Frequent I-talk is also positively related to the neurotic variety of narcissism (vulnerable narcissism); also has a positive association with sociodemographic characteristics such as (lower) status, (younger) age, & (female) gender

The story of “I” tracking: Psychological implications of self-referential language use. Amunet K. Berry-Blunt, Nicholas S. Holtzman, M. Brent Donnellan, Matthias R. Mehl. Social and Personality Psychology Compass, October 19 2021. https://doi.org/10.1111/spc3.12647

Abstract: We review extant research on the psychological implications of the use of first-person singular pronouns (i.e., “I-talk”). A common intuition is that I-talk is associated with an overly positive, highly agentic, and inflated view of the self—including arrogance, self-centeredness, and grandiose narcissism. Initial (small-sample) research provided evidence that frequent I-talk was associated with grandiose narcissism. More recent (large-sample) research, however, has found that the correlation is near zero. Frequent I-talk is, however, positively correlated with depressive symptoms, in particular, and negative emotionality (i.e., neuroticism), more broadly. Frequent I-talk is also positively related to the neurotic variety of narcissism called vulnerable narcissism. In addition, frequent I-talk has a positive association with sociodemographic characteristics such as (lower) status, (younger) age, and (female) gender; I-talk has a conditional association with truth-telling and authenticity—a correlation that appears to hinge on context. This review summarizes the literature on I-talk, provides some speculations about the emergent psychological meanings of I-talk, and provides a guide for future research.

Greater survivability of cardio vascular events allows lifestyle choices to catch-up with people

Dahl, Gordon B. and Kreiner, Claus Thustrup and Nielsen, Torben and Serena, Benjamin Ly, Understanding the Rise in Life Expectancy Inequality. IZA Discussion Paper No. 14741, Oct 8 2021, SSRN: https://ssrn.com/abstract=3934758

Abstract: We provide a novel decomposition of changing gaps in life expectancy between rich and poor into differential changes in age-specific mortality rates and differences in "survivability". Declining age-specific mortality rates increases life expectancy, but the gain is small if the likelihood of living to this age is small (ex ante survivability) or if the expected remaining lifetime is short (ex post survivability). Lower survivability of the poor explains between one-third and one-half of the recent rise in life expectancy inequality in the US and the entire change in Denmark. Our analysis shows that the recent widening of mortality rates between rich and poor due to lifestyle-related diseases does not explain much of the rise in life expectancy inequality. Rather, the dramatic 50% reduction in cardiovascular deaths, which benefited both rich and poor, made initial differences in lifestyle-related mortality more consequential via survivability.

Keywords: mortality, life expectancy, inequality

JEL Classification: I14, J10

The devil is in the detail: reflections on the value and application of cognitive interviewing to strengthen quantitative surveys in global health

The devil is in the detail: reflections on the value and application of cognitive interviewing to strengthen quantitative surveys in global health. K Scott, O Ummer, A E LeFevre. Health Policy and Planning, Volume 36, Issue 6, July 2021, Pages 982–995, https://doi.org/10.1093/heapol/czab048

Abstract: Cognitive interviewing is a qualitative research method for improving the validity of quantitative surveys, which has been underused by academic researchers and monitoring and evaluation teams in global health. Draft survey questions are administered to participants drawn from the same population as the respondent group for the survey itself. The interviewer facilitates a detailed discussion with the participant to assess how the participant interpreted each question and how they formulated their response. Draft survey questions are revised and undergo additional rounds of cognitive interviewing until they achieve high comprehension and cognitive match between the research team’s intent and the target population’s interpretation. This methodology is particularly important in global health when surveys involve translation or are developed by researchers who differ from the population being surveyed in terms of socio-demographic characteristics, worldview, or other aspects of identity. Without cognitive interviewing, surveys risk measurement error by including questions that respondents find incomprehensible, that respondents are unable to accurately answer, or that respondents interpret in unintended ways. This methodological musing seeks to encourage a wider uptake of cognitive interviewing in global public health research, provide practical guidance on its application, and prompt discussion on its value and practice. To this end, we define cognitive interviewing, discuss how cognitive interviewing compares to other forms of survey tool development and validation, and present practical steps for its application. These steps cover defining the scope of cognitive interviews, selecting and training researchers to conduct cognitive interviews, sampling participants, collecting data, debriefing, analysing the emerging findings, and ultimately generating revised, validated survey questions. We close by presenting recommendations to ensure quality in cognitive interviewing.

Keywords: Cognitive interviewing, survey research, validity, methodological innovation, qualitative research

Introduction

This methodological musing calls attention to cognitive interviewing, a qualitative research methodology for improving the validity of quantitative surveys that has often been overlooked in global public health. Cognitive interviewing is ‘the administration of draft survey questions while collecting additional verbal information about the survey responses, which is used to evaluate the quality of the response or to help determine whether the question is generating the information that its author intends’ (Beatty and Willis, 2007). This methodology helps researchers see survey questions from the participants’ perspectives rather than their own by exploring how people process information, interpret the words used and access the memories or knowledge required to formulate responses (Drennan, 2003).

Cognitive interviewing methodology emerged in the 1980s out of cognitive psychology and survey research design, gaining prominence in the early 2000s (Beatty and Willis, 2007). Cognitive interviewing is widely employed by government agencies in the preparation of public health surveys in many high-income countries [e.g. the Collaborating Center for Questionnaire Design and Evaluation Research in the Center for Disease Control and Prevention (CDC)/National Center for Health Statistics (2014) and Agency for Healthcare Research and Quality in the Department of Health and Human Services (2019) in the USA and the Quality Care Commission (2019) for the National Health Service Patient Surveys in the UK]. Applications in the global public health space are emerging, including to validate measurement tools undergoing primary development in English and for use in English [e.g. to measure family response to childhood chronic illness (Knafl et al., 2007)]; to support translation of scales between languages [e.g. to validate the London Measure of Unplanned Pregnancy for use in the Chichewa language in Malawi (Hall et al., 2013)] and to assess consumers’ understanding and interpretation of and preferences for displaying information [e.g. for healthcare report cards in rural Tajikistan (Bauhoff et al., 2017)]. However, this methodology remains on the periphery of survey tool development by university-based academic researchers and monitoring and evaluation teams working in global health; most surveys are developed, translated and adapted without cognitive interviews, and publications of survey findings rarely stipulate that cognitive interviews took place as part of tool development processes.

