An Ethical Lapse? 

The ill-advised promotion of a simple reliance on pseudonyms as the means for protecting individual’s identities in clinical and research case-study reports.



By Lynn Conway

Professor of Electrical Engineering and Computer Science, Emerita

University of Michigan, Ann Arbor, Michigan 48109

Member, National Academy of Engineering


July 14, 2004

[V 7-27-04]



The Bailey book fiasco of 2003 [1, 2, 3, 4] is leading many research universities to reexamine the principles and guidelines they use to insure the integrity of scientific research involving human subjects, and to better protect the human rights and personal safety of those human subjects.


One practice that clearly needs reexamination is the over-reliance amongst psychologists on the use of pseudonyms to “disguise” individuals’ identities in case study reports, as if that alone were an adequate means for protecting clinical and research subjects’ privacy and confidences. 


Over-reliance on pseudonyms as the means of protection appears to be irresponsible, and indeed unethical, in the cases of endangered individuals and classes of people who face grave risks and have special vulnerabilities if they are “outed” by the details within such case-study reports.


Here we examine one class of endangered persons (transgender and transsexual women [5]) and study an example publication (the Bailey book [1]), where pseudonyms were used to presumably “protect” clinical and research subjects’ identities. We discover that this practice led to major breaches of confidentiality, great risks of outings and grave dangers to the women involved.


Nevertheless, leading bioethicists are not only defending but are even promoting such uses of pseudonyms as the means for protecting clinical and research subject identities – and are doing so even after becoming familiar with the breaches of confidentiality in the Bailey book. 


This promotion of pseudonyms as a protective mechanism appears to us to be a major ethical lapse on the part of bioethicists, who appear to be ill-informed regarding the risks faced by endangered classes of people and by trans women in particular.


We believe that the overseers of research integrity should take close note of this situation, and err of the side of caution until improved guidelines can be developed for protecting the rights and personal safety of psychological research subjects who are members of endangered classes.


Transgender and transsexual women as an endangered class:


Consider the situation of transgender and transsexual women who have undergone social and physical gender transitions.  The vast majority of these women are now forced by social realities to live “in stealth”.  They must conceal their pasts from almost everyone, in order to obtain employment, build and maintain social relationships, avoid social ostracism and reduce the risk of physical attacks and violence. 


Stealth for these women is very much like going into the witness protection program. However, they must do this all on their own, without any organization to help them do it. Most newly transitioned women take on a new name and identity, move to a new location, find new employment, and then break almost all contact with past friends, family and co-workers. In most cases only a few close family members and trans friends will know of their past lives.


Trans women who are “outed” from these carefully-constructed stealth identities often face a permanent loss of their hard-won careers and of the friends, family members and social support networks they’ve built up in their new lives. 


Such losses, often occurring all at once upon outings, can be crushing blows from which a woman may never fully recover.  In some cases, a woman may try to move yet again and construct yet another new identity, but you can only imagine the angst and hardships such efforts involve.


The sudden outing from stealth can have even worse consequences for trans women than the loss of careers and all their social support mechanisms: It can lead to violent attacks on their persons and even to their deaths.


The evidence of these dangers is all around us.  Trans women, especially young minority trans women, face an epidemic of hate crimes in the United States.  For a full report on the issue, consult the Winter 2003 Investigative Report from the prestigious Southern Poverty Law Center, entitled 'DISPOSABLE PEOPLE’ A wave of violence engulfs the transgendered, whose murder rate may outpace that of all other hate killings” [5].


This epidemic of hate crimes in further documented and sadly remembered in Gwendolyn Anne Smith’s widely-known website “Remembering Our Dead” [6].


Many of these violent murders of trans women are “discovery crimes”, i.e. they occur when someone suddenly discovers that the person they are with happens to be transgender or transsexual, as in the widely publicized case of Gwen Araujo [7], the young transgender woman who was beaten to death by a group of men enraged to have discovered her gender status.


By any measure, sheer common sense tells us that transgender and transsexual women are at special risk not only for loss of careers, families, loved ones and social support in general, but are also at risk of physical attacks and even violent deaths, if they are suddenly outed by circumstances beyond their control. 


