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
Member, National
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
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
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
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
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
“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
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
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”.
References:
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.
http://www.nap.edu/catalog/10530.html
2. Andrea James, “A
Bailey-Blanchard-Lawrence clearinghouse”:
http://www.tsroadmap.com/info/bailey-blanchard-lawrence.html
3. Lynn Conway, “An
investigation into the publication of J. Michael Bailey's book on
transsexualism by the National Academies”:
http://ai.eecs.umich.edu/people/conway/TS/LynnsReviewOfBaileysBook.html
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.
http://www.splcenter.org/intel/intelreport/article.jsp?sid=96
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.
http://www.splcenter.org/intel/intelreport/article.jsp?pid=276
6. Gwendolyn Anne Smith,
“Remembering Our Dead”:
http://www.rememberingourdead.org/
7. Jordan Bagalot, “In Memory
of Gwen Araujo”, transyouth.net,
October 19, 2002:
http://transyouth.net/stories/gwen_araujo.html
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:
http://ai.eecs.umich.edu/people/conway/TS/Bailey/Clinical/ClinicalComplaint.html#3-24
9. Lynn Conway and Deirdre
McCloskey, “Publication of confidential clinical psychological case-history
information by J. Michael Bailey of
http://ai.eecs.umich.edu/people/conway/TS/Bailey/Clinical/ClinicalComplaint.html#3-28
10. Andrea James, Lynn
Conway, and Deirdre McCloskey, “Professor J. Michael Bailey of the Department
of Psychology at
http://ai.eecs.umich.edu/people/conway/TS/Bailey/Clinical/ClinicalComplaint.html#4-6
11. “Ethical Minefields: The
Sex That Would be Science”, Seed Magazine,
May/June, 2004.
http://www.seedmagazine.com/?p=article&n=above&id=130
http://www.bioethics.upenn.edu/faculty/index.php?profile=1
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:
http://ai.eecs.umich.edu/people/conway/TS/Reviews/Psychology%20Perverted%20-%20A%20Response.htm
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.
http://bioethics.gov/background/emanuelpaper.html