Transgender and gender-diverse people have higher rates of autism than cisgender people, a landmark study has confirmed.
The research, published in the peer-reviewed scientific journal Nature Communications, also found that trans people are more likely to be diagnosed with schizophrenia, ADHD, bipolar disorder, depression, learning difficulties or OCD than cis people.x
The authors, led by Varun Warrier from Cambridge University’s Autism Research Centre, used five large existing datasets to closely examine whether people who have autism are more likely to be trans, and vice versa — something that’s been posited by previous research, but only by studies using small sample sizes.
Their findings, the authors concluded, show that “transgender and gender-diverse individuals have elevated rates of autism diagnosis, related neurodevelopmental and psychiatric conditions, and autistic traits compared to cisgender individuals”.
“This study has clinical implications by highlighting that we need to improve access to care and tailored support for this under-served population,” they wrote.
Roughly one to two per cent of the population is estimated to be autistic while 0.4 to 1.3 per cent is estimated to be trans or gender-diverse.
Previous research into the links between autism and gender identity mostly used data from trans people who had been referred to a gender clinic, and had a typical sample size of “in [the] few hundreds”, the authors noted.
This created bias in terms of the type of trans person included — favouring those who have gender dysphoria, the resources to access a gender clinic and some support from family or friends in doing so — which would be exacerbated by the small sample size.
“It is important to understand what the odds are of being diagnosed as autistic in transgender and gender-diverse individuals at large, not solely in those recruited through GD [gender dysphoria] clinics,” the researchers said.
Trans people up to six times more likely to be autistic than cis people.
The scientist’s findings can be broken down into four key points.
First, across all five datasets used, trans and gender-diverse people are 3.03 to 6.36 times more likely to be autistic than cis people. This is after the researchers controlled for age and educational attainment.
Second, trans and gender-diverse people were significantly more likely to self-report autistics traits, systemising and sensory sensitivity, and scored lower on empathy traits than cis individuals.
Third, in two of the datasets, trans people were significantly more likely to have higher rates of other neurodevelopmental and psychiatric conditions, including OCD, schizophrenia, ADHD, learning difficulties, depression and bipolar disorder.
And finally, an “exploratory analysis” carried out by the researchers found that trans people were more likely to say that they suspected they had undiagnosed autism.
Explaining the overlap between an autism diagnosis and being transgender.
Making it clear that, for several reasons, their results are unlikely to be false positives, the researchers also stressed the importance of their finding that “this association with gender identity is not specific to autism”.
They also emphasised that more research into this area is needed — specifically, a more comprehensive investigation into the relative rates of each of the neurodevelopmental and psychiatric conditions in trans people compared to cis people.
In discussing why there might be this overlap between an autism diagnosis and being trans, the researchers considered that “autistic individuals may conform less to societal norms compared to non-autistic individuals, which may partly explain why a greater number of autistic individuals identify outside the stereotypical gender binary”.
Then, there is the role of “prenatal mechanisms” — like hormones that impact sex – which shape brain development and have been shown to contribute to both autism and gender role behaviour. But, the scientists said clearly, it is unclear if prenatal mechanisms also affect gender identity, and this needs further investigation.
“Finally, an alternative but not mutually exclusive explanation,” the researchers said, “is that transgender and gender-diverse individuals have elevated vulnerabilities for multiple psychiatric challenges related to stressful life experiences in the contexts of unfriendly environments, discrimination, abuse and victimisation, explaining the elevated rates of mental health diagnoses.”
Some caveats applied to their conclusions, the researchers said: in two of the datasets, intersex individuals were excluded, but this was not possible in the other three; in one dataset it was possible that non-binary people who don’t use the word “transgender” to describe themselves were excluded; and it is also possible that “gender-aware” individuals provided their sex, rather than gender.
“It is difficult to disentangle this,” the study concludes. “However, the magnitude of the sample size suggests that the effects of such misclassification will have a minimal effect on the analyses and findings.”
Chick-fil-A said Monday that it no longer plans to open a restaurant in the San Antonio airport, even though the Texas city relented after more than a year of legal wrangling that began when some city leaders opposed the fast-food chain getting a spot, citing donations made by company owners to anti-LGBTQ causes.