Trans women are therefore an endangered class and must be given special consideration regarding the confidentiality of their identities, especially in psychological clinical and research case study reports where accidental revelations of certain details of their cases could out them.



Examples of the failure of pseudonyms to safeguard individual identities in case-study reports, and of the resulting risks to trans women thus exposed:


In the work leading up to his book The Man Who Would Be Queen, psychologist J. Michael Bailey surreptitiously recruited several young minority trans women as research subjects by offering to write their letters of recommendation for sex reassignment surgery (SRS). He presented himself as if he were a clinical psychologist (in the State of Illinois), interviewing these young women prior to making the important decisions regarding their surgeries. During these brief interviews he accumulated various fragments of specific information about their case-histories, and then wrote their SRS letters [8].


However, as Mr. Bailey indicates in his book [1], he was actually using these young women as research subjects [1: p.141, p.168, p.177 ]. He then published in his book a number of the specific details he had learned about each of their case histories in order to support the scientific theory he promoted therein.  He never told the young women they were research subjects, nor that he was going to reveal those key facts about their case histories in his book.  The facts he published in each case were explicit enough to suggest that he had deep knowledge of those cases, when in fact he knew little about the women and less yet about the transgender culture and context in which they lived. Nevertheless, he later claimed to have adequately disguised the case history information taken from these clinical and research subjects by using pseudonyms. 


Unhappily the use of pseudonyms in these cases was in and of itself woefully inadequate in protecting the women’s anonymity, especially when considering their at-risk transgender status.  Why? Because Mr. Bailey recklessly revealed factual details of places, relationships and events in their lives that would allow many members of the public who might know these women (but not know that they were trans women) to infer their identities as being the women in “the book”. 


For example, consider the following cases in the book, which were discussed in an earlier formal complaint to Northwestern University [9, 10], remembering that all the young women were automatically known by context to be of Hispanic background and living in the Chicago area:


Case 1, “Juanita”:  


The young woman named “Juanita” (whom the author knows personally and who is a close friend of hers) is described thusly in Mr. Bailey’s book:


"Juanita, who has been a successful prostitute before and after sex reassignment surgery” [1: p.187 ]; “Juanita’s most recent boyfriend confronted her after penetrating her for the first time. Her vagina is shallow, and he concluded that she is not a normal woman” [1: p.190 ] “However, in 1999 Juanita invited me to her wedding. Her engagement story was quite romantic, in an odd, transsexual sort of way….The wedding was small, touching, and hilarious. Juanita’s family – mother, father, three brothers and three sisters- all attended, and of course, they knew that Juanita used to be Hector. However, neither the groom’s parents nor his son from his first marriage had any idea" [1: p.210].


Anyone who attended Juanita’s wedding will know who is involved.  Mr. Bailey caricatures the wedding as being “romantic, in an odd, transsexual sort of way”, and yet goes on to reveal that he knew that the groom’s parents and son from a former marriage had no clue that Juanita was once a boy.  Her own relatives, who knew her past but did not know she was in the sex trade, will learn it from Mr. Bailey’s book.  They will also learn intimate clinical details about her medical condition that never should have been revealed by Mr. Bailey.


Case 2, “Terese”: 


Terese is not known as a former male.  Her boyfriend, for example, does not know of her past. Mr. Bailey uses a pseudonym for Terese, but his book includes facts about her family history, immigration status and foreign travel that could easily out her to a suspicious partner:


“Terese was born Jose Garcia in Mexico. His parents divorced when Jose was young, and he was raised by his grandparents. They moved to Chicago when he was XX” [1: p. 147 ]. “In XXXX 19XX,, Terese (then XX) flew to Belgium and over a XXXX-day period, had sex reassignment surgery, learned to care for her new vagina, and recovered sufficiently to leave the hospital.” [1: p.150] (We use X’s here to avoid further propagating detailed facts widely revealed in Mr. Bailey’s book: they are accurate so far as we know.)


