Gender, sex and sexuality are separate entities. Sex is generally referred to as how we were assigned at birth and usually based on our external genitalia at birth. Sexuality/sexual orientation refers to our sexual attraction to others. Gender may be represented by our clothing, although someone early in transition or not “out yet” may still present as their sex assigned at birth.
In the early days of transgender care (1950s-1980s), there were very strict criteria for medical and surgical transition. An individual had to identify as heterosexual prior to being granted approval to begin treatment. Those days are long gone, and most adults now start treatment through what is termed an informed consent model. Surprisingly, when I started practice, this was considered controversial. However, over time the medical community has come to understand that gender is “in the eye of the beholder” and gender affirming care should be just like any other treatment that we offer. We discuss benefits and risk and the patient makes an informed decision. Care of children is an exception to this as it can be a more complex process in some ways.
While it is important to ask how your patient identifies and acknowledge their gender identity, the interaction should not necessarily revolve around it. Avoid asking intrusive questions. Just like all encounters, ask the relevant and important questions and address why they are seeing you. I have been told by patients that occasionally a provider is so “fascinated’ with their gender history that the patient felt the entire interaction focused on that and left little time to address the real reason they were presenting for care.
Transgender individuals have been marginalized and stigmatized for far too long. The days of the Jerry Springer show are over; however, it is still fairly routine to see transgender people be the subject of ridicule in the media and beyond. They may lose family, jobs and opportunities in order to transition, and all of this comes at a cost. Marginalized groups have higher rates of suicide, and individuals who identify as LGBT have some of the highest rates of suicide. Our impact as physicians can be very powerful, and we typically set the tone for how healthcare is delivered and hopefully continue to reduce the stigma around this group of individuals. My goal is to make sure that the care I deliver is inclusive and to continue to teach medical students both the ordinary aspects and the intricacies of gender diverse care.
Continued...