“We are always evaluating potential new locations in the hopes of serving existing and new customers great food with remarkable service.” Chick-fil-A said in a statement. “While we are not pursuing a location in the San Antonio airport at this time, we are grateful for the opportunity to serve San Antonians in our 32 existing restaurants.”
In May last year, Texas Attorney General Ken Paxton asked U.S. Department of Transportation Secretary Elaine Chao to look into whether the city had broken federal law or transportation department regulations. He said the fast-food chain’s exclusion from the airport amounted to discrimination “due to the expression of the owner’s religious beliefs.” The complaint prompted an FAA investigation that ended July 24 with an informal resolution for San Antonio to allow Chick-fil-A to seek a lease in the city-owned airport.
Some Texas leaders broadly supported the company. Republican Gov. Greg Abbott signed a bill in 2019 in defense of Chick-fil-A and religious freedom. And on Monday, Paxton, also a Republican, heralded the agreement between San Antonio and Chick-fil-A.
“This is a win for religious liberty in Texas and I strongly commend the FAA and the City of San Antonio for reaching this resolution,” Paxton said in a statement. “To exclude a respected vendor based on religious beliefs is the opposite of tolerance and is inconsistent with the Constitution, Texas law, and Texas values.”
The FAA did not immediately returns calls seeking comment.
“The city itself offered to resolve the FAA investigation informally following Chick-fil-A’s publicly stated change-of-position on its charitable giving policy,” a city spokesman told San Antonio TV station KSAT. “The city maintains that at no point did it discriminate against Chick-fil-A.”
Atlanta-based Chick-fil-A has faced opposition elsewhere over its donations worth millions of dollars to groups that oppose same-sex marriage.
A Navy veteran is suing the US government after doctors allegedly forgot to tell him he tested positive for HIV in the 1990s.
The South Carolina man says he was unaware he was living with HIV for more than two decades after government health workers failed to inform him of his test results.Read More
A federal lawsuit explains how he was tested in November 1995 at a Department of Veterans Affairs (VA) medical centre in Columbia, South Carolina as part of routine lab work.
The veteran, named only as John Doe in the filing, was under the care of the department after being involved in a 1976 shipwreck which left him with post-traumatic stress disorder (PTSD).
However, “in clear contravention of the standard of care, Mr Doe was not informed of the positive HIV test until decades later”, the lawsuit states.ADVERTISING
In fact, it wasn’t until 2018 that the veteran says he was made aware of his status.
In 2014, a nurse practitioner at the Columbia facility had noted the 1995 test results in a memo. Mr Doe still wasn’t informed, the suit states.
He saw another VA doctor in 2015 who asked if he knew who his infectious disease doctor was. When he replied that he didn’t have one, the doctor reportedly asked the veteran if he knew whether he was living with HIV. Even still, the suit states, Mr Doe wasn’t made aware of his positive status.
Finally, in September 2018, the veteran visited an emergency room not affiliated with the department. It was here that he says he was diagnosed with HIV and AIDS, and immediately began treatment.
According to the suit, the veteran had by this time developed a number of related illnesses including an infection of his brain tissue.
“[He] needlessly suffered for decades with co-existing conditions common in HIV infected persons, including lymphadenopathy, neurotoxoplasmosis, muscle aches and joint pain,” the lawsuit says.
“Had defendants acted within the standard of care, Mr Doe would not have suffered the losses he has suffered, and will continue to suffer in the future, and more likely than not, he would not have developed AIDS.”
The veteran’s lawyer Chad McGowan said he is responding to antiretroviral therapy, but has “had essentially 25 years of wear and tear for having no treatment”.
“He feels extremely guilty about the girlfriends he’s had over the last 25 years because he didn’t know.”
The Department of Veteran Affairs told the Associated Press it “does not typically comment on pending litigation”.
According to the Terrence Higgins Trust, a person who is diagnosed and starts treatment early can expect to live as long as person without HIV.
Once the treatment has lowered the levels of the virus in a person’s blood – their viral load – they are unable to pass on HIV and the virus is no longer able to damage their immune system. This is known as being undetectable (meaning tests can no longer detect HIV in a person’s blood). Undetectable equals untransmittable.
An Australian court has given permission for a 16-year-old trans girl to receive gender-affirming hormone therapy, overruling her mother who opposes her transition.
The girl, given the name Imogen during proceedings, had “expressed a consistent, persistent and insistent view that she wishes to move to… gender affirming hormone treatment”, the judge said in his ruling at the Family Court.