Box 1.

The need for cognitive interviewing: examples from developing a tool to measure respectful maternity care among rural women in central India

Context: respectful maternity care in rural central India

We used cognitive interviewing to examine survey questions for rural central India, adapted from validated instruments to measure respectful maternity care used in Ethiopia, Kenya and elsewhere in India. This process illuminated extensive cognitive mismatch between the intent of the original questions and how women interpreted them, which would have compromised the validity of the survey’s findings (Scott et al., 2019). Two examples are provided here.

Cognitive interviews revealed that hypothetical questions were interpreted in unexpected ways

A question asked women whether they would return to the same facility for a hypothetical future delivery. The researchers intended the question to assess satisfaction with services. Some women replied no, and, upon probing, explained that their treatment at the facility was fine but that they had no intention of having another child. Other women said yes, despite experiencing some problematic treatment, and probing revealed that they said this because they were too poor to afford to go anywhere else.

Cognitive interviews revealed that Likert scales were inappropriate

The concept of graduated agreement or disagreement with a statement was unfamiliar and illogical to respondents. Women did not understand how to engage with the Likert scales we tested (5-, 6- and 10-point scales, using numbers, words, colours, stars, and smiley faces). Most respondents avoided engaging with the Likert scales, instead responding in terms of a dichotomous yes/no, agree/disagree, happened/did not happen, etc., despite interviewer’s attempts to invite respondents to convert their reply to a Likert response. For example, when asked to respond on a 6-point Likert scale to the statement ‘medical procedures were explained to me before they were conducted’, a respondent only repeated ‘they didn’t explain’. Other respondents, when shown a smiley face Likert scale, focused on identifying a face that matched how they felt rather than that depicted their response to the statement in question. For example, when asked to respond to the statement ‘the doctors and nurses did everything they could to help me manage my pain’, a respondent pointed to a sad face, explaining that although the doctors and nurses helped her, since she was in pain her face was ‘like this’ (i.e. sad). Without cognitive interviews, survey enumerators would unknowingly record responses unrelated to the question at hand or would attempt to fit respondent dichotomous answers into Likert scales using whatever interpretation the enumerator saw fit.

Cognitive interviewing recognizes that problems with even one detail of a survey question can compromise the validity of the data gathered, whether it is an improper word, confusing phrasing, unfamiliar concept, inappropriate response option, or other issue. Without cognitive interviews, gaps between question intent and respondent interpretation can persist, severely compromising the quality of data generated from surveys (Box 1). Furthermore, cognitive mismatch is often impossible to detect after data collection. Instead, responses recorded in the survey are taken as ‘true’, regardless of whether the respondents understood and answered the question in the intended manner and regardless of the assistance, adjustment, or interpretation provided by enumerators.

In this article, we argue that cognitive interviewing should be an essential step in the development of quantitative survey tools used in global public health and call attention to the detailed steps of applying this method in the field. We start by reviewing what cognitive interviewing is and consider the varied definitions and use cases in survey tool development. We next outline the recommended steps in survey tool development and then provide an overview of how to go about cognitive interviewing. We close by reflecting on the broader implications of cognitive interviewing.

While people themselves were the most accurate about the majority of their abilities, their verbal and spatial intelligence were only estimable by informants or strangers, respectively

Hofer, Gabriela, Laura Langmann, Roman Burkart, and Aljoscha Neubauer. 2021. “Who Knows What We Are Good At? Unique Insights of the Self, Knowledgeable Informants, and Strangers into a Person’s Abilities.” PsyArXiv. October 21. doi:10.31234/osf.io/u73xf

Abstract: Who is the best judge of a person’s abilities—the person, a knowledgeable informant or strangers just met in a 3-min speed date? To test this, we collected ability measures as well as self-, informant- and stranger-estimates of verbal, numerical and spatial intelligence, creativity, and intra- and interpersonal emotional competence from 175 young adults. While people themselves were the most accurate about the majority of their abilities, their verbal and spatial intelligence were only estimable by informants or strangers, respectively. These differences in accuracy were not accompanied by differences in the domains’ relevance to people’s self-worth or observability to strangers. These results indicate self-other knowledge asymmetries for abilities but raise questions about the reasons behind these asymmetries.

Rolf Degen summarizing... We blindly impute higher moral qualities to good-looking people, even more so than qualities of a non-moral kind

Beauty Goes Down to the Core: Attractiveness Biases Moral Character Attributions. Christoph Klebl, Joshua J. Rhee, Katharine H. Greenaway, Yin Luo & Brock Bastian. Journal of Nonverbal Behavior, Oct 20 2021. https://link.springer.com/article/10.1007/s10919-021-00388-w

Abstract: Physical attractiveness is a heuristic that is often used as an indicator of desirable traits. In two studies (N = 1254), we tested whether facial attractiveness leads to a selective bias in attributing moral character—which is paramount in person perception—over non-moral traits. We argue that because people are motivated to assess socially important traits quickly, these may be the traits that are most strongly biased by physical attractiveness. In Study 1, we found that people attributed more moral traits to attractive than unattractive people, an effect that was stronger than the tendency to attribute positive non-moral traits to attractive (vs. unattractive) people. In Study 2, we conceptually replicated the findings while matching traits on perceived warmth. The findings suggest that the Beauty-is-Good stereotype particularly skews in favor of the attribution of moral traits. As such, physical attractiveness biases the perceptions of others even more fundamentally than previously understood.