Bringing public attention to these details of "Terese’s" case history puts her in an extremely dangerous situation.  Many gender transitioners have been murdered after such revelations have outed them to partners.  This example illustrates Mr. Bailey’s reckless disregard for the lives and well-being of his clinical and research subjects, and the total inadequacy of pseudonyms as a protective mechanism in such cases..


Case 3, “Kim”: 


Mr. Bailey initially spotted Kim on one of his “research field trips” to the Crobar (a night-club in Chicago), as he says in his book:


“I cannot decide whether Kim is transsexual, and in a tribute to her beauty, I decide for now not to approach her. If she is transsexual, I will have other chances to meet her, and I will probably also have the opportunity to find out from others without asking her directly. So I leave. [1: p. 142 ].


Mr. Bailey later described Kim to his research subject Anjelica Kieltyka, indicating that he’d like to meet her socially. Anjelica reports that he asked if she knew this woman, and whether she was transsexual. She said yes to both questions. Sensing an opportunity to help Kim, Anjelica arranged for Kim to go see Mr. Bailey for clinical interviews for eventual approval for SRS surgery, as she had done for several other young transsexual women. Kim then met Mr. Bailey for clinical interviews on two occasions in his office at Northwestern University.


When reporting in his book on these meetings with Kim, Mr. Bailey does not point out that the meetings were clinical interviews, nor that he wrote letters for sex reassignment surgery for any of the women.  Instead he refers to Kim as being interviewed for “the study we were conducting”.


“Sure enough though, when I told my transsexual informants about her they recognized the description and claimed Kim as one of their own. I arranged to interview her for the study we were conducting. When she came to my laboratory, my initial impression was reconfirmed. She was stunning. (Afterwards, my avowedly heterosexual male research assistant told me the he would gladly have had sex with her, even knowing that Kim still possessed a penis.)” [1: p.182 ].


Mr. Bailey thus reveals that "Kim" was originally from “XXX” (a very small country having a population of only a few hundred thousand) and that he admired her during visits to Crobar, which is the real name of the club. Mr. Bailey must have known that almost all of Kim’s friends and acquaintances call her “Kim from XXX”, so that XXX had become her virtual last name. Thus his book openly reveals the name by which she is widely known, while identifying her as a transsexual woman who “still has a penis.” 


These cases all involve young Hispanic trans women from the city of Chicago, Illinois, further facts of their case histories that are clear by context. By willfully publishing detailed clinical case-history information about these three young minority women, women who came to him for help in obtaining their SRS surgery letters, Mr. Bailey put them at grave risk of the loss of their entire social support networks and of violence against their persons. In reaction to Mr. Bailey’s egregious actions, the young women’s supporters and mentors have filed formal complaints against Mr. Bailey with both Northwestern University and the Illinois Department of Professional Regulation [8, 9, 10]



How could Mr. Bailey make such gross errors in judgment?


Mr. Bailey believed a priori in the theory of transsexualism which he set out to prove and teach in his book [1].  Caught up in sex-obsessed theoretical speculations that trans women are incredibly rare, exotic, sexually-perverted men who are mentally defective – and thus not fully-human – he apparently never considered that ethical protections might apply to them.  It was in this context that he recruited the young transsexual research subjects, by holding out the promising lure of SRS letters if they came to him and let him interview them and “socialize” with them.


Over the years from 1994-1999, during which he recruited and interviewed these subjects, Mr. Bailey only met a tiny number of trans women, perhaps six to eight in all, (most were young Hispanic women brought to him for SRS letters by their mentor Ms. Kieltyka).


When these young women were in Mr. Bailey’s presence, they were totally open with him about their stories. He was a powerful authority figure who appeared very interested in them, and they responded with very open and candid discussions of their life experiences.


However, Mr. Bailey had so little awareness of trans culture, that he was totally unaware that the majority of these women were living in stealth and only shared their intimate stories with each other (and him) but almost no one else.  Such young women carefully compartmented their lives, as intelligence agents might do, and only talked openly about their trans experiences when amongst other trans women.


