Keywords

Introduction

Terminology

Gender identity is one’s internal sense of being male, female, both, or neither – it is a product of both innate and external influences. Biological sex , in contrast, is assigned at birth based on anatomical, gonadal, and genetic elements. Also in contrast to biological sex, gender identity can shift over time. The discourse and language around gender is evolving rapidly in our country. Many people, particularly in the younger generations, now describe their gender identity on a spectrum that defies the historical binary of men/women. These individuals may use words like gender fluid, gender non-binary, gender nonconforming, genderqueer, or gender variant to describe their felt gender [1]. The vast majority of people identify as cisgender , which means they have a congruent sex and gender identity (e.g., a male that identifies as a man), whereas transgender individuals have a gender identity that does not match their assigned sex (e.g., a birth-assigned female that identifies as genderqueer or a birth-assigned male that identifies as a woman). Gender expression is an outward presentation of gender – for example, the clothes, makeup, piercings, or hairstyle one chooses may be feminine, masculine, or androgynous. For transgender individuals, body modifications as result of gender-affirming hormones and surgeries may be an important part of their gender expression . Gender transition is the process of shifting one’s outward gender expression, usually to match one’s internal sense of gender (e.g., from feminine to masculine). For some individuals, gender transition could mean starting gender-affirming hormones and changing one’s name/pronouns; for others, it might be something subtler like a shift to more masculine clothing.

Case Study

In 2012, Dr. Elliott Elson took the first step in his gender transition. After decades of suppressing the dissonance between his biological sex and gender identity , he finally accepted that his gender identity was masculine-of-center and made a conscious decision to shift his gender expression by starting to shop in the men’s department. Four years later, after continuing to experience gender dysphoria, he decided to transition further – to change his name, adopt masculine pronouns, and start gender-affirming hormone therapy (i.e., testosterone). Three months after that decision, he administered his first hormone injection of testosterone. At that point, only his closest circle of family and friends knew about his plan to transition. For the next few months, he continued to live and work as Allison while his body subtly started to take on a more masculine form. Four months after his first shot of testosterone, he had “top surgery” to remove his breasts. In the weeks following the surgery, he made a broad announcement of his transition to his colleagues, extended family, and friends – at this time, he asked everyone to start calling him by his chosen name, Elliott, with male pronouns. Shortly thereafter, a judge approved his case for legal name change to Elliott.

Case Scenario

Long before Dr. Elliott Elson came out as transgender in professional circles, his gender identity and expression had been masculine-of-center. One challenge Dr. Elson faced in being gender nonconforming in a professional environment – where dress codes have historically been dictated by gender – was finding acceptable professional attire that could comfortably house (and simultaneously hide) his female-bodied self. While vulnerable on many levels, it felt important to present his authentic gender in his professional life. A few years ago, he attended a faculty event dressed head-to-toe in masculine attire (including shirt and tie) and he was greeted by a senior, white male colleague with a hearty, “Hello, young lady!” Dr. Elson was mortified. This colleague’s comments demonstrated complete disregard for Dr. Elson’s masculine gender expression: he felt undressed and unseen.

Discussion

Gendering: Binary Assumptions

Gendering is one mechanism that perpetuates the historical invisibility of gender diversity. Most of us move through our daily lives making automatic, binary assumptions about people’s gender identities – subconsciously categorizing the people around us as “men” or “women.” This is called gendering. The way we have gendered an individual subsequently informs the words we use to speak with/about that individual – for example, pronouns (he/she), honorifics (Mr./Ms.), and certain terms of respect (ma’am/sir) all have inherent gender meaning. It is important to recognize that this process of subconscious sorting is a way in which we make assumptions about the people around us and that sometimes our assumptions will be wrong. When our assumption is wrong, it is called misgendering . Being misgendered (e.g., when a transman is called “Ma’am” instead of “Sir”) is a common and often distressing experience for transgender individuals.

How to Do Better

Pay attention to people’s gender expression . Just because you can discern someone’s assigned sex at birth does not mean that you know that person’s gender identity. Look for cues like clothing, hairstyle, makeup, jewelry, and accessories – these are intentional choices people make in order to present their gender to the world. A simple best practice to avoid misgendering people is to simply ask what name they wish to be called and what pronouns they use, and then use them.

Do not conflate sexual orientation and gender identity. Sexual orientation is an identity that describes to whom/what gender(s) someone feels sexually attracted – this is often simplified to men/women/both, which reinforces a binary gender construct. Transgender people, like their cisgender counterparts, might identify as gay, straight, queer, bisexual, etc. Before his gender transition, people who noticed Dr. Elson’s masculine presentation may have assumed he identified as a “butch lesbian”; however, his presentation was an expression of his gender identity and not his sexual orientation.

Case Scenario

A month before Dr. Elson planned to announce his gender transition to his fellow faculty/staff (and 3 months into gender-affirming hormone therapy), about half of his patients were perceiving him as a man, which felt encouraging. On one occasion when a patient referred to him as “Sir,” a nurse overheard and became visibly upset because she felt the patient had mistaken Dr. Elson’s gender. He told the nurse that it was fine and encouraged her to let it go. Yet, she took it upon herself to correct the patient and let him know that Dr. Elson was a “ma’am.”

Despite Dr. Elson’s attempts to ask the nurse not to intervene, she did anyway. For the nurse, it was a matter of respect – her behavior was likely motivated by feelings of protectiveness toward Dr. Elson. For him, however, it was more than a matter of feeling affirmed in his felt gender: It was also a matter of safety. He was “passing” as a man, and the nurse “outed” him to this patient.