The Mid-Life Dip in Well-Being: We find remarkably strong and consistent evidence across countries of statistically significant and non-trivial U-shapes in age with and without socio-economic controls

The Mid-Life Dip in Well-Being: a Critique. David G. Blanchflower & Carol L. Graham. Social Indicators Research, Oct 19 2021. https://link.springer.com/article/10.1007/s11205-021-02773-w

Abstract: A number of studies—including our own—find a mid-life dip in well-being. Yet several papers in the psychology literature claim that the evidence of a U-shape is "overblown" and if there is such a thing that any such decline is "trivial". Others have claimed that the evidence of a U-shape "is not as robust and generalizable as is often assumed," or simply "wrong." We identify 409 studies, mostly published in peer reviewed journals that find U-shapes that these researchers apparently were unaware of. We use data for Europe from the Eurobarometer Surveys (EB), 1980–2019; the Gallup World Poll (GWP), 2005–2019 and the UK's Annual Population Survey, 2016–2019 and the Census Bureau's Household Pulse Survey of August 2021, to examine U-shapes in age in well-being. We find remarkably strong and consistent evidence across countries of statistically significant and non-trivial U-shapes in age with and without socio-economic controls. We show that studies cited by psychologists claiming there are no U-shapes are in error; we reexamine their data and find differently. The effects of the mid-life dip we find are comparable to major life events such as losing a spouse or becoming unemployed. This decline is comparable to half of the unprecedented fall in well-being observed in the UK in 2020 and 2021, during the Covid19 pandemic and lockdown, which is hardly “inconsequential” as claimed.

Discussion

An early psychology literature argued that there was no relationship between well-being and age. This appears to have been based on studies that included a handful of people with tiny sample sizes. Even where there was evidence of a U-shape, it was denied in the literature. We reworked a few of these studies using same data and showed there were U-shapes, and their scale was large and comparable to the loss of a spouse, or a job. Some studies have failed to find U-shapes but generally they have been based on small sample sizes,

In addition to our findings of U-shapes using life satisfaction data from the Eurobarometer we also looked at Cantril's ladder of life satisfaction in the Gallup World Poll data and found U-shapes with and without controls for an additional 64 non-European countries. We found similar U-shapes for the UK from the Annual Population Surveys.

Two more recent papers (Galambos et al., 2020, 2021) suggested there was little evidence of U-shapes based on a literature review of 28 papers. We showed that that the authors had misclassified many of these paper's findings. Indeed, after misclassifications have been accounted for and ineligible studies dropped, B&G found that there were zero that didn't find any evidence of U-shapes. Of the 28 papers 21 found U-shapes and three had mixed evidence while four had to be excluded as they did not set the criteria set by GKJL1; of note is that GKJL2 did not dispute any of these re-classifications.

We have also identified an astonishing 387 additional papers that the authors had ignored that did find U-shapes, making 403 in total. Indeed, we count a total of 373 published in a vast array of peer-reviewed journals in English, including 73 in this journal alone, that find U-shapes, which was the main criterion the authors set for examination. When this was pointed out to the authors by us in an earlier paper (Blanchflower & Graham, 2021a) the authors claimed that they did not set out to do an exhaustive review because they "wanted to show support for the view that not all researchers find the U shapes". Hence, their analysis is advocacy not science. There is a U-shape in well-being in midlife.

On the basis of this evidence, it is clearly inappropriate to dismiss the literature on the U-curve as “overblown” or the scale of the effects as trifling, inconsequential or even "trivial". We have shown that the effects of the mid-life dip are comparable to major life events like losing a spouse or a job. We show that the drop from teenage years to the midlife low is about half the size of the unprecedented drop in life satisfaction that occurred during the COVID19 pandemic.

Beyond being empirically interesting, there are implications for substantial parts of the world’s population. These dips in well-being are associated with higher levels of depression, including chronic depression, difficulty sleeping, and even suicide. In the U.S., deaths of despair are most likely to occur in the middle-aged years, and the patterns are robustly associated with unhappiness and stress. Across countries chronic depression and suicide rates peak in midlife. The mid-life dip in well-being is robust to within person analysis, also exists with the prescribing of anti-depressants and it extends beyond humans. The evidence comes from both longitudinal and cross-section data, which complement one another, as noted in a recent report by The Lancet’s COVID-19 Commission Mental Health Task Force. It remains puzzling then why some psychologists continue to suggest that well-being is unrelated to age.

Based on the significant evidence we present, the decline in mid-life well-being seems real and consequential and has robust linkages to other serious markers of ill-being. The mid-life dip is real, it applies to most of the world’s population, excepting countries in which it is very difficult to age—such as those with very high levels of absolute poverty and conflict and low levels of life expectancy. It links to behaviors and outcomes that merit the attention of scholars and policymakers alike. These include rising rates of despair and reported pain among the middle-aged in many rich countries and associated premature mortality due to despair-related deaths, and some similar if less well documented patterns in developing economies. Among other things, more public awareness of how common this mid-life dip is might help those navigating its worst manifestations to make it through to a happier and longer life.

The overwhelming evidence from four hundred and nine papers, and counting, as well as the evidence presented here, support the conclusion that there is a midlife low in well-being. This is among the most striking, persistent and consistent patterns in social science. 

Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners

Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. Lisa Littman. Archives of Sexual Behavior, Oct 19 2021. https://link.springer.com/article/10.1007/s10508-021-02163-w

Abstract: The study’s purpose was to describe a population of individuals who experienced gender dysphoria, chose to undergo medical and/or surgical transition and then detransitioned by discontinuing medications, having surgery to reverse the effects of transition, or both. Recruitment information with a link to an anonymous survey was shared on social media, professional listservs, and via snowball sampling. Sixty-nine percent of the 100 participants were natal female and 31.0% were natal male. Reasons for detransitioning were varied and included: experiencing discrimination (23.0%); becoming more comfortable identifying as their natal sex (60.0%); having concerns about potential medical complications from transitioning (49.0%); and coming to the view that their gender dysphoria was caused by something specific such as trauma, abuse, or a mental health condition (38.0%). Homophobia or difficulty accepting themselves as lesbian, gay, or bisexual was expressed by 23.0% as a reason for transition and subsequent detransition. The majority (55.0%) felt that they did not receive an adequate evaluation from a doctor or mental health professional before starting transition and only 24.0% of respondents informed their clinicians that they had detransitioned. There are many different reasons and experiences leading to detransition. More research is needed to understand this population, determine the prevalence of detransition as an outcome of transition, meet the medical and psychological needs of this population, and better inform the process of evaluation and counseling prior to transition.

Discussion

This study was designed to explore the experiences of individuals who obtained medical and surgical treatment for gender dysphoria and then detransitioned by discontinuing the medications or having surgery to reverse the changes from transition. The findings of this study, however, should not be assumed to be representative of all individuals who detransition. Although this study further documents that detransitioners exist, the prevalence of detransition as an outcome of transition is unknown. Only a small percentage of detransitioners (24.0%) informed the clinicians and clinics that facilitated their transitions that they had detransitioned. Therefore, clinic rates of detransition are likely to be underestimated and gender transition specialists may be unaware of how many of their own patients have detransitioned, particularly for patients who are no longer under their care.

This research demonstrates that the experiences of individuals who detransition are varied and the reasons for detransition are complex. Nearly all participants identified as transgender or nonbinary at the start of their transition and most sought transition because they did not want to be associated with their natal sex, their bodies felt wrong the way they were, and they believed that transition was the only option to relieve their distress. Some were helped by transition and only detransitioned because they were pressured to do so by people in their lives, society, or because they had medical complications. Some were harmed by transition and detransitioned because they concluded that their gender dysphoria was caused by trauma, a mental health condition, internalized homophobia, or misogyny—conditions that are not likely to be resolved with transition. These findings highlight the complexity of gender dysphoria and suggest that, in some cases, failure to explore co-morbidities and the context in which the gender dysphoria emerged can lead to misdiagnosis, missed diagnoses, and inappropriate gender transition. Some individuals detransitioned because their gender dysphoria resolved, because they found better ways to address their symptoms, or because their personal definitions of male and female changed and they became comfortable identifying as their natal sex.

The study sample was predominantly young natal females, many of whom experienced late-onset gender dysphoria which mirrors the recent, striking changes in the demographics of gender dysphoric youth seeking care as well as the youth described by their parents in Littman (2018) (see also Aitken et al., 2015; de Graaf et al., 2018; Zucker, 2019). Concerns have been raised that this new cohort of gender dysphoric individuals is unlike previous cohorts. Professionals have started to call for caution before treating this cohort with interventions with permanent effects because the etiologies, desistance and persistence rates, expected duration of symptoms, and whether this new population is helped or harmed by gender transition is still unknown (D’Angelo et al., 2021; Kaltiala-Heino et al., 2018). The natal females and natal males in this sample differed on several dimensions, including that natal females were younger than natal males when they sought transition, when they decided to detransition, and at the time of survey completion. Natal females were more likely than natal males to have experienced a trauma less than one year before the onset of their gender dysphoria and were more likely to have felt pressured to transition. Compared to natal males, natal females remained transitioned for a shorter duration of time before deciding to detransition. Additionally, natal females transitioned more recently than natal males, so their experiences may vary due to changing trends in the clinical management of gender dysphoria and the cultural settings in which they became gender dysphoric.

The study findings covered a wide range of detransition experiences that are consistent with the diversity of experiences described in previously published clinical case reports and case series. Overlap of findings include: transition regret; absence of transition regret; re-identification with birth sex; continued identification as transgender; improvement or worsening of well-being with transition; retransitioning; detransitioning due to external social pressures; nonbinary identification; and recognizing and accepting oneself as homosexual or bisexual (D’Angelo, 2018; Djordjevic et al., 2016; Levine, 2018; Pazos Guerra et al., 2020; Turban & Keuroghlian, 2018; Turban et al., 2021; Vandenbussche, 2021). The population in this study is similar to the population in Vandenbussche in that both were predominantly natal females in their mid-20s. Because the current study recruited in 2016–2017 and Vandenbussche recruited in 2019, the similar mean age of participants may reflect the age of individuals who can be reached in online detransitioner communities. Several findings in this study were consistent with Vandenbussche’s findings, including similar reasons for detransition (realizing that their gender dysphoria was related to other issues, finding alternatives to address gender dysphoria, gender dysphoria resolved, etc.). Although these two studies were recruited in different years, had different eligibility criteria, and included participants from several countries, it is possible that there may be some overlap of study populations.

The current study findings provide additional insight into the complex relationships between internalized homophobia, gender dysphoria, and desire to transition. Contrary to arguments against the potential role of homophobia in gender transitions (Ashley, 2020), participants reported that their own gender dysphoria and desire to transition stemmed from the discomfort they felt about being same-sex attracted, their desire to not be gay, and the difficulties that they had accepting themselves as lesbian, gay or bisexual. For these individuals, exploring their distress and discomfort around sexual orientation issues may have been more helpful to them than medical and surgical transition or at least an important part of exploration before making the decision to transition. This research adds to the existing evidence that gender dysphoria can be temporary (Ristori & Steensma, 2016; Singh et al., 2021; Zucker, 2018). It has been established that the most likely outcome for prepubertal youth with gender dysphoria is to develop into lesbian, gay, bisexual (LGB) (non-transgender) adults (Ristori & Steensma, 2016; Singh et al., 2021; Wallien & Cohen-Kettenis, 2008; Zucker, 2018). And, temporary gender dysphoria may be a common part of LGB identity development (Korte et al., 2008; Patterson, 2018). Therefore, intervening too soon to medicalize gender dysphoric youth risks iatrogenically derailing the development of youth who would otherwise grow up to be LGB non-transgender adults. Participants who detransitioned because they became comfortable identifying as their natal sex and because their gender dysphoria resolved further support that gender dysphoria is not always permanent.

