pedals. I may need a taller seat, but I think I've got it adjusted just about right for now.

I didn't realize just how much I missed the open air, the swooping feeling of moving through the city. Aaaahhh. Freedom.

Tell me about your biking life-style in the comments...

Death Cab for Cutie video

2009-05-06T23:09:00.000-07:00

OK, I usually don't go pop culture here.
But I think Death Cab for Cutie is fantastic, and this little video is quite moving. Of course, the suburbanites pictured could have saved themselves a lot of hassle (and gas) if they had been sensible enough to live in the city instead of fire-prone hill country, but I digress.

Counting LGBT People in Health Studies - Update

2009-05-02T10:12:00.000-07:00

Thanks to the hard work of the National Coalition for LGBT Health , Woolverine, and many people who called their senators, 7 more senators signed on to Sen. Whitehouse's (D-RI) call for the National Institutes of Health to start asking survey respondents about their sexual orientations and gender identities.
That data will be invaluable for investigating health disparities affecting sexual and gender minorities (both adverse and beneficial), and also identifying the causes of those disparities.

Send your thanks to Senators
Sheldon Whitehouse (D-RI)
Jack Reed (D-RI)
Bob Casey, Jr. (D-PA)
Chris Dodd (D-CT)
Ed Kennedy (D-MA)
John Kerry (D-MA)
Bob Menendez (D-NJ)
Jeff Merkley (D-OR)

Canada does it.
Massachusetts does it.
California does it.
Why can't all states benefit from this information?

Counting LGBT People in Health Studies. ACT NOW!

2009-04-22T12:24:00.000-07:00

Counting lesbian, gay, and bisexual people in health studies has a relatively short history. And yet, a fairly large number of lesbian, gay, and bisexual people have been identified so far, especially from the California Health Interview Survey (CHIS), and various States have included information on sexual orientation in their Behavioral Risk Factor Surveillance Systems (BRFSS) and Youth Risk Behavior Surveys (YRBS).
But there is no nationally representative dataset that yet captures sexual orientation data, making it very difficult to do the kind of research I am most intereted in - looking at the impact of normative heterosexuality on health. Because most of the studies that do include sexual orientation data happen in States that are relatively friendly (VT, RI, MA, CA, WI, etc.), it is difficult to find a comparison group exposed to higher levels of societal homophobia.

To a small degree, one can use relationship status from the national BRFSS and NHANES datasets to identify sexual minorities, but because these people are by definition in marriages and marriage-like couples, it is unclear what biases play out in becoming a couple, and what impacts this has on health.

So, to do the kind of research I want to do, we need national datasets that ask about sexual orientation identity, not just imputing it from partnership status.

So, is this post totally self-serving? Self-serving, yes, but I wouldn't be the only beneficiary.
Right now, there's no way for people in most of these United States (and her territories, PR, VI, GU, AS, CM) to know whether the trends that have been identified in Massachusetts, Vermont, Wisconsin and California apply to their populations as well.
And because the data would be Federally collected, it would be available to a much broader range of researchers (such as graduate students and people without a huge research funding apparatus behind them), enabling a much broader set of eyes and minds to grapple with LGBT health concerns than has been able to so far.

A question about gender identity has, as far as I know, only been asked in one wave of the Massachusetts BRFSS, and those results have not yet been released. So there's no solid information on the health of transgender people in any State.

Hats off to Senator Sheldon Whitehouse (D-RI) for initiating a "Dear Colleague" letter to ask the Senate to set aside $2M to ask questions about sexual orientation and gender identity on the National Health Interview Survey is a good start. Those questions should be standard questions asked on the National Health and Nutrition Examination Survey (NHANES) and the BRFSS core demographic module as well.

Call your own Senator at (202) 224-3121 and ask them to sign on by calling Jordanna Davis in Senator Whitehouse’s office.

Another place that we should be getting more information is from birth and death records. Vermont does this already, but many of the States with civil union laws do not yet collect this information on standard birth and death certificates. And the National Vital Statistics Sytem should revise its procedures to allow capturing this information from the States that do collect it.

How Are You Healthy?

2009-04-15T20:36:00.000-07:00

How are you healthy?
A simple enough question.

But there's a lot more going on there than meets the eye.

After yesterday's rant, I felt the need to regain some balance by talking about something really awesome that's happening in the field of public health. The how are you healthy? campaign on LifeLube.com and on buses in Chicago, and sponsored by various partners, really hits the spot.

It's real
All the photos are of real guys, who really wrote real things about themselves. There's just something refreshing about seeing actual guys telling you actual things about their actual lives, instead of ad copy printed next to a model. How do I know it's real? Because I know some of the guys who have written in and are shown on the website. That's how.

It's inviting
Unlike most public health campaigns, it's not about fear. It's not about guilt. It's not about putting some unattainable goal in front of you. It's not about telling you what to do, or more accurately, telling you what not to do.
I like to think of it as the perfect antidote to the usual "To Don't" list that we get from public health all the time.
The question - how are you healthy? - invites you to reflect, to celebrate what's going well, to personalize your own answer.

It's outwardly oriented
By putting the campaign on buses in Chicago, the campaign is clearly outwardly focused - not just for gay men, but for the whole city.
Most health campaigns try to 'target' an audience. I don't know about you, but when I feel targeted, my reaction is to duck, dodge, get out of the way. I don't wanna get shot. Or, when I the campaign is targeted at someone else, I breathe a sigh of relief, not my problem, I don't have to worry about it.
The other problem with targeting a message by putting it in the public square is that bus ads, subway ads, billboards, even print ads in gay newspapers are a really lousy way to target an audience - you miss most of the people you want to get, and a whole lot of people get annoyed, including a large proportion of the 'target' audience.
But more about the outward orientation of the how are you healthy? campaign.

gay. sexy. healthy.
The straightforward assertion that the words gay. sexy. healthy. belong together is a radical departure from public health research and practice over the last 30 years. It directly challenges people to question the fast and easy elision between 'gay' and 'sick' or 'immoral'. It challenges the notion that sex is what makes us sick. By starting from the assumption that gay men are healthy, the implication is that everyone can learn health tips from us, gay, bi, and straight alike. Now, if you've been in a yoga class lately, or had a personal trainer, you know that's true already.
By stressing that sexy is healthy, it challenges all those public health messages about cutting back, denying our sexuality.