Discussion

Transition: Trapped Between “He” and “She”

Deciding to gender transition is usually preceded by months or, more likely, years of contemplating the risks, benefits, and alternatives. And once someone makes the decision to transition, there is a thoughtful process for how and when to come out to one’s friends, family, and colleagues. Transitioning is often a long and fraught journey. Gender-affirming hormones work slowly to exert their effects over months-to-years [2]. Yet, the person transitioning must decide on discrete moments to change names/pronouns, to announce one’s transition to family/friends/colleagues, and to swap bathrooms. One of the most vulnerable times during gender transition is the interval between deciding to transition and the carefully timed announcement of transition to family/friends/colleagues. Agonizing moments inevitably arise when asserting one’s authentic gender identity would undermine one’s intentional and precisely timed plan for coming out.

How to Do Better

If someone’s gender presentation shifts over time, you can ask them again about their name and pronouns. If someone tells you that they have no preference for pronouns, that could be a signal they are in the process of transition or they do not feel safe in the current context to voice their preference. In that case, consider using neutral words (e.g., they/them, sibling, parent, child) when talking with/about them.

Unless specifically instructed to do so, do not speak to someone else’s gender. As in this case, you may inadvertently “out” that individual. Many people in the LGBTQ community are “out” in certain spheres (e.g., with friends) but not in others (e.g., work) – this is obviously a delicate decision when one in six transgender people report having lost a job due to revealing their gender identity at work [1]. Perceived safety is an important part of the equation when deciding to be “out.” People who identify as sexual and gender minorities vigilantly scan their environment to determine whether it is safe to be out in any given context. And when safety is uncertain, they may hide their identity by censoring personal life from conversations, avoiding pronouns, and modifying dress/presentation. Every time a person hides their gender/sexual minority identity, however, they add to the problem of invisibility for LGBTQ people. Moreover, that person internalizes a message that it is not safe or okay to be themself – this is internalized self-stigma. Internalized stigma is a major driver of violence and discrimination against gender minorities and contributes to the extremely high prevalence of mental illness, suicide, and addiction among transgender people [1, 3].

Case Scenario

Shortly before Dr. Elson’s legal name change, he went to his primary care provider’s office for blood work to check for the levels and side effects of his gender-affirming hormones . When he registered with the front desk staff, he told them that his preferred name was “Elliott” with “he/him” pronouns. Nonetheless, he got called from the waiting room by the phlebotomist as “Ms. Elson.” As he walked down the hall, he told the phlebotomist that he had a different preferred name and did not use “Ms.” The phlebotomist shrugged off Elliott’s concern with a quick “OK.” As the phlebotomist was drawing Elliott’s blood, he tried to broach the topic again by explaining that he was transgender and Elliott was his new name. The phlebotomist replied, “There is nothing I can do until you legally change your name.”

After this experience, in correspondence to his primary care provider Elliott detailed the incident and his distress over being outed to the entire waiting room when the phlebotomist called him by the wrong name. The primary care doctor sent back a supportive message and assured Elliott she would let her office manager know.

Discussion

Patient Perspective

Healthcare access is challenging for gender minorities. Electronic health records (EHRs) have historically not included fields for gender identity [4]. Many transgender people have had outright negative experiences when they try to access the health system, such as being refused care or misgendered by healthcare staff. Fear of a negative experience causes many transgender people to delay seeking care when they need it [1].

From a broader perspective , the lack of intentional data collection about sexual and gender minorities in EHRs and on major institutional/national surveys has contributed to the ongoing invisibility of this population and the health disparities they experience. The current US government administration intends to roll back recent gains by removing/failing to add sexual orientation and gender identity questions on several important national surveys. This is certain to reinforce the status quo of invisibility [5].

How to Do Better

Make a change to your professional environment that promotes safety and inclusivity. Insist that your EHRs collect both sex and gender identity . Consider hanging LGBTQ inclusive posters, wearing a supportive pin, or offering LGBTQ-geared reading material. Assure access to an all-gender restroom. Every staff member that has patient contact – from registration to phlebotomists to providers – needs to be trained on respectfully interacting with transgender and gender-nonconforming people. Being summoned from a busy waiting room by the wrong name is not only distressing but also presents a safety issue because it “outs” that individual.

If you hear colleagues insisting that a patient’s gender identity is irrelevant because they treat all patients the same [4], speak up. Explain how their perspective is skewed by the structural mechanisms that have tried to erase and suppress gender diversity over time [6]. Tell them about the implicit biases that we all have, which drive ongoing health disparities for patients in minority groups [7, 8]. Tell them that we as healthcare providers, with our privilege and our vital impact on vulnerable lives, must fight against these implicit biases every single day.

Conclusion

Gender identity is an underrecognized aspect of diversity in the human species. The preceding case scenarios illustrate a few ways that transgender people are uniquely vulnerable. As we all work to ensure the safety and respect of transgender people, commit yourself to the following imperative actions: Recognize and challenge your own automatic binary gender assumptions both in the clinical setting and in your personal life. Tune in to gender expression. Demonstrate your respect for gender diversity by asking about a person’s chosen name and pronouns to avoid misgendering. Examine your clinical environment and cultivate a trans-inclusive atmosphere. If you need training in caring for transgender people, seek out educational opportunities. Insist that data is collected on gender identity because measurability equals visibility. Recognize your role of privilege as a healthcare provider and use it to speak up when you see biases in your clinic, family, and community.