The data in this study strengthen, with first-hand accounts, the rapid-onset gender dysphoria (ROGD) hypotheses which, briefly stated, are that psychosocial factors (such as trauma, mental health conditions, maladaptive coping mechanisms, internalized homophobia, and social influence) can cause or contribute to the development of gender dysphoria in some individuals (Littman, 2018). Littman also postulated that certain beliefs could be spread by peer contagion, including the belief that a wide range of symptoms should be interpreted as gender dysphoria (and proof of being transgender) and the belief that transition is the only solution to relieve distress. The current study supports the potential role of psychosocial factors in the development of gender dysphoria and further suggests, by participant responses that transitioning prevented or delayed them from addressing their underlying conditions, that maladaptive coping mechanisms may be relevant for some individuals. The potential role of social influence is demonstrated as well. First, when respondents were asked to describe how they currently feel about having identified as transgender in the past, more than a third endorsed the option, “Someone told me that the feelings I was having meant that I was transgender, and I believed them.” Second, a subset of participants experienced the unique friendship group dynamics reported in Littman where peer groups mocked people who were not transgender and popularity within the friend group increased when respondents announced their plan to transition. Additionally, respondents identified several social sources that encouraged them to believe that transitioning would help them including: YouTube transition videos, blogs, Tumblr, and online communities. And finally, 20.0% of participants felt pressured to transition by social sources that included friends, partners, and society. More research is needed to further explore these hypotheses.

The current study and the Turban et al. (2021) analysis of the USTS data share some similarities and differences. Similarities include the use of convenience samples, targeted recruitment, and anonymous data collection. The findings of Turban et al. (including external pressures to detransition and transgender identification after detransition) are a subset of the array of experiences described in the current study. The current study differed from James et al. (2016) and Turban et al. in that it enrolled participants based on the criterion of detransition after medical or surgical transition regardless of how they currently identified, recruited from communities with diverse perspectives about transition and detransition, used a precise definition for detransition that specifies the use of medication or surgery, and included answer options that were relevant to many different types of detransition experiences. In contrast, the USTS only enrolled transgender-identifying individuals regardless of whether they medically or surgically transitioned, recruited from communities likely to have similar perspectives about transition and detransition, and provided multiple choice answer options that were relevant to a narrower range of detransition experiences (James et al., 2016). Further, the definition used by the USTS for “detransitioned” (having “gone back to living as [their] sex assigned as birth, at least for a while”) is quite vague. Although Turban et al. provide valuable information about the subset of transgender-identifying people who may have detransitioned, the current study provides a more comprehensive view of individuals who detransition after medical or surgical transition.

Over the past 15 years, there have been substantial changes in the clinical approach to gender dysphoric patients notable for a shift from approaches that employ thorough evaluations and judicious use of medical and surgical transition (the watchful waiting or Dutch approach, the developmentally informed approach, and the medical model of care) to approaches with minimized or eliminated evaluation and liberal use of transition interventions (the affirmative approach and the informed consent model of care) (Cavanaugh et al., 2016; de Vries & Cohen-Kettenis, 2012; Meyer et al., 2002; Rafferty et al., 2018; Schulz, 2018; Zucker et al., 2012b). This trend is prominent in the U.S. where the American Academy of Pediatrics endorsed the affirmative approach in 2018 and Planned Parenthood currently uses the informed consent model to provide medical transition in more than 200 clinics in 35 states (Planned Parenthood, 2021; Rafferty et al., 2018). It is plausible that an unintended consequence of these clinical shifts may be an increase in people who detransition. Many participants in this study believe that they did not receive an adequate evaluation by a clinician before transition. The definition of “adequate evaluation” was not provided in the survey and may be open to respondent interpretation. But given the complexities of the gender dysphoria described in the current study, one might consider a low bar of “adequate” to be the exploration of factors that could be misinterpreted as non-temporary gender dysphoria as well as factors that could be underlying causes for gender dysphoria. The most recently emerging approach to gender dysphoria is called the “exploratory approach” which is a neutral psychotherapeutic approach to help individuals gain a deeper understanding of their gender distress and the factors contributing to their dysphoria (Churcher Clarke & Spiliadis, 2019; Spiliadis, 2019). The study’s findings suggest that an exploratory type of approach may have been beneficial to some of the respondents. Future research is needed to determine which patients are best treated by which approaches long term.

Patients considering medical and surgical interventions deserve accurate information about the risks, benefits, and alternatives to that treatment. In this sample, nearly half of the participants reported that the counseling they received about transition was overly positive about the benefits of transition and more than a quarter reported that the counseling was not negative enough about the risks. Several participants felt pressured to transition by their doctors and therapists. If these types of clinical interactions are verified, exploration is needed to determine the extent to which this situation occurs and what measures might be taken to ensure that clinicians provide patients with their options accurately and dispassionately.