Mr. Bailey apparently never realized that these women were at risk for great losses if their families, friends, co-workers and others ever learned that they were trans – or learned some of the specific intimate details about their lives (such as the fact that some had become sex workers temporarily in order to get the money to pay for their surgeries, etc.).


He must have thought that these young women carried on and told everyone about themselves in the same way they talked about their stories when together with him. However, nothing could be further from the truth.  In fact, most of the young women were highly secretive about their pasts whenever amongst “nons”.


It was from within this mind-set that Bailey and his publisher (the National Academies), in complete ignorance of the dangers he was creating for these women, launched his voyeuristic expose of intimate details of these women’s lives. And he and his publisher did so with enthusiasm and gusto, apparently in hopes that “transsexual sex stories” would sell lots of copies of his book. 



But what do expert bioethicists say about the Bailey case?


Many ethicists have found the Bailey case to be intriguing, and have commented upon the current investigation of his research misconduct. Consider the following report of the reactions of one of the country’s leading bioethicists in the article “Ethical Minefields: The Sex That Would be Science”, Seed Magazine, May/June, 2004 [11].


“Arthur L. Caplan, director of the Center for Bioethics at the University of Pennsylvania, says he believes the book does constitute scientific research. But he says Bailey didn’t need to get consent because he used pseudonyms, and a review panel “wouldn’t spend more than 15 minutes thinking about this proposal” before approving it.”


This ethicist suggests that a psychology researcher can recruit research subjects without informing them that they are research subjects nor obtaining consent from them when publishing their case histories, as long as he uses pseudonyms when reporting those case histories.  He thus apparently approves of Mr. Bailey’s acting as if he were a clinical psychologist when interviewing those women who came to him for SRS approval letters, and then, as a researcher, publishing details of those clinical case histories under pseudonyms as research case-histories.


What is wrong with this picture?  Just about everything. 


What principles of research ethics could possibly justify the surreptitious conduct of psychological research on unwitting subjects who do not know they’re being used as research subjects?


The above statement also reveals that this expert ethicist is clueless (as was Mr. Bailey) regarding the at-risk endangered status of transgender and transsexual women. He shows no awareness of the need to prevent any detailed information about their individual case-histories from ever being published without their expressed permission, and even that only after a full and open disclosure of what is intended to be published about their cases. 


Could this expert have fallen into the same trap Mr. Bailey did?  Could he himself visualize trans women as extremely rare male sexual deviants who live openly-bizarre highly-marginalized lives, and that whatever they said about their case-histories to Mr. Bailey they probably openly say to everyone else around them too?  Could he have arrived at this stereotypical view by having read Mr. Bailey’s book?


Whatever the reason, rather than use plain common sense and reflecting on the dangers that trans women face, a prominent expert bioethicist here promotes the use in their cases of the simplistic paradigm of pseudonym protection used for routine case-study subjects.  While that paradigm might be adequate for protecting psychological case-studies of people suffering from stress headaches or love-match problems, it is woefully inadequate for protecting the identities of the endangered class of trans women.  



The challenge to psychologists:


As a result of the Bailey book fiasco, the credibility of the field of psychology has been seriously undermined [12, 13].  Furthermore, Mr. Bailey’s thoughtless revelation of details of the case-histories of his trans research subjects has made trans women increasingly fearful of sharing their life-stories with any clinical or research psychologists.


Now that the green light has been given by one of the nation’s leading bioethicists [11] to the open publication of psychological case-studies by merely using pseudonyms to disguise identities, the future trend is easy to predict: 


More and more trans women will attempt to bypass the current gender-counseling system. They will search for and then share information about how to go directly to surgeons and other needed medical caregivers (especially in other countries where the requirements are more lax), without first gaining official letters of approval from the psychological “gate-keepers” in the United States. 


Trans women will seek to circumvent the current system in increasing numbers, so as to avoid ever having anyone compile detailed case-history dossiers about their lives, especially people who, like Mr. Bailey, hope to someday gain fame and notoriety by selling deliberately lurid “sexy science books about transsexuals”.