rant on research
But if you look at the research literature, you could be excused for coming away thinking that gay men are disease-ridden, addicted, and self-destructive. Why? Because that's all that gets published. I've been looking hard, and aside from a paper by Evelyn Hooker in 1957, I haven't been able to find one single example of a quantitative study which starts from the premise that gay men are inherently healthy.
Recently, there's been a lot of attention paid to 'health disparities', usually implying a negative health disparity between a racial/ethnic minority and non-Hispanic whites, but sometimes a negative health disparity affecting women, and occasionally a negative health disparity affecting sexual minorities or gender minorities. I haven't found any examples of a positive health disparity affecting sexual minorities in the literature, but if you've been reading my blog lately, you know I've been finding them aplenty in raw data sets. Which implies one of two things: that researchers are not looking for positive health disparities, or that they are not making it through the peer review process and into print. My hunch is that the former plays a much bigger role, having been through the same indoctrination in public health, I can assure you that it's very hard to turn the paradigm of risk->disease around to begin thinking about positive health outcomes, and harder still to turn around ideas about who's supposed to be sick.
At any rate, the idealistic goal of identifying health disparities is that highlighting how oppressed groups suffer disproportionately will motivate political action to address the social forces causing those disparities.
But by measuring the result (health disparities) and not the cause (social forces) directly, this leaves health disparities research in an atheoretical limbo, results waiting for an interpretation. And as such, identifying health disparities but not directly measuring their causes may serve to undermine the very goal the researchers have in mind. Rather, these atheoretical results, hanging in mid-air as it were become evidence for some that the affected groups are inherently susceptible, inherently weak, and have none to blame but themselves. That these disparities, while unequal, are justified, to be expected, even fair.

back to looking outward
And the other big problem with identifying only negative health disparities is that when there are positive health disparities, there is an opportunity to learn their causes, and to export that knowledge beyond the oppressed minority group into the society at large.
And that's the other thing I love about the how are you healthy? campaign. It's gay men talking to gay men, but anyone is invited to sit in and learn what we have to say, what works, and adopt whatever may work in their own lives as well.

So tell your story. Send in a snapshot. Join the fun.

Dissecting the News

2009-04-14T11:43:00.000-07:00

All right, I've tried to play nice.
I've tried to focus just on 'Research Worth Reading', because I know that if I spend much time worrying about reporting that drives me nuts, it drives me nuts.

The following paragraph is nothing special. It is ordinary, standard reporting on HIV/AIDS. Which is perhaps a large part of why it is so frustrating.
It is basically a throw-away paragraph in the middle of a recent article in the Miami Herald on a somewhat related topic, but certainly not the main point of the reporting.

"Recent Florida figures show an increase of 48 percent in newly reported HIV cases in Miami-Dade County from 2006 to 2008 and 74 percent in Broward County. This might have occurred because of an enhanced reporting system, said [Spencer] Lieb [, Florida Department of Health Bureau of HIV/AIDS]. Yet, some of the gay population have increased HIV/AIDS complacency, which can lead to riskier sexual behaviors."

So, let me dissect this paragraph, and describe why I find this sort of banal ordinary coverage so infuriating that I can't stand to read anything about gay men's health in the mainstream press, and why over half the reporting in the gay press is equally frustrating.

The reporter notes that there has been an increase in reported cases of HIV in two South Florida counties. Whoa, you may think, why such a large increase, why are there so many new infections in South Florida?
The second sentence gives by far the most likely explanation: that these Florida counties have initiated a program to get more cases of HIV reported - not that there are so many new cases, just that more are being reported to county and state officials. This new program, coupled with the recent encouragement from CDC to do routine HIV testing, probably means that a lot of people who have had HIV for many years, got tested for the first time in the last two years, or got re-tested. And that's why there are so many new tests being reported.
You see the same phenomenon in any community that puts effort into getting more HIV reporting done, and we should expect to see increases in HIV reporting all over the country as CDC's recommendation to test everyone regardless of risk factors gets implemented.

But, the reporter couldn't leave it alone at that. Instead, he went on to find a way to blame gay men for the increase in HIV reports: "increased HIV/AIDS complacency". Why? Why not just keep it simple and to the point - that most likely the increase in new HIV case reports is about reporting procedures, not an increase in new infections. In fact, the reporting of more cases should be cause to celebrate - the main topic of the article is about disclosing one's HIV status to sexual partners. If there are more HIV case reports, then that by extension means more men know their status, and at least have the possibility of disclosing. What's not to love? More people know they are infected, and have the opportunity to use that information to make their lives better.

The first time I heard about gay men "becoming increasingly complacent" about HIV infection was over 15 years ago. I remember because I was among the people who tried to warn the gay community about becoming complacent about HIV.
But after fifteen straight years of becoming more and more complacent (if you believe what you read), one wonders if there is any room to get even more complacent.
It would seem that that gay men must be the most complacent people on the face of the Earth, especially when it comes to getting HIV.

So what's wrong with raising the warning about HIV complacency among gay men? And why is it such an easy scapegoat? A fast-and-ready explanation for any blip in HIV/STD rates that comes across the radar?

To describe someone as complacent (in the context of HIV prevention jargon) implies that they already understand the potential consequences of getting infected with HIV, but just don't care. The dominant narrative about complacency among gay men goes something like this: "I know I might get infected, but I know a lot of guys who are infected, and they look healthy to me. What's so bad about taking a pill every day? At least then I won't have to worry about getting infected any more." It is interesting to note that complacent in the dictionary means something quite different, but that's another story.
So, why this construction of gay men as knowledgable, but unmotivated to protect themselves so appealing?
From the dominant narrative of public health, clothes may make the man on the outside, but choices really make the man. Choices about sex, in this case.
And having choices implies having options. Having options implies having the information to make informed choices. Having information implies sufficient education about choices. And to complete the circle, making healthy choices implies that one values health above other concerns in life.
So, the 'failure' that gay men's supposed complacency highlights out of this network of ideas is that gay men are simply tired of making informed healthy choices.
What are the alternatives? Going backwards through my assertions, it could be that gay men don't value their health above all other concerns in life, implying that we are either saddled with a death wish, or our priorities are so debauched that health takes a back seat to some other need. OK, that's not an appealing picture to paint of gay men (though of course many do take that route, even I'm afraid to say, within our own community).
Perhaps there's a failure of education, that gay men just don't know what their choices are. Well, that implies that either the vast bulk of public health efforts in HIV prevention (educating gay man and others about their "choices") has failed. Whoa, we're not going there! Or, perhaps that gay men are just pain stupid, or naive. Again, kind of a no-starter (although there are plenty of people, even within our communities, who pull out these sorts of explanations regularly).
It could also be that gay men are making unhealthy choices because we're insane, crazy, irrational. Or, as the people who like to rely on these sorts of explanations often prefer to say, that we are so drug-addled that rational healthy choice-making is compromised.

Anyway, you're by now getting the point, that describing gay men as "complacent" about getting HIV is perhaps the least noxious of the explanations driven by the dominant narrative structure of public health.

But that still leaves out what's wrong with constantly describing gay men (or at least some subset of us) as complacent? First off, based on what? Note that there is no reference for the statement in the article, it appears to have just appeared there at the whim of the reporter (or his editor). Second, compared to whom? The implication is that gay men are now more complacent than gay men were in the past (or than men of the same age in years past). I don't know about you, but I don't think I've yet met a gay man who just doesn't give a hoot about whether he gets or has HIV, past or present.
So where are these complacent hordes of gay men?