There are several obstacles to obtaining accurate rates of detransition and desistance, including stigma and the low numbers of detransitioners who inform their clinicians that they detransitioned. One approach to bypass some of these barriers would be to incorporate non-judgmental questions about detransition and desistance into nationally representative surveys that collect health data. For example, the Behavioral Risk Factor Surveillance System contains an optional module about sexual orientation and gender identity that includes two questions to explore gender issues (Downing & Przedworski, 2018). By changing one existing question, “Do you consider yourself to be transgender?” into two questions, “Have you ever, at any point in your life, considered yourself to be transgender?” and “Do you currently consider yourself to be transgender?” and by adding a follow-up question if answers indicate past but not current transgender identification, “Did you ever take puberty blockers, cross-sex hormones, anti-androgens, or have any surgery as part of your transition?”, valuable information about desistance, detransition, and current transgender identification could be obtained. These types of questions may also be of use in clinical practice and electronic medical records. The information gained about rates of detransition and desistance would enhance transgender healthcare by aiding informed consent processes at the start of any medical or surgical transition.

One of the strengths of this study is that it is one of the largest samples of detransitioners to date. Other strengths include the use of a precise definition for detransition, enrollment of detransitioners regardless of their post-detransition gender identification, recruitment from communities with likely divergent views about transition and detransition, and collaboration with two individuals who had detransitioned which helped to create a survey instrument with questions relevant to a variety of detransition experiences and enhanced the recruitment efforts.

There are several limitations to this study that should be considered when interpreting the findings. Like Vandenbussche (2021), James et al. (2016), and Turban et al. (2021), this study used a cross-sectional design, anonymous surveying, and a convenience sample and therefore shares the same limitations that are inherent to these methodologies. These limitations include that conclusions about causation cannot be determined, identities of participants cannot be verified, and the findings of this study may not be generalizable to the entire population of people who detransition or to people outside of the countries where participants were from. Although this study reached out to communities with differing perspectives about transition and detransition, targeted recruitment and convenience samples always introduce the limitations associated with selection biases which should be addressed in future research. Finally, many of the participants in this study had less than ideal outcomes to their medical and surgical transitions, and it is possible that these experiences may have colored some of the responses.

Additional research is needed to determine the prevalence of detransition as an outcome of transition and to identify and meet the psychological and medical needs of the emerging detransitioned population. Because many individuals who detransition re-identify with their birth sex, are no longer connected to LGBT communities, and don’t return to gender clinics, future research about detransition needs to expand recruitment efforts beyond gender clinics and transgender communities. The development and testing of non-medical interventions for gender dysphoria could provide valuable options to be used as alternatives or in conjunction with medical and surgical treatments. Because of the potential for some to experience trauma, mental health conditions, internalized homophobia, and misogyny as gender dysphoria, research needs to be conducted on the evaluation process before transition to find approaches that respectfully and collaboratively explore factors that might contribute to gender-related distress. There continues to be an absence of long-term outcomes evidence for youth treated with medical and surgical transition and a lack of information about the trajectories of youth experiencing late-onset gender dysphoria–research is needed to address these gaps. Continued work is needed to reduce rigid gender roles, increase representation of gender stereotype nonconformity, and to address discrimination and social pressures exerted against people who are transgender, lesbian, gay, bisexual, and gender stereotype non-conforming.

Greater Internet access predicts a larger gender news gap, while female representation in politics interacts with political freedom and press freedom to influence the size of the gap

Explaining the Gender Gap in News Access Across Thirty Countries: Resources, Gender-Bias Signals, and Societal Development. Macau K. F. Mak. The International Journal of Press/Politics, October 19, 2021. https://doi.org/10.1177/19401612211049444

Abstract: The gender gap in news access affects the opportunities available for a particular gender to advocate politically, as news consumption contributes to citizens’ understanding of politics and their political participation. Given the significance of the issue, this study uses multilevel modelling and investigates how resources (Internet, education, household income), gender-bias signals (female political representation and economic participation), and societal development (press freedom, political freedom, and economic development) influence the size of the gender news gap. The analysis of multinational cross-sectional survey data (N = 61,677) shows that greater Internet access predicts a larger gender news gap, while female representation in politics interacts with political freedom and press freedom to influence the size of the gap. This study does not only advance the understanding about the individual and societal factors influencing the gender news gap, but also provides insights into solutions to alleviate the gap.

Keywords: gender news gap, gender inequality, news access, multilevel modelling, Internet access, gender-bias signals, press freedom, political freedom

Male and female fetuses respond differently to COVID-19 virus

Maternal SARS-CoV-2 infection elicits sexually dimorphic placental immune responses. Evan A Bordt et al. Sciece Translational Medicine, Oct 19 2021. DOI: 10.1126/scitranslmed.abi7428

Abstract: There is a persistent bias toward higher prevalence and increased severity of coronavirus disease 2019 (COVID-19) in males. Underlying mechanisms accounting for this sex difference remain incompletely understood. Interferon responses have been implicated as a modulator of COVID-19 disease in adults, and play a key role in the placental antiviral response. Moreover, the interferon response has been shown to alter Fc receptor expression, and therefore may impact placental antibody transfer. Here we examined the intersection of maternal-fetal antibody transfer, viral-induced placental interferon responses, and fetal sex in pregnant women infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Placental Fc receptor abundance, interferon stimulated gene (ISG) expression, and SARS-CoV-2 antibody transfer were interrogated in 68 human pregnancies. Sexually dimorphic expression of placental Fc receptors, ISGs and proteins, and interleukin-10 was observed following maternal SARS-CoV-2 infection, with up-regulation of these features in placental tissue of pregnant individuals with male fetuses. Reduced maternal SARS-CoV-2-specific antibody titers and impaired placental antibody transfer were also observed in pregnancies with a male fetus. These results demonstrate fetal sex-specific maternal and placental adaptive and innate immune responses to SARS-CoV-2.

