A recent study shows that chronic exposure to discrimination and stigma can negatively impact the health of trans and nonbinary people. But it also shows that a strong sense of community can help alleviate those impacts. The findings are part of the broader Trans Resilience and Health Study, co-led by Jae Puckett, an assistant professor at Michigan State University, and Zachary DuBois, an assistant professor of anthropology at the University of Oregon.
DuBois joins us to talk about the recent findings, as well as the broader effort to explore trans resilience and health across the U.S.
This transcript was created by a computer and edited by a volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. A recent study found that chronic exposure to discrimination and stigma can negatively impact the health of trans and nonbinary people. But there was a bright spot in the research, a kind of flipside, a strong sense of community can promote well being. These findings are part of the broader Trans Resilience and Health Study, co-led by Zachary Dubois. He is an assistant professor of anthropology at the University of Oregon and he joins us now. Welcome to the show.
Zachary DuBois: Thanks for having me.
Miller: This new work, as I noted, is part of your broader Trans Resilience and Health Study. What was the impetus for that project?
DuBois: Well, as you mentioned, my friend and colleague, Jae Puckett, and I, designed this study together. So they are faculty in the psychology department at Michigan State University and we really wanted to design something that was targeting this idea of trans resilience. And this was in 2018. We had heard about that memo that was leaked. People may remember the memo that was leaked during the Trump Administration where they were indicating that they wanted to rigidly define sex and gender. And this would have been at the federal level as binary, as unchangeable and really based on very narrow aspects of human biology. So this would have really further oppressed and stigmatized trans and nonbinary people in the United States. When we heard about this–and we certainly see this kind of legislation and these kinds of attacks have only escalated since at the state level–we decided that we wanted to design a study to learn more about what it’s like for trans people who are living in varied sociopolitical contexts or in different states and how stigma and stress and also resilience impact our health.
Miller: That word “resilience” is right in the title of your overall project. Is there a commonly-accepted definition of resilience?
DuBois: This is a really great question because it really is this idea of resilience, as you’re saying, that guides a lot of what we’re hoping to learn about in our study. In fact, during one of the interviews, we actually just asked participants to share how they defined the term and then what it looks like or what it means in their own life. In terms of general understanding, I think most of us for definitions, most of us think of the term resilience as meaning something positive. So either being able to recover quickly from stress or hardship or trauma or having those things somehow make less of a long lasting negative impact. So that would be whether that’s on physical or mental health or just more generally in a person’s life.
Miller: What does resilience mean to you personally?
DuBois: Well, I would say that there are a lot of really valid critiques of this specific term that I agree with. So often, people use phrases like “bouncing back from harm.” They use metaphors to talk about resilience. And I certainly think that’s true, that that’s what we can experience in terms of what this word may mean to us, but there’s something about the term that also limits what we think is possible, right? It’s focused on survival more than thriving. And I really think that in thinking about trans lives, for instance, there’s this fixation on what we call deficit models or focusing, for instance, on gender dysphoria. And increasingly as a community, we’re really trying to talk more about trans joy and gender euphoria and the fact that we can thrive and not just survive. So resilience can be kind of limiting in that way.
Miller: You ended up focusing on four states that occupy very different parts of the American political spectrum. And obviously, within each state, there is a huge spectrum of everything that we’re talking about here. But the four states are Oregon, Michigan, Nebraska and Tennessee.
How did you go about recruiting participants in these four states?
DuBois: So we recruited in ways that are fairly typical for this kind of community-based work. We advertise the study certainly through social media, Instagram and Facebook and things. And then we also reached out to local organizations in each state, specifically targeting organizations that provide support and different kinds of resources to trans and nonbinary people. We asked them to circulate the information about the study. We also relied heavily on word of mouth in the community itself. So for people to share the information about the study with one another. And overall, we got a huge and really positive response from people in each state.
Miller: What kind of medical data did you collect?
DuBois: One of the things that’s really quite unique about this project - and I want to speak to the fact that you’re using the word “medical.” When people think of trans people, a lot of people think about our medical health or think through a medical kind of model. And that’s because of gender-affirming care. So that’s what makes sense. And a lot of studies are clinical and medical in that way. And this one is a bit different in that we didn’t collect data in a clinical environment. So we’re not in a hospital setting. This is not a clinical sample in that way, where people come into the doctors and then get recruited to a project. I’m an anthropologist, Jae is a psychologist. And what we did instead is this community-based recruitment to learn more about the experiences of trans people in these different states and also integrate experiences with these health measures.