How else might the reporter have handled this - well, the obvious one would have been to keep it to the point - there was no need to go into new HIV stats in this article. But having gone there, just stick to the most logical, likely explanation, that more tests have been getting done, and therefore more positive results have been coming in. Period. Or, if he really needed someone to blame, how about going after Federal prohibitions on HIV prevention money being spent in a way that might "promote" homosexuality? It's hard to avoid denigrating homosexuality when it's legally prohibited to "promote" it. How about going after "one-size-fits-all" social marketing campaigns that conflate homosexuality with drug use, HIV, and self-pity?
There are so many worthy targets outside the gay community, yet somehow it's easiest to bear the blame ourselves.
After all, we're used to it. Maybe we are complacent after all.

Research Worth Reading

2009-03-31T20:59:00.000-07:00

A report out of the UK gives some promising news, or is it depressing. I'm not sure.

The authors surveyed 1,328 shrinks of various sorts about how they would deal with a client whose main goal was to change from lesbian, gay, or bisexual into a heterosexual.
Only 55 (4%) said that they would help an LGB person try to become straight.

I don't know if it's promising that so few (UK) psychiatrists and therapists would help someone try to change their sexual orientation, or depressing that so many would.
It gets more depressing when you read on to discover that an additional 10% would try to refer the prospective client to someone else who would be willing to help them try to change.

This comes 52 years after the British Wolfenden Report concluded that "none of our medical witnesses were able ... to provide any reference in the medical literature to a complete change".

I think the most interesting part of the report, though, is the justifications that the shrinks who said they would try to help someone change their sexual orientation gave.
Although they reported a wide range of justifications, I want to focus on the idea of promoting patient autonomy. A quick sample of these follow:

“We have a responsibility to assist our patients with self-determination.”

“It is up to the person themselves to decide which direction to go in. I am just the sounding board for them to make their own decisions.”

“Client ultimately knows best and may have deep religious beliefs that influence them enormously.”

“(the) client is ‘the expert’ and I deal with their realities rather than mine.”

“People should be given the opportunity to choose to redirect their sexual feelings depending on their circumstances. For example the homosexual man I helped to become heterosexual came from a working class background where it was completely unacceptable to deviate from the norm. It was extremely important to him to be accepted by that community.”

The dilemma for me is that I'm a big proponent of autonomy and self-determination; that health care providers should spend more time helping people get where they want to go, and less time telling them where to go.
So, on the one hand, I agree with this (small minority) of shrinks that patient autonomy is a very strong ethic that should not be violated.

Any yet, I wonder how many of these shrinks would be such strong defenders of patient autonomy when presented with someone who wanted to become lesbian or gay? How many would assist someone who wanted to develop the ability to see through walls? Or who felt that their life would be so much better if they were just three inches taller?
Would these shrinks be such forceful advocates of patient autonomy when a person wants help to live as the gender they feel they are, not the body they were born into?

I believe the kindest thing to do would be to explain that the change they are trying to undertake is not possible, but perhaps it is better to humor someone's interest in trying to change their orientation long enough to develop a deeper therapeutic relationship that can begin to help them find more realistic ways to live in their bodies, in their minds, and in their communities in a more harmonious fashion.

Hmmm. Certainly has me confused about what the "right" thing to do is.

Annie Bartlett, Glenn Smith, Michael King. (2009). The response of mental health professionals to clients seeking help to change or redirect same-sex sexual orientation. BMC Psychiatry 9:11. http://www.biomedcentral.com/1471-244X/9/11

Report of the Committee on Homosexual Offences and Prostitution. (1957). Her Majesty's Stationary Office, London.

What Explains the General Health Advantage of Gay Men in New York City?

2009-03-12T11:03:00.000-07:00

In 2007, the New York City Community Health Survey asked men (and women) how they identified their sexual orientation, and also the standard question "Would you say that your health in general is: Excellent, Very Good, Good, Fair, or Poor?"
44 of 153 self-identified gay men (29%) said they were in excellent health, while 563 of 3,049 self-identified heterosexual men (18%) said they were in excellent health. So, gay men were almost twice as likely to report excellent health (odds ratio = 1.95, 95% confidence interval 1.36-2.79).

What gives? Well, aside from gay men being in better health, there might be a lot of other potential explanations. Like, what if men who identify as gay are just on average younger? Or less likely to live in poverty? Or less likely to be unemployed? All those things are strongly associated with one's subjective assessment of health.

So, I tried controlling for age, race/ethnicity, employment status, educational attainment, being foreign-born, and the ratio of the household's income to the poverty level set for a household of that composition (the poverty threshold for a household with two adults and three kids is a lot higher than the poverty threshold for someone living alone).

Of these, controlling for the ratio of income to poverty made the biggest difference. After controlling for the income:poverty ratio, self-identified gay men were 60% more likely to report excellent health (odds ratio 1.60, with a confidence range of 1.11-2.31).

Controlling for all of them simultaneously explained more of the gap, with gay men being almost half-again as likely as straight men to report excellent health (odds ratio 1.46, confidence range 0.99-2.16).

Still, all things equal, wouldn't you rather be gay in New York City?

Then, I decided to break it down by borough. Gay men in Manhattan were 67% more likely to report excellent health (odd ratio 1.67, confidence range 0.99-2.80), gay men in Brooklyn were 37% more likely to report excellent health (odds ratio 1.37, confidence range 0.58-3.23), and gay men in Queens were only 15% more likely to report excellent health (odds ratio 1.15, confidence range 0.40-3.28). There weren't enough men in this particular sample to say anything worthwhile about the Bronx or Staten Island.

Hmmm... looks like where you live as a gay man has a big influence on how you feel.

Excellent Health among Polish MSM

2009-03-01T11:24:00.001-08:00

In the Polish General Social Survey, they asked about the gender of sexual partners in 1994.
Extreme caution should be used interpreting these numbers, because I'm sure there are cultural and linguistic differences in how the questions are interpreted and answered between the US and Poland.
That and the numbers are fairly small. In general I try to avoid combining gay and bi, or MSM with MSMW, but in this case, the numbers were small enough that I wanted to get more stable estimates.

Only 2 of 31 men who said they had sex with at least one man since age 18 reported excellent health (6% {0%-15%}), while 48 of 322 men who said they never had sex with a man since age 18 reported excellent health (15% {11%-19%}).

I'm nervous about saying much of anything about this data, but it seems like the proportion of men reporting excellent health is lower than the US data, but I would attribute that to language differences until proven otherwise. However, within that context, it does appear that men who have had sex with men in Poland are less likely to report excellent health, perhaps speaking to the general attitudes towards homosexuality in Poland - although not having been to Poland I'm not in a position to say. Anyone with more relevant experience want to comment?