Popular version: https://news.harvard.edu/gazette/story/2021/10/male-and-female-fetuses-respond-differently-to-covid-19/

DISCUSSION

Our results demonstrate the impact of fetal sex on the maternal and placental immune response to SARS-CoV-2, and the potential consequences for neonatal antibody-mediated immunity. We show that maternal SARS-CoV-2 infection is associated with reduced maternal SARS-CoV-2-specific IgG titers in the setting of a male fetus. SARS-CoV-2-specific placental antibody transfer to the male fetus was reduced despite up-regulation of placental Fc receptors in SARS-CoV-2-exposed male placentas; males were unable to overcome the reduced maternal titers and the highly fucosylated glycan profile of the spike protein-specific antibodies. Mirroring Fc receptor expression, placental expression of interferon stimulated genes and proteins was also sexually dimorphic, with notable up-regulation noted in male placentas in the setting of maternal SARS-CoV-2 infection. Collectively these findings provide evidence of maternal-placental-fetal immune crosstalk in the setting of maternal viral infection, with fetal sex playing a key role in modifying maternal humoral responses and placental innate and adaptive immune responses.

Epidemiologic data point to a persistent male bias in the development and severity of COVID-19 disease in adults, children, and infants (6, 8, 9, 82, 83). Male COVID-19 patients are three times as likely to require admission to intensive care units and have higher odds of death than females (84). This male-biased vulnerability to maternal SARS-CoV-2 infection mirrors the male-biased risk of mortality and morbidity across the perinatal period (1–3). Our findings of sexually dimorphic placental innate immune responses to infection, coupled with sex differences in transfer of maternal humoral immunity, may provide insight into increased vulnerability of male infants to morbidity and mortality.

Although the impact of fetal sex is not consistently evaluated in studies of placental function (85), sex-specific alterations in the placental transcriptome have been described in both normal and pathologic pregnancies (86–89). Sex differences in the placental immune response to prenatal infections and other immune stressors have been described in human and animal models (54, 90–93), but have not been examined in SARS-CoV-2 infection. Here we report that maternal SARS-CoV-2 infection induces a sexually dimorphic placental antiviral innate immune response, with up-regulation of ISGs in male, but not female, placentas. Male-specific stimulation of placental ISGs following SARS-CoV-2 exposure is consistent with the heightened male immune responses reported in SARS-CoV-2-infected adult and pediatric cohorts (5, 6, 8–10, 42, 94). Interestingly, although we did not see evidence of maternal viremia nor placental, cord blood, or neonatal SARS-CoV-2 infection (28, 95), and the majority of maternal infections represent mild or moderate disease, there is still evidence of altered placental gene expression and an antiviral response in the placentas of male pregnancies. This indicates that even a mild maternal infection in the absence of placental or fetal infection has the potential to affect placental function and fetal development.

Due to their immature immune system, newborns rely on the passive transplacental transfer of maternal antibodies for initial protection against infectious pathogens (15, 18, 96). Although previous reports in adults have noted sex differences in the production of SARS-CoV-2-specific antibodies (42, 97), sex-biased maternal production and transplacental transfer of SARS-CoV-2-specific antibodies has not been well-described. We previously reported impaired placental transfer of maternal SARS-CoV-2-specific antibodies in the setting of maternal COVID-19 (28, 29). Although there are known sex differences in adult antibody production in response to SARS-CoV-2 infection (42, 94), little is known about sex differences in maternal titers or transplacental antibody transfer (98, 99) in the setting of maternal SARS-CoV-2 infection. Our finding of decreased maternal antibody titers against all measured SARS-CoV-2-specific antigens (S, S1, S2, RBD, N) when the fetus was male versus female was a difference not observed for influenza or pertussis-specific antibodies. Reduced maternal SARS-CoV-2-specific IgG titer in male pregnancies was undoubtedly a driver of the reduced transplacental transfer noted in male fetuses (15). This finding of impaired placental transfer of SARS-CoV-2-specific antibodies, more pronounced in males, is consistent with the male-specific reduction of placental transfer of maternal IgG reported in a non-human primate model of maternal stress (98). Reduced maternal antibody titers in the setting of a male fetus were likely attributable to suppressed maternal pro-inflammatory responses in the setting of a male fetus, which have been described in prior studies and may function to improve tolerance of the fetal allograft (13, 14). The direct correlation between pro-inflammatory response and increased antibody production noted in COVID-19 infection (66, 67) suggests that blunted maternal inflammatory responses in the setting of a male fetus may limit maternal antibody production in the setting of acute infection. Whether the male-biased impairment in placental SARS-CoV-2-specific antibody transfer renders male infants more vulnerable to early-life SARS-CoV-2 infection remains unclear, as the amount of antibody necessary for protection against SARS-CoV-2 infection is unknown and there are few sex-disaggregated reports of neonatal (100, 101) or infant infection (8).

Although the up-regulation of Fc receptor expression in male placentas may represent a compensatory placental response driven by reduced maternal antibody titer and transplacental transfer of SARS-CoV-2 antibodies (22, 102, 103), this response was likely reinforced by the increased IFN signaling in males versus females. IFN-stimulated signaling may impact placental antibody transfer via alteration in Fc receptor expression and function (104–106); for example, Type I IFN signaling is known to up-regulate Fcγ receptor expression on monocytes (107). Hofbauer cells, tissue-resident macrophages of the placenta, express FcγRI, II and III (23). The male-specific Hofbauer cell hyperplasia in placentas exposed to maternal SARS-CoV-2 infection could therefore also be contributing to increased placental FcγRI and FcγRIII expression in males.

