As healthcare professionals, we are in the privileged position to make a positive difference to all children and young people. Being able to make a gender-diverse child or adolescent feel that they’re being listened to, and that they’re being included and accepted should be the norm.
What does trans mean?
Trans is an umbrella term to describe people whose gender is not the same as, or does not sit comfortably with, the sex they were assigned at birth (Stonewall).
What does non-binary mean?
Non-binary is an umbrella term for people whose gender identity doesn’t sit comfortably with ‘man’ or ‘woman’. Non-binary identities are varied and can include people who identify with some aspects of binary identities, while others reject them entirely (Stonewall).
What does cis-gendered mean?
Someone who is cis-gendered is Someone whose gender identity is the same as the gender they were assigned at birth.
What is a pronoun?
Pronouns are the words we use when talking about people. In the English language, they are “he/him”, “she/her” or “they/them”. The latter can be singular or plural. It is easy to make assumptions about people’s pronouns, but people may specify a set to be used. We should use those that the patient has chosen over the pronouns we think or assume we should be using.
Which words should I use?
Trans and non-binary are often used independently, though some people consider non-binary to be a subset of trans. The term gender-diverse is often used to include anyone who does not identify as cis-gendered. It is an imperfect term and should be used with caution, so as to not homogenise a heterogeneous population. It should be noted that this is a Western-centric point of view. Gender is not as simple as the terms here imply; it’s complex and different cultures experience it differently.
The Gender Unicorn
The gender unicorn is a lovely infographic from transstudent.org that helps explain the complexity of gender identity.
As healthcare professionals, we are used to speaking about the sex someone has been assigned at birth. It’s the first question new parents are asked and how they are named and typically raised. Even babies who are initially deemed intersex can now be chromosomally tested to assign them a sex.
As they grow, children develop their own gender identity. They develop an awareness of gender around two years of age. Some children align themselves with a gender which is different to their sex assigned at birth at this time. They may, or may not, be gender diverse when they grow up. It is clear, though, that some children identify themselves as having a different gender identity from the sex they were assigned at birth from a young age.
Gender identity refers to how we feel about ourselves in relation to our gender internally. A simply analogy, which I use here with extreme caution, is to think of masculine as blue and feminine as pink and non-binary as any other colour. A cis- or trans- person may know themselves to be pink or blue; a non-binary person may know themselves as purple, somewhere between masculine and feminine, or as yellow, a completely different colour outside of the pink/blue spectrum.
If this person considers themselves to be masculine, they may identify as a trans male (a man whose sex assigned at birth was female) or a cis male (a man whose sex assigned at birth was male). Similarly, a person who considers themselves feminine may identify as a trans woman (a woman whose sex assigned at birth was male) or a cis woman (a woman whose sex assigned at birth was female). The gender label refers to a person’s identity and trans/cis refers to whether a person was assigned this gender label at birth (cis- people were, trans- people were not).
A non-binary person is referred to as such. They may provide clarity when needed with their assigned gender at birth, which may be listed as AFAB, assigned female at birth, or AMAB, assigned male at birth.
A person may, or may not, express their identity with a new name, new pronouns, new clothes, a new haircut, or medical/surgical gender-affirming treatments. Gender expression is not required for gender identity and people may not express their gender identity for many reasons. A person is a trans- man or woman or non-binary person regardless of how they show their gender identity to the world. Equally many people are able to live their lives entirely as their gender identity, without qualifying that they are trans.
How do I ask about this?
We are in an incredibly privileged position. People may show us parts of their identity that they haven’t shown others. A trans man may live his whole outside-hospital life without anyone having any idea that he is trans, and yet when he comes to the hospital with abdominal pain it is vital that we know he has ovaries that may be torted. A trans woman who does not express herself day-to-day as a woman due to safety fears may disclose to you that she is using hormone therapy. This may change your differential when she has her leg pain.
Because being trans was previously considered a mental disorder and because some aspects of society are not kind to trans people, some people may be stressed, nervous or scared. The Stonewall Unhealthy Attitudes Report shone a spotlight on why this may be. 20% of NHS staff have witnessed negative remarks made about trans people in healthcare. We need to be sensitive, and open-minded, ask when we don’t know and apologise when we’ve misunderstood.
Do you have any examples of questions I can ask?
“Do you feel comfortable in your gender identity?” is the standard question I ask all teenagers during a HEEADSSS conversation. The HEEADSSS assessment is a great place to ask about gender identity. Adolescents, trans, non-binary and cis-gendered, are so clued up. They will know what you’re asking and why.
If you feel it is important to go further, try “Would you mind sharing it with me?” and then “How can I support you with this during your stay in the hospital?” or “Who supports you with this in the community?”. If you need a deeper medical and surgical history, then you can add “Do you take hormonal therapies or blockers? Which ones? Where do you get those prescribed and monitored?” and “Have you had any surgeries to affirm your gender? Which ones? When and where? Did you have any complications?”
Be clear if you’re asking to do a test that is typically associated with a gender. For example, in a trans male with vomiting, it would be sensible to do a pregnancy test, but it is important to highlight that this is a test you should do in anyone over 12 with a uterus, regardless of their sexual activity or gender. By clearly naming it as a medical test for an anatomical reality, rather than “something we have to do for all girls…I mean young people… I mean gahhh”, the person understands that you appreciate both their identity and the appropriate differential for their problem.
Only ask the questions if they are genuinely relevant. Being trans can feel as if a lot of people can, and will comment on your body. As medical professionals we sometimes do need to know and comment but, we mustn’t abuse the privileges.
Why is this important to healthcare providers?
Trans- and non-binary people face discrimination in healthcare settings. The system is not set up with them in mind. Some Electronic Healthcare Records only allow procedures to be ordered on designated genders, despite the fact that many trans- men have a uterus and many trans- women have a prostate. They also suffer from healthcare workers having poor knowledge and the fear of experiencing discrimination. This can make accessing healthcare more stressful than for their cis-gendered counterparts.
These issues are resolvable. Just by reading this article, I hope you might become more fluent with your knowledge of the basic terminology. If you want to get more involved, many hospitals have LGBTQI+ teams working to make better systems. If you’re feeling confident and safe in your allyship you might consider wearing a rainbow badge or adding your pronouns to your email sign-off.