There are many responsible, highly-experienced gender counselors who would never publish details of their clients’ lives (except in rare cases where there is some good reason to do this, and when it is done with the client’s full permission). These caregivers often provide much-needed assistance to their clients regarding the many emotional and practical issues they face during transition.  However, even these counselors may find their practices in decline, as trans women become afraid that even they might someday reveal their case-histories under pseudonyms. This is a very sad state of affairs, because many women may avoid valuable and needed counseling out of an unwarranted fear of all psychologists. 


It would appear that clinical and research psychologists need to come up with and strongly enforce a rigorous system for protecting the identities of their trans clients and subjects. Otherwise, we predict that clinical and research psychologists will be seeing a rapidly shrinking percentage of transitioning women as time goes by.


In the interim, before such new protections are worked out, we recommend that transitioners require their clinicians (and any scientific researchers they may encounter) to sign strict non-disclosure agreements regarding their case-history information.



The challenge to ethicists and to overseers of research integrity:


The Bailey case demonstrates that pseudonyms totally fail to adequately protect the identities of at-risk psychological research subjects (in this case transgender and transsexual women). This failure is obvious by common sense means, independent of what expert ethicists say to the contrary.


When expert ethicists’ advice fails the test of common sense in such an important situation, all ethicists should question the foundations upon which they have been basing their pronouncements.


As this case has clearly demonstrated, much sounder and more robust principles must be articulated on which to decide what is and what is not allowable regarding gathering and publishing clinical and research case-history information on at-risk and endangered classes of people – and regarding whether or not such people must be informed when they are being used as research subjects. It is yet another example of the current crisis in science regarding the use of human subjects in research [14].  


In the meantime, it would appear wise for university overseers of research integrity to err on the side of caution, to closely monitor any proposed psychological research on transgender subjects, and to tightly control any releases of case-history details about individual transgender people without their explicit and informed permission.  Otherwise, history is doomed to repeat itself, and our universities and at-risk communities will experience more “Bailey fiascos”.






1. J. Michael Bailey, The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism, The Joseph Henry Press of the National Academies, 2003.


2. Andrea James, “A Bailey-Blanchard-Lawrence clearinghouse”:


3. Lynn Conway, “An investigation into the publication of J. Michael Bailey's book on transsexualism by the National Academies”:


4. Heidi Beirich and Bob Moser. “Queer Science: An 'elite' cadre of scientists and journalists tries to turn back the clock on sex, gender and race”, Southern Poverty Law Center Investigative Report, Winter 2003, Issue 112, pp.18-19.


5. Bob Moser, “ 'DISPOSABLE PEOPLE’ A wave of violence engulfs the transgendered, whose murder rate may outpace that of all other hate killings”, Southern Poverty Law Center Investigative Report, Winter 2003, Issue 112, pp.10-20.


6. Gwendolyn Anne Smith, “Remembering Our Dead”:


7. Jordan Bagalot, “In Memory of Gwen Araujo”,, October 19, 2002:


8. Andrea James and Lynn Conway, “J. Michael Bailey performing unlicensed clinical therapy”, formal complaint to the Illinois Department of Professional Regulation, March 24, 2004:


9. Lynn Conway and Deirdre McCloskey, “Publication of confidential clinical psychological case-history information by J. Michael Bailey of Northwestern University”, formal complaint to the Illinois Department of Professional Regulation, March 28, 2004:


10. Andrea James, Lynn Conway, and Deirdre McCloskey, “Professor J. Michael Bailey of the Department of Psychology at Northwestern University performed unlicensed clinical therapy”, April 6, 2004:


11. “Ethical Minefields: The Sex That Would be Science”, Seed Magazine, May/June, 2004.


12. Joan Roughgarden, “The Bailey Affair: Psychology Perverted”, February 11, 2004:


13. Peter Hegarty, Penny Lenihan, Meg Barker and Lyndsey Moon, “The Bailey Affair: Psychology Perverted: A Response”, UKPFC News, March 19, 2004:


14. Anne Wood, Christine Grady and Ezekiel J. Emanuel, “The Crisis in Human Participants Research: Identifying the Problems and Proposing Solutions”, Department of Clinical Bioethics, National Institutes of Health, September 2002.