So what we were using is really novel, really coming out of anthropology, what are called minimally-invasive biomarkers sampling. And what that means is that in addition to doing interviews, these were in-person interviews at baseline. Then a year later, we collected health measures and often, these were in people’s homes or community centers where we could connect with folks. In other words, not in a hospital environment. Some people came to the universities but not everybody. We drove all around the state. What we collected were things like blood pressure, a blood spot from a finger poke that can tell us about inflammation levels and blood lipids. We also took salivary samples. So people took those at home with little tubes and then mailed them back to us. And that’s where we got this measure of the stress hormone, cortisol, that’s described in this recent paper.
Miller: How did the fact that many of your subjects are transgender affect the way you thought about the health data you were going to be collecting and how would you collect it?
DuBois: Oh, that’s a good question. Again, there’s a lot of research that is collected in clinical environments and that makes sense when we’re trying to understand, for instance, long-term health related to gender-affirming care. But because we are interested in really trying to understand more about stigma and embodied stigma and stress and how these can affect health and then also resilience, measuring things that are related to stress and the systems that are impacted through stress physiology is really helpful. We all experience stress, but it can tell us for instance, when you’re part of a marginalized group or you experience stigma and inequality and discrimination and victimization. That kind of stress lands in the body on top of normal everyday stressors.
So the type of measures that we took are really aiming to sort of give us more clarity around that kind of embodied experience, to look more towards health risks that can be exacerbated because of these experiences of stress and inequity. And also through the minimally-invasive aspect of these biomarker measures–as I describe, people could come into the university–we could do this in people’s homes. These are all portable devices. This is really methodologically important because a lot of trans people have experienced trauma and harm through the medical system, and there’s stigma there. So in having this be a community-based study where we ourselves are trans-identified, being able to connect with people one-on-one in that way and being given agency around even doing some of these measures, we are very thoughtful about designing how we collect those measures in ways that are inclusive and recognizing people’s experiences.
Miller: Just so I understand. For example, if you had people go into medical centers where blood samples would be taken, the fear is that that act could actually lead to spikes in hormones that would mess up the data. That there’d be potentially a stress related to those environments, which would invalidate the very stuff that you wanted to learn.
DuBois: Certainly, potentially that’s true. And people probably have heard of the phrase “white coat hypertension.” For people who have anxiety, going to the doctors to measure your blood pressure can heighten your blood pressure. So certainly, that’s one of the things that you’re speaking to that can happen. Absolutely. It’s very important to assess those things.
I just want to be clear, we want to improve the nature and quality of care that people get in those medical environments. But you’re right that our study was not assessing that per se. We did talk to people about their experiences with medical professionals during the interviews, but we weren’t trying to measure stress related to that. So you’re right, we wanted to capture more of what people were experiencing in their day-to-day life.
And also, we didn’t want to limit who might participate. Because the other side of what you’re getting at is that people who participate in studies that are through clinical environments or accessing clinical care…and there’s so many reasons why people aren’t or can’t, and we wanted a broad sample of participants to include people that may live very far away, for instance, from even places where gender affirming care is provided. So we wanted to go to them, not require them to come to us in a medical environment.
Miller: What differences did you find in terms of cortisol or hormone regulation among the various participants in your study?
DuBois: What we found overall was…and I’ll just say cortisol is the primary stress hormone that we measure in humans. And this is a hormone that people often think of as a bad thing because they think it’s related to stress. So I just want to start by saying it’s not bad in itself. Cortisol is a hormone that does a lot of things in the body. It affects how we feel, it affects our energy levels and it affects our immune systems and how they function and we secrete it all day in a normal kind of rhythm. I’m setting up what we found so that folks understand. Usually your body secretes cortisol higher in the morning and then it goes down over the course of the day. And that’s a normal rhythm. So we took three measures from participants because we wanted to understand if that system was deregulated or is it working in its normal way. And that’s important because it does speak to how we respond to stress.