Also interesting is that 31 of 322 men said they had had sex with a man, a much higher percentage than we usually see in US telephone surveys. Should I interpret that to mean that more men have sex with men in Poland, that more are willing to admit it during a telephone survey, or that the question wording is confusing enough that a relatively large proportion gave answers incongruent with their experiences?

I got this data from ICPSR.

Measuring Well-Being

2009-03-01T08:17:00.000-08:00

While looking for more data on the well-being of gay men relative to str8 men, I came across this initiative in Europe to measure national (and individual) well-being. I don't ordinarily put much stock in these quiz yourself things, but I think the questions they are asking are useful, and it was kind of fun to compare myself to the various European nations that participate.
Although I have Polish, Irish, Scottish, English & Norwegian heritage (and probably more), my own profile more closely resembles the Hungarians - anhedonic but satisfied. Maybe I should visit there, when I can afford to travel again.
And I score really high on autonomy, which is probably a main (non-material) component of why wealthier people generally have much better health than poorer people.

more on gay blood donors

2009-02-25T20:32:00.000-08:00

A few months back, I posted about the existence of gay blood donors, at least in the General Social Survey.
Now, I have more information from a more authoritative source, with fewer obvious data problems.

The National Health And Nutrition Survey (NHANES) has been periodically conducted, recently on a two year basis.
By combining several surveys together (1988-1994, 1999-2000, 2001-2002, 2003-2004 & 2005-2006), I was able to look at a reasonable number of sexual minority males' blood donation histories in comparison to heterosexual males.

Like GSS, you can break down sexual orientation in different ways in these datasets, each way yields slightly different sample sizes.

sexual orientation identity
Among 75 men who say they are gay, 2 (3%) said that they donated blood in the previous year, and 2 of 56 men who said they were bisexual did (4%), while 214 of 3,873 heterosexually-identifying men gave blood in the previous year (6%).

men who have had sex with men
Among 65 men who have only had sex with men, 2 (3%) said they donated blood in the previous year. 5 of 264 men who had sex with men and women (2%) said they gave blood. 667 of 9,560 men (7%) who have never had sex with a man gave blood.

men who have had sex with a man in the last year
It's one thing for a man who had sex with another man a long time ago to give blood, it's another thing to consider recent sexual activity. Of 117 men who say they had had sex with a man in the last year, 2 said they gave blood (2%), while 209 of 3,626 men who said they had not had sex with a man in the last year did (6%).

Banning gay men isn't working
These figures suggest that the US ban on blood donations from any man who has had sex with a man since 1978 is not working, and should therefore be re-worked in order to create a more sensible donation policy. One that doesn't feel discriminatory. One that doesn't encourage lying. One that isn't so ridiculous that it brings other more reasonable exclusions into doubt. One that doesn't conflate homosexuality with risk.

The numbers from these surveys are more credible than the ones I got from the GSS, which showed an implausibly high rate of blood donations regardless of sexual orientation.
NHANES is based on an in-person survey (the NHANES people literally drive up to your house with an 18-wheeler containing a mobile medical examination center), rather than the random digit dialing of the GSS.

My interest in pulling these data together is merely to document the existence of gay/bi blood donors, and that it is not an especially rare phenomenon, not to say exactly how many gay/bi men donate blood (or straight men for that matter). For that, we'd need even larger samples...

Proud of my grandfathers...

2009-02-11T19:12:00.000-08:00

So, the other day I heard about the boost in wind power that's likely to come about as part of the stimulus. I figure that GE's turbines are probably likely to be heavily favored in the US now matter how they stack up to the turbines from Denmark & Spain.
I had a faint memory that my grandfather had something to do with turbines at GE, so I called my mom, and she confirmed that her dad worked at GE in Schenectady as a turbine inspector, doing the final inspections on these enormous pieces of equipment before they got shipped out.
So, finally something to be proud about GE for, despite decades of harsh layoffs that severely affected my extended family in upstate NY.

A little more about my mom's dad. He arrived in the US as an infant in the arms of a single mother from Krakov, Poland just before the turn of the 20th century. I'm not sure how he and his wife met, but they settled on a small subsistence farm in Schohaire county, outside Albany/Schenectady, that my uncle continues to maintain to this day.
They raised eight children on that farm, my granddad working nights at the GE plant inspecting turbines, and working days on the farm with his wife and kids.
Somehow, they managed to keep all those kids fed and clothed, no mean feat in itself, but their proudest achievement was sending each and every one of those kids through college.
And now I'm teaching college. Pretty dang cool.

So, my mom and dad met while teaching at Ithaca High School, where they both started teaching after college. My dad was also a crew coach at Cornell, but that's another story.

His dad was a chemical salesman for Monsanto for most of his life, towards the end of his career he got into training other chemical salesmen. He was for a brief period the head of the New England Chemical Club, who used to invite various of the Red Sox out to their dinners and watch them make asses of themselves getting drunk among the various employees of the chemical industries.
And now I do research on the impact of chemicals on people's health. Pretty dang cool.

His dad (my great-granddad) in turn was something of an inventor, which I didn't know until various patents started showing up on the internet - an umbrella design - one of the early designs for a carbeurator - and a modular box design. I don't know if he made money off any of these inventions or not, and I don't know much else about the man at all. But an umbrella design, how cool is that. I'm tempted to go out and have one special-made for me using his design.

The Case of Sally Goodman

2009-02-07T13:18:00.000-08:00

Just found out that a short entered in the National Film Challenge 2008 48 hour competition The Case of Sally Goodman was shot in the house I live in. Apparently my dog gave a bunch of the crew allergies, so they had to cut out some scenes with sniffling in them.

John park's office is my roomie's bedroom, the cafe is our kitchen, and everything was shot right here in the span of one day. Pretty impressive!

LGBTI Health Summit - Chicago, August 2009

2009-02-07T12:42:00.000-08:00

Come to Chicago to the LGBTI Health Summit!
It's a great place to meet fun thoughtful sexy people.
I've been to my share of academic/professional conferences, and if I have any choice in the matter, I'll never go to one again.
The Health Summits are a different matter - spiritually enriching, intellectually stimulating, and cruisy, too. Totally rejuvenating.
See you there!