Justice Garry Watts said Imogen is legally competent to consent to the treatment, correctly diagnosed with gender dysphoria, and that hormone therapy is in her best interests.
Her father, who supports her transition, said the judge’s decision came as a relief.
“We got the result last night and we had a bit of a cry,” he said, according to the Sydney Morning Herald.
Imogen’s father described the judge as “very fair” in hearing both sides, and invested in finding out what was in his daughter’s best interests.
Imogen, who has described herself as female since she was seven, will now be able to access the feminising hormone oestrogen.
In Australia, any form of medical transition for under-18s – puberty blockers, hormone treatment, or gender-confirming surgery – used to have to be approved by a court.
Since a 2013 ruling, it’s been possible for parents and children to access puberty-blocking drugs without a judges approval.
In 2017, another court ruled that trans youth and their parents could consent to hormone treatment without needing to go to court. But the role of the court in assessing disputes – like in Imogen’s case, where one parent supports her transition and one opposes it – had remained unclear.
This week’s Family Court decision “improves certainty” for families and transgender young people, said the Inner City Legal Centre in Sydney.
In his judgement, Justice Watts said that the court will only intervene in access to hormone treatment for trans youth if a parent or doctor disputes the child’s legal competency to consent, the diagnosis of gender dysphoria, or the proposed treatment.
In Imogen’s case, her mother disputed all three. But Watts said that Imogen was an “adolescent of intelligence and maturity”, legally competent to consent and that hormone treatment is in her best interests.
The Inner City Legal Centre said “the court’s judgment confirms that the existing law is that a medical practitioner seeing a young person under the age of 18 cannot initiate stage one, two or three treatment without establishing parental consent”. If there is a dispute, the court must intervene.
An outspoken Christian preacher and activist is accusing his daughter’s school of violating her First Amendment rights by forcing her to change out of a shirt proclaiming that “homosexuality is a sin.” He is contemplating legal action. Brielle Penkoski, the daughter of Rev. Rich Penkoski, attends Livingston Academy, a public high school in Livingston, Tennessee. During the school day on Tuesday, Aug. 25, she was allegedly asked to change out of a black T-shirt shirt bearing white letters asserting that “homosexuality is a sin.”
The shirt references the New Testament passage of 1 Corinthians 6:9-10. When she refused to change out of the shirt, she was sent home from school, her father told The Christian Post in a recent interview. Penkoski, who regularly speaks out in opposition to things like homosexuality and Drag Queen Story Hour events, runs an organization called Warriors for Christ, which describes itself as a “pre-denominational ministry” that has a global online presence.
A man in Perth, Australia, has been jailed for five years after he failed to disclose that he was living with HIV to four sexual partners – all of whom later tested positive for the virus.
The 30-year-old, who has not been named to protect the identities of his victims, told the four men that he did not have HIV before having condomless sex with them, the West Australian reports.
A court heard that the accused had actually been diagnosed with HIV in 2012.
In 2013, he told a man that he did not have HIV before having condomless sex with him. His sexual partner was later diagnosed with the virus.
In 2014, he told another man through the dating app Squirt that he did not have HIV. A year later, the two met and had condomless sex. Just weeks later, his sexual partner became ill, and he tested positive for HIV four months later.
In 2012 the accused embarked on a long-term relationship, and told his boyfriend that he did not have HIV. They started having condomless sex in 2014, but his boyfriend’s suspicions were aroused in 2015 when he found antiretroviral medication.
The boyfriend went for a HIV test and discovered that he too had the virus. They separated a year later.
Following that incident, the accused met up with a man through Tinder and had condomless sex with him after claiming that he did not have HIV. That man also tested positive.
Man who lied about HIV status ‘extraordinarily selfish’.
The offender was arrested in January 2018 and charged with unlawfully engaging in an act that was likely to endanger his victims’ life, health or safety.
In his sentencing, district court Judge Troy Sweeney said the man had been “reckless” by failing to disclose his HIV status to the four men.
The Trump administration is siding with religious leaders who ordered a Catholic school in Indiana to fire a teacher in a same-sex marriage, saying the church’s actions are protected by the First Amendment.