Normally, when you experience a stressor, cortisol does go up and then ideally, it goes down afterwards, so it’s helping our body respond to that stressor. It’s important to see if that system is working properly or if it’s been somehow deregulated. And that’s what happens when we’re chronically exposed to stress or we experience regular acute stress. That system can get thrown off. In our studies, people are exposed over the course of the day to more gender-related, what we’re calling enacted stigma, and this includes things like discrimination, rejection and victimization. We found that in measuring these measures, people who were exposed actually had a blunted response, so a lower level of cortisol is produced in the morning and this is usually when that would be higher. So this is an indication of a certain kind of dysregulation that’s really important and it can mean that the body is challenged in terms of stress response.
Miller: When you say that people who had a higher level of encountering enacted stigma, is that based on geography or on their reports of what they experience wherever they happen to live in the course of their days? In other words, I guess what I’m really wondering is if you could chart these differences in cortisol in, say, blue states versus red states, or did it not map out that cleanly?
DuBois: Yeah, great question. So it did not map out that cleanly, which is really what you’d expect. Because what we do know is that while there are implications of legislation at the state level, there’s a lot of variation within each state. We’ve got communities that are very dynamic in rural southern states just as we do in northern urban centers. And pit those against each other because it’s generally what people think of as progressive or more conservative. So you’re right that what we are seeing is more on an individual level when we asked people in the survey to describe their experiences of stigma and they completed several surveys and scales.
What we found is people who reported experiencing higher levels or more frequent levels of experiences of discrimination, rejection and victimization in particular, when we compared those individuals to individuals who had less enacted stigma, we see differences in cortisol response. So it means that the experience is driving that difference in stress response. And certainly, a larger study that had more states included, where we could get just a larger sample size, would be capable of being able to assess more comparatively across many states. But with four states, it’s really challenging to make that claim around blue versus red for instance, but it does allow us to see the impact of those experiences. So if we see legislation, for instance, that increases acts of discrimination or fails to protect people from it, then what we can see here is that if individuals are experiencing more inactive stigma, that can negatively affect health. So the implications are downstream.
Miller: What made the biggest positive differences in terms of the health effects that you were able to measure. What helped people the most?
DuBois: What we found is really moralizing, I’ll say. It gives us some hope that people who are more connected to their communities…and by that, we’re specifically referring to other trans and nonbinary people. What we found is people are more connected, and have more of what we’re calling robust patterns of cortisol response. So that blunting, that dysregulation was kind of buffered by the fact that people were reporting to be connected. We asked again, through surveys, for people to share with us how connected they felt with other people who share their gender identity, how much they feel part of that community, to what degree they feel a sense of belonging and if they also feel isolated or separated from people - so getting at that that opposite side of that connectedness. And we found that even with that really simple measure of community connectedness, more connection meant a healthier cortisone response.
Miller: Do you think that your research suggests concrete actions that allies or organizations can take to support trans people who are more likely to encounter, what you call, enacted stigma? What are the lessons here for people who want to help?
DuBois: These are big questions. I think that we know that gender marginalization, that stigma, that inequality and that stress, harm people. We know that inequality harms people in so many ways, including mental and physical health. We also know, through so many studies with many communities, that support and connection can kind of mitigate the negative effects of those experiences to a degree. So certainly, that’s one thing as to how concretely can we provide access to support? How can we fund centers and organizations that enable trans nonbinary people to connect with one another more directly, and [in] safe and meaningful ways? How can we support that? How can we stand against legislation that criminalizes trans people as people in public space and in public life?
These things happen after this study with some of the escalations in states like Florida, for instance. These things happen after this study. And so what, instead, we’re seeing is the opposite of what can help. So standing against those kinds of legislative proposals and increasing the degree to which trans people are protected legally against discrimination, based on gender expression and gender identity, would be really key structural-level changes. And in addition, I think broadly, culturally as a society, being more open minded to recognize that people express their gender and feel at home in their bodies in varied ways, in diverse ways. Anything we can do to increase the acceptance of that and the inclusion of trans people in positive ways without judgment and stigma.
Miller: Zachary DuBois, thanks very much.
DuBois: Thank you.
Miller: Zachary DuBois is an assistant professor of anthropology at the University of Oregon.
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