Excellent health in the Current Population Survey (March Supplement)

2009-01-26T15:58:00.000-08:00

Another data source that has data on general health is the "Current Population Survey", which is the dataset the US Gov't uses to estimate the unemployment rate, among other things. They interview about 47,000 to 57,000 households every month from all over the country.
Mostly they ask about who in the household is employed, unemployed, looking for work, etc. But every March, they ask a lot more questions, mostly about income & benefits, including health insurance.
Near the very end of the survey, they ask about the general health of everyone in the household, and that's what I'm interested in. The datasets are pretty huge relative to the capacity of my computer, so I've only been able to look at one year, 1998, so far.
In 1998, out of 64,659 households, I could identify 25,821 couple-headed households with non-imputed data on health. 23,124 of these were mixed-sex married, 1,366 were mixed-sex unmarried, and 24 were same-sex unmarried.
Admittedly, 24 couples out of 64,659 households is a pretty disappointing yield, but I'm told that as the years go on, more and more same-sex couples get accurately recorded, so I'm looking forward to more data from the other 10 years. But, on the plus side, 24 couples have 48 men in them, so that makes the sample size a bit more robust.
As you can see from the chart, there's really not much difference between the proportion of men in male couples who report excellent health (33%, 20%-46%), and the proportion of men in mixed-sex unmarried couples (33.6%, 31.1%-36.1%), or the proportion of men in mixed-sex marriages who do (31.0%, 30.4%-31.6%).
So, the fact that these results don't support the findings I'm seeing from California is mildly disappointing, but it's also clear that gay men (at least the ones in live-in relationships) aren't in dramatically worse health, which is what you'd expect to find given how we have been portrayed in the medical literature thus far.

I'm especially excited about the prospects for this dataset for a few reasons. First, it uses the same methodology (with minor twists) over an 11 year time span, so there is a lot of data to work with, even if the gay men in relationships are probably not representative of all gay men (but neither are married men representative of all straight men, for that matter), and since it spans an 11-year period, it might be possible to look at trends in 'excellent' health over time.
Second, they try to interview about half the same households the following year, so it would be possible to look at changes in health status over time (though this would only be true for one year's change for any individual), and also health in relationships that last vs. those that dissolve.
Finally, and best of all, is that the survey covers the whole geography of the United States, so I can look at health in relation to homophobia levels much more in-depth than is possible within the state of California. Perhaps the health of gay men is better in California and New York City than straight men, and worse than straight men in Wyoming and Nebraska, that might help explain why many of the national studies don't show much difference...
What do y'all think?

401 in the House

2009-01-22T07:34:00.000-08:00

What an exciting week! Filled with visitors from Rhode Island...

Martin has been visiting for a few days, we walked all over town with his friends Sam and Byron, and did a bunch of touristy things on a gorgeous Sunday after dim sum. Then on Tuesday we played badminton at the Y, and last night had a gym date & dinner in the Castro.

Sam from the public health Dep't at Brown came out for a postdoc interview at UCB/UCSF yesterday and we had a grand time catching up. She's doing really interesting work looking at the effect of court-mandated desegregation orders on teen pregnancy rates. I can't wait to read it.

And tonight, I'm going to see Beach Blanket Bablyon with woolverine and ellison. We've got one extra ticket, so if you know me & want to go, don't be bashful. It will only go to waste otherwise...

More Results on Gay Men in Excellent Health

2009-01-19T12:04:00.000-08:00

So, I've looked at two more datasets in examining this phenomenon which started with noting that gay men were more likely to be in excellent health than straight men in the California Health Interview Study (CHIS).
Many thanks to Randy Sell at Drexel who has collated information on a large number of national and state-level studies that ask people about their sexual orientation and/or sexual partners at www.gaydata.org.

In the General Social Survey (GSS), a large telephone survey that has been on-going since 1972, they asked about the sex of respondent's sexual partners in the last year, the last 5 years, and since age 18, in various combinations since 1988. (I used this same dataset to look at the phenomenon of gay men giving blood, which can also be considered as an indicator of well-being).

In the GSS, 33% of men who had sex exclusively with other men over the prior five years (26%-40%) were in excellent health, virtually identical to the 33% (31%-34%) of men who had sex exclusively with women over the prior five years.
Looking at sexual partners just in the last year, 35% of men who had sex only with men in the previous year (29%-42%) were in excellent health, about the same as 34% (33%-35%) as men who had sex only with women in the previous year.

In the National Household Survey on Drug Abuse (NHSDU), on on-going telephone survey used to understand drug use in the US, they asked about sexual partners in one year, 1996. For reasons I don't understand, they never asked before or since. If they had, this survey could have been one of the best sources of information on LGB population health.

52% of the 58 men who reported sex only with males were in excellent health (39%-65%), which is much higher than the 36% of the 3,196 men who reported sex only with women (35%-38%).

The proportion of men who had sex with men who reported excellent health in this survey was a lot higher than in other surveys, too, so I'd be a little cautious in putting much faith in these particular results.

Tuna, the turd burglar

2009-01-17T08:58:00.000-08:00

There's just no polite way to say this.
My dog is an aficionado of human waste. Especially when it is redolent with the flavors of a hard night out drinking.

Oh, it's not just Tuna. All dogs are turd burglars. Keep that in mind when you're thinking about that cute puppy in the window. It'll be a cute puppy for another 2-3 months, and then you've got a full lifetime of turd burgling ahead of you. It's worth it, but just walk into it with your eyes open.

We take our morning walk in Buena Vista Park at about 8:30-9, and given how many other dogs have been running around sniffing it out, I'm amazed that any of it is left for us on the late end of the morning shift.

But every once in a while she'll come strutting out of the bushes, a little swagger in her step, and of course the shit-eating grin, smacking her lips. So, when we get home, I hose out her mouth and feed her a breath-freshener.

One of Harvey Milk's great accomplishments was a pooper-scooper law, memorialized in the recent movie Milk. I'm wondering what we can do about the human waste problem in the city now... Of course, the vast majority of our un-housed citizens figure out a way to take care of these needs hygienically (if you can call the bathroom at Carl's Jr. on UN Plaza hygienic), but I'm thinking maybe we should be handing out sturdy large-size plastic bags alongside the blankets and food.

New York City MSM more likely to be in excellent health

2009-01-16T21:06:00.000-08:00

More evidence that gay men are more likely to be in excellent health than straight men...
The New York City Department of Health and Mental Hygiene kindly makes data from its BRFSS available online.
Since 2002, they have been asking men their sexual orientation and also whether they have sex with men. Although the sexual orientation data is in there, it is not accessible on the website broken down by gender. But the sex with men variable is, so I used that as the closest approximation until I can get my hands dirty with the SAS programming.

The upshot is that in 5 out of 6 years, men who have sex with men were more likely to be in excellent health, after age-adjusting, than their (mostly) heterosexual counterparts.

When averaging the six years together, 27.5% (24.4%-30.6%) of New York City's MSM population were in excellent health, compared to 21.5% (20.7%-22.3%) of mostly heterosexual men in New York City.

That's very similar to the results from CHIS. After combining data from 2003,2005 & 2007, the proportion of California gay men in excellent health is 26.6% (23.1%-30.2%), compared to 22.1% (21.5%-22.6%) of straight men in California. These results are not age-adjusted like the NYC results, but I don't think that would make much difference.