In a 35-page amicus brief filed on Tuesday, the Department of Justice argued that the Roman Catholic Archdiocese of Indianapolis — which fired gay high school teacher Joshua Payne-Elliott last year — is, like other religious employers in the U.S., “entitled to employ in key roles only persons whose beliefs and conduct are consistent” with its “religious precepts.”
In addition, the brief states, the “Constitution bars the government from interfering with the autonomy of religious organizations.” Payne-Elliott’s battle with the Archdiocese of Indianapolis started last spring, two years after he married Layton Payne-Elliott, who teaches at a different Catholic high school in Indianapolis.
A Miami-Dade County jail is facing potential legal action after two transgender women said they were mistreated and humiliated at the jail following their arrests at a Black Lives Matter rally.
“Initially I think we can all say it was a very inspiring experience,” Viola, one of the arrested women, said of the rally. “Even through the rain, we were chanting, screaming our lungs out.”
But that empowering experience escalated into something more humiliating and degrading, according to Viola and Gabriela Amaya Cruz, a trans woman who was arrested alongside Viola. The women said officers started using excessive force and alleged Viola was pushed to the ground and tackled by two officers. Dramatic video shows the moment things took at turn at the protest.
More than a dozen people were arrested and all were transported to Turner Guilford Knight Correctional Center where the women alleged things got worse.
“They had no idea to where to place me,” Cruz said. “And when they said my legal name, I had to raise my hand, obviously, because it was me. And that’s when it started to get like, ‘That’s not a woman, that’s a man,’ and that’s when things got very transphobic.”
A spokesperson for the Miami-Dade Corrections and Rehabilitation Department released a statement to NBC Miami saying, in part, that the department is “committed to ensuring that all inmates in our custody including transgender persons are treated appropriately throughout our intake, classification and housing placement process.”
Rivky strolled through the Zara store in Manhattan’s fashionable SoHo neighborhood, one eye examining the racks of skirts and blouses and the other looking out for anyone she might know. She was looking for something that would fit her broad frame. Rivky made her way to the women’s dressing room line, dresses and skirts piled on her forearms. The female attendant looked confused and then chuckled. Why was this male-presenting person — wearing traditional Hasidic Jewish men’s attire — walking into the fitting room with women’s clothing?
Rivky, 41, is not your typical gender-conforming religious observer. Her white dress shirt, black vest and black slacks — the daily dress code for Hasidic men — serve as culturally acceptable covers for the bra and women’s underwear she frequently wears underneath. She feels her best when dressed in women’s attire, and at home she regularly strips down to just a bra, panties and nylon tights when she knows her wife will not be back for hours.
“It makes me feel like I want to dance for joy,” said Rivky, who asked that her full name not be published because she is not out to friends and family about her gender identity.
“If you take a magnifying glass and look into my heart, you will see 100 percent I am a girl.”
Rivky identifies as transgender but deeply buries these emotions and feelings away from her ultra-Orthodox community in Borough Park, Brooklyn. She fears that if she were to come out of the proverbial closet, she would face social expulsion or, worse, abandonment by her wife and four children. While there is no set Hasidic policy regarding those who come out as transgender, the community’s strict code of living does not condone even the slightest deviation from the Hasidic norm.
Neither biblical nor rabbinical literature points to changing one’s sex, but the Torah does discuss cross-dressing, said Rabbi Ethan Witkovsky of Park Avenue Synagogue, a prominent Conservative congregation in New York.
Deuteronomy 22:5 reads, “The woman shall not wear that which pertaineth unto a man, neither shall a man put on a woman’s garment: for all that do so are abomination unto the Lord thy God.”
Witkovsky said some rabbinical teachings might support the literal translation of this verse, while others would interpret it otherwise.
From a young age, Rivky was in tune with her womanhood, but always in secret. As a child, she mirrored her sisters and female cousins, and she dressed like a girl when she had the chance. When her mother was away, Rivky, as young as 6 years old, would sneak into dresser drawers and try on her mother’s undergarments. They were large on Rivky’s child-size body but nonetheless “amazing,” she recalled with a smile.
When she grew older, Rivky ventured to women’s stores outside her community and glanced around the racks, wistfully. She was ashamed to admit her presence and found herself telling salespeople that she was shopping for her mother or sister. That prevented her from entering fitting rooms to try on clothes, denying her the satisfaction she craved.
“I should’ve been born a girl,” she said.