Although the low maternal antibody titers in male pregnancies may have driven a compensatory up-regulation of Fc receptors in the male placenta, the up-regulation of FcγRIII and co-localization of FcγRIII with FcRn in the male placenta likely impeded placental transfer of SARS-CoV-2-specific antibodies, given their distinct Fc-glycan profile. Our Fc-glycan analysis demonstrated that SARS-CoV-2-specific antibodies were highly fucosylated in both male and female pregnancies, a post-translational modification that lowers antibody affinity for FcγRIII (69–71). The male-specific placental increase in FcγRIII expression and co-localization of FcγRIII with FcRn might therefore present an additional impediment to transferring the already-low maternal titers of SARS-CoV-2-specific antibodies to the fetus. Males instead preferentially transferred bisected (afucosylated) and agalactosylated (G0), afucosylated spike protein-specific antibodies, as afucosylated antibodies are more easily transferred by FcγRIII. Given the inflammatory nature of G0 and B antibodies (72, 108, 109), their preferential transfer might promote a more inflammatory immune response in male fetuses.

Innate immune sensing of SARS-CoV-2 involves the activation of type I and type III interferons and up-regulation of ISGs in target cells (110). Given the relative paucity of SARS-CoV-2 placental infection (28) in comparison to other pandemic infections such as Zika virus (ZIKV) (111), the increased ISG production and up-regulated IL10 expression in exposed male placentas may be a protective mechanism to prevent direct placental infection and pathology. Indeed, high IFN concentrations during pregnancy have proven protective against placental herpes simplex virus infection (112) and type III IFNs impair ZIKV transplacental transmission (113). Induction of ISGs is likely not universally protective, however. Whereas type III IFNs primarily serve a barrier defense role, type I and type II IFNs can serve a more classical immune activating or inflammatory role (31, 45). Animal models of viral infection in pregnancy implicate type I and type II interferons and ISGs in impaired placental development and fetal growth restriction (46, 50, 51, 114), conditions which can have both short- and long-term impact on fetal and offspring health. We demonstrated increased expression of IFN-γ, initiator of Type II interferon signaling, in male SARS-CoV-2-exposed placentas. IFN-γ and the Type II IFN response have been implicated in placental spiral artery remodeling, and may mediate fetal growth restriction and fetal demise in malarial and Toxoplasma gondii infection in pregnancy (50, 51, 115, 116). A transcriptomic analysis of SARS-CoV-2 response genes demonstrated that IFN-γ was an upstream regulator of host viral response in the setting of SARS-CoV-2 infection (117), with higher IFN-γ abundance associated with increased risk for SARS-CoV-2 viral entry (52) and increased mortality in moderate and severe COVID-19 illness (53). Thus, it remains unclear if the male-specific up-regulation of ISGs described here is potentially beneficial (protection from viral infection) versus harmful (increased placental inflammation, increased risk for fetal growth restriction or poor placental function). It was noteworthy that female placentas from SARS-CoV-2-negative control pregnancies generally had higher expression of interferon-stimulated genes and proteins than did male SARS-CoV-2-negative placentas. The potential for a baseline female “antiviral placental advantage” is consistent with the established increased vulnerability of the male fetus to in utero insults, including viral and bacterial infection (92, 118), and observed sex differences in baseline innate immunity described in non-placental cells and tissues (12, 119). These findings highlight the necessity of future studies assessing baseline differences in male and female placental immune responses. The long-term consequences of SARS-CoV-2-associated placental induction of Type I, II, and III IFN responses for fetal development and in utero programming of later life metabolic and neurodevelopmental outcomes remains to be determined.

A limitation of our study is the infection of participants primarily in the third trimester, because these samples were collected during the initial wave of the SARS-CoV-2 pandemic in Boston. Whether maternal SARS-CoV-2 infection in the first and second trimester alters ISG and Fc receptor expression, and how such altered expression might durably impact placental immune function, is a question that remains to be answered in future studies. It remains unclear whether the reduced SARS-CoV-2-specific maternal antibody titers, highly fucosylated glycan profile of spike protein-specific antibodies, and attenuated male-specific transplacental antibody transfer are unique to SARS-CoV-2 biology, or whether these phenomena instead reflect a common response to de novo infection during pregnancy. Future studies should assess the effect of fetal sex on maternal SARS-CoV-2 antibody titers and transplacental transfer in women infected prior to pregnancy, and the effect of fetal sex on maternal antibody responses to other de novo infections during pregnancy. In addition, although we found no association between disease severity and placental gene expression or antibody transfer, such examinations were limited by the relatively small number of women with severe or critical illness. Although our results demonstrate male-specific up-regulation of Type I and II IFNs (IFN-α and IFN-γ), and interferon-stimulated genes and proteins downstream of Type I-III signaling cascades, this study did not assess protein expression of Type III IFN-λ. Finally, although our regression models did not find time from infection to delivery to be a substantial contributor to the antibody transfer ratios, we cannot entirely rule out any contribution of timing of maternal infection to the reduced antibody transfer noted in males. However, our robust sexually dimorphic gene and protein expression results, with up-regulation of both placental ISGs and Fc receptors in males, demonstrate placental factors are a stronger driver of antibody transfer than any time-from-infection effect.

In conclusion, our comprehensive evaluation of the impact of fetal sex on placental gene expression and transplacental antibody transfer in maternal SARS-CoV-2 infection provides insight into sexually dimorphic or sex-specific placental innate and adaptive immune responses to maternal SARS-CoV-2 infection. The increased impact of maternal SARS-CoV-2 infection on male placental and neonatal immunity highlights the importance of evaluating fetal sex in future studies of placental pathology and infant outcomes in SARS-CoV-2, as well as the critical importance of disaggregating sex data in follow-up studies of offspring neurodevelopmental and metabolic outcomes. These findings may have broader implications for understanding placental immune response, male vulnerability, and passive transfer of maternal antibody in other viral infections. Studies investigating SARS-CoV-2 vaccine safety and efficacy in pregnant women should also evaluate placental immune response and antibody-transfer effects, in addition to neonatal infection rates, and report these data in a sex-disaggregated fashion (120).