Anyone want to speculate as to why gay men (at least in California and New York City, if not Canada) are more likely to be in excellent health than straight men? What lessons can straight men learn from us to be healthier?

Canadian Gay Men Only Slightly Healthier than Straight Men

2009-01-16T15:33:00.000-08:00

Came across a neat study done by Statistics Canada. They interviewed about 260,000 Canadians for the study in 2003 & 2005 (Canadian Community Health Survey, CCHS). They found that gay men were slightly more likely to be in "very good or excellent" physical health (65.4%) than heterosexual men (63.9%, difference not statistically significant) but slightly less likely to be in "very good or excellent" mental health (73.8% vs. 75.4%, also not statistically significant).

I used the population from the California Health Interview Survey (CHIS) that most closely matches the Canadian study for comparison, adults aged 18-59 interviewed in 2003 & 2005, and lumped "excellent" and "very good" the same way they did. In California, 61.2% of gay-identified men reported "very good or excellent" general health, versus 54.3% of heterosexual men, a much larger difference.

The first thing that jumps out at me is that Canadian men seem to be a much healthier lot no matter what their sexual orientation is.

But it does leave me scratching my head - why are gay men more likely to be in excellent health than straight men in California - but not necessarily so in Canada, which has had a much friendlier political climate? Hmmmm...

Research Worth Reading (2)

2009-01-13T22:47:00.000-08:00

Well, the first installment of Research Worth Reading was such a hit I'll try my hand at another.

This article is interesting to me because it attempts to measure the impact of a changing society on gay men's health, which is similar to what my dissertation thesis work was about, too. My interest is mainly in their approach and rationale. Unfortunately, their results didn't pan out the way I would have hoped, but it's important to take negative results humbly into consideration as well.

I came across this article while doing some background reading on excellent health, in my quest to understand why gay men (at least in California) are more likely than str8 men to be in excellent health.

Health-related quality of life in homo- and bisexual men attending a sexually transmitted disease clinic in Sweden.
Lars E. Eriksson & T. Berglund (2007)
International Journal of STD & AIDS 18:207-211.

In 1996, these guys asked 164 men who came to the Karolinska University Gay Men's Health Clinic (basically an STD clinic, from what I can tell) a ton of questions about their well-being and quality of life, and then they did the same thing again in 2004 with 201 different gay/bi men.
They reasoned that since major shifts in Swedish law had occurred between these dates (gay rights protections and recognition of similar gender marriage), the quality of life of gay men would have improved as a result.
So, they compared the average health/well-being/quality of life of the gay/bi men they interviewed in 1996 with the gay/bi men interviewed in 2004. All-in-all, there was not any big improvement, counter to their expectation.
For example, they measured 'general health perception' on a scale from 0-100, and half the men in 1996 gave responses between 72 and 94, while in 2004, half the men gave responses between 67 and 94, so there's really not much difference in these distributions.

Why not?
The authors puzzled over why they didn't see improvements in gay men's health in Sweden: "Firstly, it might require a longer time frame for the positive changes in legislation and attitudes to have positive influences on the individual experience of health-related quality of life. Secondly, other factors could counteract the legal and attitudinal changes... {such as} hate crimes related to homophobia, a phenomenon that has increased in Sweden during the last few years. Another reason could be the increased vulnerability due to health aspects. For example, since the 1990s, the STD incidence among MSM has increased...in Sweden."

Of these, I find the first the most compelling. Although in my own study, there doesn't seem to be much, if any, lag time between the societal attitudinal changes resulting in passing a gay rights law and reductions in white male teen suicide rates. On the other hand, the men they studied were mostly adults, whose general well-being may be more influenced by conditions during their own adolesence than the rapid changes that occurred in Sweden in the late 1990's. If that's the case, they might well see effects if they compared young gay men who "came of age" since 2000 to young gay men who came of age in years past.
The second argument (that some countervailing force undid whatever benefits came about from changes in societal attitudes around homosexuality) rings hollow to me. I base this on the fact that, in the US anyway, one finds the highest hate crime rates in areas that are most tolerant of homosexuality. At first, this doesn't make sense, but when you stop to think about it, crimes are only counted if they are reported, and once reported if they are taken seriously and recorded. So, it is not surprising that hate crime reporting is higher in more tolerant areas, even if hate crime rates may not be.
The third argument (that rising STD rates are responsible for gay/bi men in Sweden not feeling their best) also rings hollow to me. It might affect the gay men who do get STDs, but that's a minority, and the overall distributions of health are pretty much the same in both years, it's not like some men are feeling less healthy and others are feeling healthier, resulting in the same average.
One explanation that they seem not to have considered is that the gay/bi men that they interviewed in both years were generally very healthy on all subscales, so that there just wasn't a lot of (statistical) room for improvement. For example, over half the gay/bi men in 1996 reported no pain at all, and thus scored 100/100 on that scale. So, it would be virtually impossible to show any improvement in that measure. And that was the case for 6 of the 13 subscales they assessed.

At any rate, the thing that excited me about this paper was that it is another example of trying to understand the impact of shifts in public discourse on health, and it was also looking at health as a positive attribute, not the absence of illness. It's too bad that their results didn't pan out...

Gay Men in Excellent Health - More from CHIS

2009-01-09T16:35:00.000-08:00

So, I decided to look at this phenomenon of gay men being more likely to report being in excellent health than straight men from a slightly different angle - namely does it make a difference where one lives.
In particular, does the social environment of heteronormativity play a role in gay men being more likely to report being in excellent health?

The recent vote in California on whether to restrict the legal definition of marriage to "one man and one woman" (OMOW) seems like a pretty good way to define an area's heteronormativity, the more people who endorsed proposition 8, the higher the level of heteronormativity. Got this data from the California Secretary of State's Statement of the Vote.

So, using AskCHIS, I got estimates for the proportion of gay men and straight men reporting themselves to be in excellent health for 11 regions of the state: the counties of Los Angeles, San Francisco, and Riverside, and then 8 groups of counties (East Bay, South Bay, North Bay, Sacramento area, North & Sierras, Central Coast, Orange & San Bernardino, San Diego & Imperial, and the San Joaquin (Central) Valley). I had to use groups of counties in order to get enough sample size to estimate the proportion of men reporting excellent health within each region.

The proportion of gay men reporting excellent health was highest in San Francisco county, 34%, but this needs to be taken with a pretty big grain of salt, because the CHIS survey data would be compatible with a range from 25% to 42%. The lowest proportion of gay men in excellent health was in Riverside county, 13%, with a range compatible with the survey from 5% to 21%.
These two seem to line up with my hypothesis pretty well, in that only 25% of San Francisco voters endorsed a OMOW definition of marriage, while 65% of Riverside county voters did.
But, voters in the San Joaquin Valley (San Joaquin county down to Kern) endorsed OMOW by 70%, and yet had the 2nd highest proportion of gay men reporting excellent health: 32%, range 12% to 51%. So, it's not like there's a one-to-one correspondence.