Despite temptations, Rivky kept her desires clandestine, believing they were sinful thoughts that needed to be purged.
“I would pray to God, ‘Take this away from me,'” she recalled.
But the more she pushed her womanhood away, the stronger her feminine wishes would return. Rivky continued to fight them off and kept to tradition when the Hasidic community arranged her marriage at 18. More than two decades and four children later, concealing her true identity left Rivky feeling incomplete. Only in the past 10 years has she realized that the only way to make peace with herself is to embrace those thoughts. Her urge to be the woman she has always wanted to be — after decades of hiding — grew stronger and stronger.
“I wanted to take off my beard,” she said. “I wanted to grow my hair.”
Rivky’s face glowed under tangled facial hairs when she discussed how she wants to take hormones some day. She also dreams of growing her hair long and styling it. She does, however, already shave her legs and chest hair from time to time, she confessed.
In small and subtle ways, Rivky increasingly started to express her gender identity, while keeping her friends and relatives in the dark. Her wife, however, had her suspicions and conveyed her disapproval. The couple have not discussed Rivky’s identity as a transgender lesbian, but Rivky said she knows that if she were to come out, she would lose her wife and children.
While coming out to those within her religious community is still a bridge too far for Rivky, she has taken steps to open up to those outside her Hasidic circle.
On a recent Sunday, Rivky attended a monthly feminist gathering in Brooklyn called Sacred Space, which celebrates and empowers women of all and no religious backgrounds. Women of various ages flashed smiles, exchanged hugs and gathered in a large circle around pastel furniture at the meeting room in the borough’s trendy DUMBO neighborhood. Attendees began introducing themselves, and Rivky, dressed in slacks and a dress shirt with her long curly sidelocks falling from her balding head, spoke up.
“If you take a magnifying glass and look into my heart, you will see 100 percent I am a girl,” Rivky announced in a Yiddish accent. She attended the event to see the co-host, Abby Stein, an openly transgender woman who was once an ultra-Orthodox rabbi. Rivky listened to Stein attentively, admiring her courage and openness, and then ducked out of the meeting early, as confidentiality was a concern.
Rivky yearns to assimilate into a larger society that extends beyond Brooklyn’s ultra-Orthodox community, and without blowing her cover, she relies on Facebook as an outlet. Hasidic Jews typically do not use social media, but Rivky’s account is disguised, and it is strictly used for expressing her womanhood. Her Facebook cover image is of a rainbow flag with the words “love is love,” and her profile photo is of a polished woman’s hand holding a red rose. Her tag line reads, “A transgender girl who appreciates seeing a smile on her friends lips when they are painted hot red!”
An estimated 1.4 million adults identify as transgender in the United States, according to the Williams Institute at UCLA School of Law, although it is unknown how many trans Americans, like Rivky, are not open about their gender identities. For those who do come out, living openly is not without its challenges: According to the Human Rights Campaign, the country’s largest LGBTQ advocacy group, transgender people often face discrimination in housing, employment and health care, among other hurdles.
Stein, 28, is no stranger to the challenges of both the proverbial closet and coming out as transgender in the Hasidic community. A former rabbi, Stein said she struggled with her gender identity since she was at least 5 years old, recalling anger toward her parents at the time for not letting her wear dresses and telling her mother that the genitalia she was born with “doesn’t belong there.”
Stein was born into a large family of 12 children, and she socialized with no one outside her close-knit Hasidic circle in Brooklyn growing up. She divorced her wife, pursued a secular education and then came out as transgender in 2015. Stein was ostracized by her religious community, and her ex-wife severed ties, as well, because Hasidic leaders forbade their remaining in contact. She does, however, get to visit with her son from time to time. Now, five years after having left the community, she still savors the freedom fueled by that difficult decision.
“Even sometimes just waking up in the morning and walking in the streets you can be yourself,” she said. “Being yourself every day is really powerful. I can’t overstate that enough.”
She finds value in the opportunity to meet people from all walks of life rather than be confined to one group that shares the same religious and cultural values.
“I could never form strong friendships before I came out,” she said, adding that now, after having traveled to six continents and becoming friends with diverse groups of people, that aspect of her life is thriving. Over the past few years, Stein has become a global LGBTQ rights activist and has given lectures in more than 20 countries, hoping to inspire courage, resilience and inclusion. Her autobiography, “Becoming Eve: My Journey from Ultra-Orthodox Rabbi to Transgender Woman,” was released in November.
