As a future medical professional and a member of the LGBTQI+ community, I often wonder how we can tailor our care to some of the most vulnerable members of our society, especially in terms of healthcare: transgender people. From the violence black trans women are currently facing in the USA, to laws across the world that forbid “cross-dressing”, to the outdated Belgian law that requires transgender people to medically transition in order to legally change their gender and name, it’s clear that this discrimination can be found worldwide. In February and March, the second year medical program focuses on hormones and reproductive health: a fantastic trap for cis- and heteronormative thinking, that excludes trans, non-binary and intersex people.
Content warning: mentions of transphobia, mental illness and suicide.
Now hold up, I can hear some readers saying: what the hell are you talking about? When talking about queer health, there is so much vocabulary and a whole bunch of identities to unpack. Education about this language is the first step towards compassionate and empathetic healthcare for trans and intersex folks, which is why I’d like to start this article with some basic terminology.
LGBTQIAP+
This is one of the longest and most inclusive acronyms currently in use to describe the “lesbian, gay, bisexual, trans, queer, intersex, asexual, pansexual and others” community. It includes everyone who is not straight and/or cisgender.
Cisgender
Cisgender simply means that someone identifies with the gender they were assigned at birth, usually based on their external genitalia. It can be shortened to cis. Cisnormativity is the perception that everybody is cisgender, and it blankets society like unrelenting smog.
Transgender
anyone who does not identify with the gender they were assigned at birth. A transgender woman has been assigned male at birth, a transgender man has been assigned female at birth. But then there are also trans people who don’t feel like a man or a woman...
Nonbinary
Nonbinary is an umbrella term (but also a specific identity for many people) for anyone who doesn’t fall within either of the two binary genders.
Gender
This is a construct (like money, justice, and a twelve-month calendar) that people use to define themselves in relation to society and the people around them. Just because it’s something “manmade”, doesn’t mean that it isn’t real.
Throughout human history, different civilizations have had different constructs of gender. Certain Indigenous American tribes identify a gender known as Two-Spirit, and in South Asia, there is a third gender called hijra or kinnar. Through Western colonisation, many of these identities were forcefully erased, and people around the world now tend to view gender as a binary system, with just women and men.
Though nonbinary identities are being increasingly recognised, this does not mean that they are “made-up”, nor are they a recent “fad”. Though information spreads much more quickly these days, thanks to the internet, people have been calling themselves nonbinary, or genderqueer, since the middle of the twentieth century. There have been many gender-nonconforming people even before then, some of whom would have identified with any of numerous modern gender identities (agender, bigender, genderfluid, neutrois… google them!). In other words: transgender people have been around for as long as humans have.
If you cannot trust your doctor to understand your unique relation to gender, how will you talk about other health issues?
Biological sex and intersex are the last terms I would like to address. Many people argue that, “well, if gender isn’t a binary scale, then surely sex is? Males have XY chromosomes, penises, and body hair, and females have XX, breasts and uteruses.” Unfortunately, I’m going to try to break down that barrier for my readers as well. Intersex people are individuals who, through a variety of hormonal differences, different anatomical development, and just plain luck, don’t easily fall into that male/female dichotomy. Biological sex actually includes a range of factors including primary and secondary sex characteristics, hormones, and chromosomes, that we all have in varying degrees, which humans have, for ease of use, arbitrarily divided up as “normal male” and “normal female”.
Even before a child is born, parents often know its sex. However, in some cases, at birth, the genitalia can be ambiguous. Often, these genitalia are surgically “corrected”: sometimes because of legitimate health concerns (such as a non-functioning urethra), but other times, because of purely cosmetic reasons. Intersex people have been reported to experience significant trauma from these cosmetic surgeries, especially when the parents have been dishonest about their health situation. Intersex people also face discrimination later in life: Semenya Caster, a South African runner with hyperandrogenism, was forced to take hormone-reducing drugs to be allowed to continue running in the women’s category from 2009 through 2016.
So now we’ve had a run down of only a few of the most important terms to understand trans and intersex healthcare. The next question is: why does it matter? Gender and sex play an unfortunately large role in medical care: depending on the build of your body, symptoms may present differently. Honest communication between physician and patient is important to come to the correct diagnoses and treatment plans. If you cannot trust your doctor to understand your unique relation to gender, which is an essential part of your identity, how will you talk about other health issues? Additionally, there are health matters that are specifically important to queer health.
One poignant example: trans youth have incredibly high mental illness and suicide rates, which are compounded by bullying, having to remain “closeted”, an unsupportive family environment and gender dysphoria. This is distress and discomfort caused by the knowledge that your external presentation and your gender do not align. Not all transgender people experience this, but many do, leading to significant damage to mental health. Dysphoria can be alleviated by transitioning for some people: this means taking steps to make your external appearance and gender align. This can include binding your breasts, changing your clothes, choosing a new name and using different pronouns, but it also can mean starting hormone replacement therapy, or undergoing gender confirmation surgery. Having a supportive primary care physician makes coordinating “medical” transition that much easier.
Understanding the differences between sex and gender, binary and nonbinary genders, and being able to empathetically communicate that understanding can make the difference between a patient seeing you for a follow-up or not. It can even make the difference between a patient seeking help at a later time, from anybody. The LGBTQIA+ community, and especially trans and intersex people, have a lot to fear from the outside world. However, they can have every health complaint cisgender people have, and in some cases, are significantly more likely to experience those complaints. This is why I advocate teaching future healthcare professionals early on to think in more open-minded and less cisnormative terms. Let’s start now: your genitalia do not determine your gender. Only you can tell us that.