Among straight men, the highest proportion reporting excellent health was also in San Francisco, 26% (23%-30%), and the lowest was in the San Joaquin Valley, 19% (17%-21%). In general, there was a much tighter correlation between the proporotion of str8 men reporting excellent health and how voters endorsed the OMOW restriction of Prop8. The tight correlation has mostly to do with the fact that there are more str8 men, and therefore better estimates of how healthy they are.

Of course there are many other potential explanations for why gay men (and str8 men) seem to be healthier in areas that are less homophobic (as measured by endorsing Prop8) in the CHIS data. For instance, it could be that older people are more likely to live in the more homophobic areas, and since old people are less likely to report being in excellent health, that's why you see fewer gay and str8 men reporting excellent health in the more homophobic areas.
Also, the mode of analysis I used is very preliminary - not only no control for potential confounders, but also the estimates of how likely men are to report being in excellent health is based on some pretty small numbers. But, it's enough to get the brain juices flowing, and perhaps to help me convince CHIS to give me access to individual-level data files...

Disarm BART Police

2009-01-08T11:07:00.000-08:00

The murder of Oscar Grant on January 1st by BART police officers Johannes Mehserle and an as yet unidentified accomplice who held him face down with a knee to the neck has got me (and a lot of people) hopping mad.
There is no need for transit police officers to have lethal force at their disposal.
I love BART. It's a great asset to my lifestyle, being able to commute conveniently with a minimum of pollution. But it makes me fear for my safety knowing that these officers are armed. This morning, I saw a BART officer at the top of the stairs at the Downtown Berkeley station and I waited until he left before leaving the station. I didn't want to be anywhere near him.

Research Worth Reading

2009-01-02T19:58:00.000-08:00

About a month ago, I was engaged in an on-line discussion about what constitutes 'lousy' research. In my opinion, the majority of health research related to gay men qualifies as 'lousy'. But, I thought it would be a good idea to focus on research worth reading, holding up examples of research that is well conceived and thought-provoking.

So, I went on to webofscience.com and rooted through the most recent stuff pertaining to 'gay' and 'health'. I went through literally hundreds of titles and dozens of abstracts before finding the first article that I actually wanted to read.

So, here's the first installment of 'research worth reading'.

A Phenomenological Investigation of the Experience of Taking Part in 'Extreme Sports'
Carla Willig, City University, London, UK
Journal of Health Psychology 13(5):690-702
DOI: 10.1177/1359105307082459
Abstract: "This article is concerned with what it may mean to individuals to engage in practices that are physically challenging and risky. The article questions the assumptions that psychological health is commensurate with maintaining physical safety, and that risking one's health and physical safety is necessarily a sign of psychopathology. The research was based upon semi-structured interviews with eight extreme sport practitioners. The interviews were analysed using Colaizzi's version of the phenomenological method. The article explicates the themes identified in the analysis, and discusses their implications for health psychology theory and practice."

The thing that grabbed my attention about this article is that it is trying to understand 'risk' from an inherently non-pathological perspective. Basically, the author interviewed eight people who frequently engage in extreme sports (sky diving, mountaineering, etc.) about why they do it and what they get out of it.
I thought that was a brilliant strategy to get past some of the problems presented by risk-oriented thinking in various health fields, and she definitely puts it in that same context.

She encourages the reader to imagine a parallel non-pathologizing approach to understanding health-related risk taking, from smoking and diet, to speeding and unprotected sex. And so I was reading along thinking about what parallels there were to what she reported hearing in those interviews with gay men and sex. Some of it seems to fit perfectly, and some seems incongruous. The point, for me anyway, is not to portray gay sex as entirely analogous to extreme sports, but rather to begin to re-conceptualize the reasons gay men have sex they way they do that isn't about 'making bad choices' on one hand, or being completely overwhelmed by structural forces (the internalization of homophobia, racism, etc.) on the other. Of course, this re-conceptualization happens all the time, but it seems to have a hard time sinking in to public health types.

A choice quote framing her motivation for conducting the study:
"... behavioural choices that do not prioritize health and safety constitute a challenge to psychologists, and one way of meeting this challenge has been to re-conceptualize such choices as the product of psychopathology or false beliefs, and thus not really choices at all. ... An alternative viewpoint would be that there is more than one rationality and that ... it is possible, and worthwhile, to attempt to bring to light their meaning and value to those who engage in them."

Parallels with the experiences of, and motivation to participate in, extreme sports
Just imagine the parallels while reading these quotes about extreme sports participation.

"...among those who practise a particular extreme sport there may exist a strong bond and strong feelings of comraderie generated by being together during moments of great vulnerability."

"The experience offers its participants access to combinations of feelings and sensations which are not available in everyday life."

"In some cases, a sense of loss of control and letting other people take responsibility for one's safety forms an important part of the experience as a whole."

"...taking part in these activities constitutes an extremely important part of one's life and that one's sense of self, identity and well-being is clearly bound up with them. ... life without it was inconceivable."

"Gaining experience and getting better at performing the sport generated a sense of mastery, and this was experienced as rewarding."

"... one's world is reduced to the immediate present. Participants described life becoming very 'simple' and 'straightforward' ... Participants experienced this sense of being in the present as calming and relaxing, comparable to a 'meditative state'. It allowed them to lose themselves in the present and to be momentarily freed from the concerns and responsibilities associated with everyday life."

"...taking part in extreme sports on a regular basis was experienced as therapeutic, reducing stress levels and preventing the build up of tension by minimizing the significance of past and future concerns."

"the experience of extreme sport provided something vital for participants which they could not access in other ways."

"There was a sense of pleasure through feeling alive, energized and vital ... sometimes lasting for days afterwards. They were felt throughout the body and they seemed to lie outside the normal range of emotions experienced by participants in their everyday life."

"...what may appear, from an outsider point-of-view, as reckless ... participants' own accounts suggest that what is required is a carefully staged scenario which produces just the right balance between challenge and comfort in order to allow a certain kind of {transcendent} experience to become possible."

"...the acquisition of the necessary skills and experience takes place over time, ... and may involve status and identity formation within the context of a community of likeminded and supportive peers."

"...taking part in extreme sports activities means more to participants than searching for thrills and excitement, ... they are making informed choices rather than simply acting out unresolved conflicts or implementing distorted cognitions."

"These observations raise questions about the extent to which taking part in extreme sports may itself constitute a therapeutic experience."

"From this perspective, the adoption of what may appear to be extreme, excessive or maladaptive practices or preferences may, in fact, be ways of (re-)establishing psychological balance by adding missing meaning elements and by allowing neglected or marginalized dimensions of existence to be lived."

bottom monologues

2008-12-08T17:40:00.000-08:00

Hey bottoms, tell your story. You'll be glad you did.