But while Stein has found beauty and inspiration in her expanded world, the loneliness that comes from the loss of her Hasidic friends and family still creeps in from time to time. Stein said that for years after she was shunned by her religious community, she would call her mother every Friday, even though her mother would avoid answering the phone or answer and immediately hang up when she realized Stein was on the other end of the line. Stein called less frequently, reaching out only on holidays, and eventually she stopped calling altogether.
“Being yourself every day is really powerful. I can’t overstate that enough.”
The fear of alienation and losing her family is what kept Rivky on guard during her SoHo shopping trip. But despite the uneasiness, the experience was a mini-vacation, because her wife was out of town.
“Just walking into this environment makes me feel womanized, girlish,” she said while walking into Club Monaco.
“I like heels. Something pointy,” she said before settling on a pair of pink pumps at a nearby shoe store. Her size was not available, but that did not stop her from squeezing what she could of her foot into the shoe and admiring the dainty look in the mirror.
Rivky abides by social distancing rules during the COVID-19 pandemic, but she said the most difficult part has been the lockdown on self-expression. Her family is home more than usual now, which means bras, panties and other expressions of her gender identity are relegated to their own version of quarantine.
There’s “very little time to express my feminine self,” she said dejectedly. A quick trip to the market is her excuse to escape the social construct and at least call her non-Hasidic friends to discuss her frustration. Rivky said her fear of “remaining a man” is greater than her fear of contracting a dangerous virus.
Rivky remains caught between two worlds, and she yearns to one day reconcile her inner gender identity with the person she presents outwardly. On some days, she feels that her coming out is closer, but for now, she continues to sneak out for short shopping trips and to message people through her secret Facebook account.
“Keeping the FEMININE flame’s burning and it gets stronger and wider,” she recently wrote on Facebook. “I am getting closer to living my feminine dream.”
“All female athletes want is a fair shot at competition,” a young woman can be heard saying over a video of several athletes preparing to run a race. “But what if that shot was taken away by a competitor who claims to be a girl but was born a boy?”
That controversial digital ad — which then shows a teen boy outrunning his female competitors and shrugging at them with indifference afterwards — is one of three released this week by the American Principles Project, a Virginia-based conservative think tank, and its PAC. The group issued a statement Thursday saying the political ads are part of a $4 million effort to “target persuadable Democrats and independent voters in key swing states.”
Half of the campaign budget will be spent in Michigan, a state Trump won in 2016 but now lags in the polls, and the American Principles Project confirmed it will release ads in Wisconsin “in the coming weeks.” The group said it hopes the Michigan ads draw attention to the support of Democratic presidential candidate Joe Biden and Sen. Gary Peters, D-Mich., “for policies which would allow biological males to compete in women’s sports and push children into dangerous, life-altering sex-change” procedures.
The two other ads feature Kevin Whitt, a man who says he lived as a woman for 17 years before deciding to detransition. Whitt warns viewers that “treatments to change the gender of a minor are very dangerous and irreversible.”
The Biden and Peters campaigns did not immediately respond to a requests for comment.
National LGBTQ advocacy groups, including the Human Rights Campaign and GLAAD, were quick to denounce the campaign.
“These ads perpetuate dangerous stereotypes, traffic in misinformation, and put the lives of transgender people at risk,” GLAAD President and CEO Sarah Kate Ellis said in a statement. “Sites and social media platforms like YouTube and Facebook should decline to run them and send a message loud and clear that those who would use their platforms to peddle hate and lies will not be tolerated or validated.”
The Human Rights Campaign also called for social media companies to take down the digital ads, saying they are blatant lies from an “outdated playbook.”
“APP wants a future where LGBTQ people can be fired, denied housing, refused business services or health care solely because of who they are. But they know full well that they’re on the wrong side of this issue and the wrong side of our future.”
Representatives from Facebook and YouTube did not immediately respond to NBC News’ requests for comment regarding the ads.
This is not the first time APP has funded an ad campaign with the hopes of making transgender rights a political wedge issue. Last year, it funded a similar campaign amid the Kentucky governor’s race, though the group’s preferred candidate, Republican Gov. Matt Bevin, lost to Democrat Andy Beshear.