So will Trevor, Alex & Erik. And so will I.

gay blood donors exist

2008-12-06T14:40:00.000-08:00

Gay blood ban
It's my belief that the ban on gay blood donations should be overturned.
The ban is patently discriminatory, based on stereotypes, but justified under the mantle of medical science. It's just one example of how rank prejudice is remade as scientific, sanitized, made to appear ethical.
Technically, the ban is on a man who has "had sex with another man, even once, since 1978". There is no ban on women who have had sex with a man, although there are specific categories of male sexual partners that trigger excluding a potential donor from giving, if she has had sex with them in the last 12 months.

Does the ban "work"?
Does the ban in fact keep gay men from giving blood? The simple answer: no.
The more complicated answer: in the General Social Survey, respondents were asked (in 2002 and 2004) whether they had donated blood in the past year, and also several questions about the sex of their sexual partners. Here are the results, using three different definitions of sexual partners...

Among 36 men who reported at least one male sexual partner in the last year, 6 (17%) said they gave blood in the last year. This is somewhat lower than the 22% of 826 men with exclusively female partner(s) who said they gave blood.

Among 43 men who reported at least one male sexual partner in the last five years, 6 (14%) said they gave blood in the last year, while 21% of 884 men who had sex only with female partner(s) said they gave blood.

Among 58 men who reported sex with at least one male sexual partner since their 18th birthday, 4 (7%) reported giving blood in the last year, while 21% of the 942 men who reported no male sexual partners since turning 18 reported giving blood.

There are good reasons for being a bit skeptical about these data, but more on that later...

Adverse consequences
If the ban on gay blood donors doesn't "work", then is it worth maintaining? What are the consequences of maintaining a patently discriminatory policy?

1) An unjust ban on gay blood donors encourages lying. Anyone (straight or gay) who sees the exclusion of gay men as discriminatory will begin to question the validity of the other screening questions, perhaps taking liberties with answering screening questions that have a valid basis for protecting the blood supply.

2) It justifies discrimination in other areas. The fact that most people believe the screening questions on the blood donation form have some scientific or medical basis makes it appear as though this form of discrimination is beyond questioning. Justification of discrimination in one setting encourages people to justify for discrimination in other areas (even on a different basis).

3) The ban makes it unclear how a gay man should approach donating blood. By having an outlandishly discriminatory donor exclusion policy, blood banks are in effect encouraging each gay blood donor to make up, in his own opinion, when it is safe enough for him to give blood. Whereas a policy in line with the other donor exclusion policies would set a more realistic set of limits that gay blood donors would be more likely to honor.
A consequence of this is that the ban on gay blood donors may in fact make the blood supply less safe.

4) The ban reduces the potential pool of donors, in more ways than is immediately apparent.
4a) It is well documented that gay men are more likely to give altruistically in a variety of ways, thus the ban cuts out a segment of the population that would otherwise be eager to give. Although gay men represent a small proportion of all potential donors, and even though many gay men would be excluded for medically justified reasons (such as having unprotected anal sex in the last six months), the exclusion of a motivated group of potential donors may not be a great idea.
4b) The blatantly discriminatory nature of the ban on gay blood donors has already started to lead to a wider backlash. Some straight men, and women of all sexual orientations, get a bitter taste in their mouth from the obvious discrimination of banning men who've had sex with even one man, even once, since 1978. This bitter taste shrinks the pool of potential donors, probably in much larger numbers than the gay men excluded from giving currently.
4c) College campuses, settings where many people initiate a lifetime habit of giving blood, are also settings where action is likely to be taken against discriminatory policies, and in fact blood drives have been canceled on several college campuses already, with the promise for such action to expand in the future. Can the blood supply afford to lose all these potential future donors?

who are the gay blood donors?
I don't know. I'd love to talk to a few to get a better sense of what motivates a gay man to give blood. How does giving blood relate to a man's sense of well-being? How does being refused the opportunity to do so without lying relate to a man's health? Are gay blood donors much more scrupulous about the other screening questions to compensate for lying on one question? Or are they more likely to overlook the other questions?

data limitations
the number of men who report male sexual partners is already pretty small in the GSS (36-58, depending on which question), and the number of these men who report giving blood is even smaller, 4-6. So, it is possible (if unlikely) that these are all data errors. That is, it is at least theoretically possible that 6 respondents weren't paying close attention when asked either about giving blood, their sexual history, or both questions, and gave answers at variance with their actual experience. Or, the telephone interviewer may have slipped when entering the number corresponding to the person's answer.
In addition, there are good reasons to think that the proportion of people saying that they gave blood is considerably higher than the number who actually did give blood. For one thing, a small handful said that they gave blood monthly, even weekly. Blood centers generally ask donors to wait at least two months between donations, so these answers are highly suspect. The other thing is that over 20% of the GSS respondents reported donating blood, but probably no more than 10% of the population actually does donate blood.
However, my point was merely to document that gay blood donors exist, not to give a precise estimate of how many gay men are blood donors. Better data would be needed to make that estimate.

more healthy gay men

2008-12-03T21:44:00.000-08:00

I just looked at the data in the MIDUS-2 study, and the sample is just too small to say, but it looks like gay men and straight men are just about equally likely to be in 'excellent' health. As in CHIS, bisexual men may be somewhat less likely to report excellent health.
On to the next dataset...

gay men in excellent health

2008-12-01T15:37:00.000-08:00

Just had an idea for a research project.

I was chatting with Rachel about why my research seems so alone in the world - nobody in the Public Health world seems to have picked up on the utility of looking at empirically measured changes in societal heteronormativity as having the potential to affect health impacts - and I don't know why. Gay & lesbian people 'get it' instantly. Public health types seem to get confused by not knowing precisely which biochemical pathway a change in law would need to activate.

Anyway, I was working last week on data from the CHIS, and noticed that gay men (in the aggregate) are more likely to report being in 'excellent' health than straight men. My public health training told me to ignore it - 'excellent' health is not a disease, after all. It's a squishy endpoint, who knows what it means?

But something sparked in me during the conversation with Rachel.
Why are gay men more likely to be healthy than str8 men? Maybe it's not a strange question. Maybe it's an endpoint that's worth a little more investigation.

I know that nobody in the epidemiology world will believe it if it's a single finding. As large as CHIS is, it is only one dataset. So now I need to go poking around in other datasets which ask similar questions - and fortunately there's a lot of them.

I'll keep you posted...

BoneHenge!

2008-11-27T10:11:00.000-08:00

This is a shout-out for my aunt and uncle who are involved in a project to recover the bones of a sperm whale that washed up near Cape Lookout, North Carolina.
They are having a shed built on their land in Carteret County to house the bones until they can be re-articulated and put up for display in the nearby maritime museum.