While cisgender persons feel that their experience of gender – their gender identity – agrees with the cultural norms surrounding their sex assigned at birth, transgender/gender-nonconforming (GNC) persons feel that their experience of gender is incongruent with their sex assigned at birth.1 Specifically, a transgender man is a person born with a vagina and therefore assigned female at birth who experiences himself as a man. A transgender woman is a person born with a penis and therefore assigned male at birth who experiences herself as a woman. A gender nonbinary person is someone with any sexual assignment at birth whose gender experience cannot be described using a binary that includes only male and female concepts, and a gender fluid person is someone whose internal experience of gender can oscillate.1 While these examples represent only a few of the many facets of gender diversity, the general terms trans and gender nonconforming (GNC) are widely accepted as inclusive, umbrella terms to describe all persons whose experience of gender is not congruent with their sex assigned at birth.
Dr. Joey Bahng
It is pivotal that medical providers understand that a person’s sex assigned at birth, gender identity, gender expression, sexuality, sexual practice, and romantic attraction can vary widely along a spectrum in each distinct category.2 For example, the current social norm dictates that someone born with a penis and assigned male at birth (AMAB) will feel that he is male, dress in a masculine fashion, and be both sexually and romantically attracted to someone born with a vagina who was assigned female at birth (AFAB), feels that she is female, dresses femininely, and likewise is sexually and romantically attracted to him. One possible alternative reality is a person who was born with a vagina that was therefore AFAB that experiences a masculine gender identity while engaging in a feminine gender expression in order to conform to social norms. In addition, they may be sexually attracted to people whom they perceive to be feminine while engaging in sexual activity with people who were AMAB. Informed medical care for trans persons starts with the basic understanding that an individual’s gender identity may not necessarily align with their gender expression, sex assigned at birth, sexual attraction, or romantic attraction.
As obstetrician-gynecologists, we are tasked by the American College of Obstetricians and Gynecologists to provide nondiscriminatory care to all patients, regardless of gender identity.3 We must be careful not to assume that all of our patients are cisgender women who use “she/hers/her” pronouns. By simply asking patients what names or pronouns they would like us to use before initiating care, we become more sensitive to variations in gender identity. Many providers may feel uncertain about how to initiate or respond to this line of questioning. One way that health care practices can begin to respectfully access information around gender identity is to create intake forms that include more than two options for gender or to alter their office visit note templates to include a section that prompts the provider to include a discussion surrounding gender identity. By offering these opportunities for inclusion, we become more welcoming of gender minorities like transgender men seeking cervical cancer screening.
There are a number of reasons that trans persons have limited access to the health care system, but the greatest barrier reported by transgender patients is the paucity of knowledgeable providers.4 to an already marginalized patient population. Familiarity with this terminology normalizes the idea of gender diversity and subsequently reduces the risk of providers making assumptions about patients that contributes to suboptimal care.
Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Joyner and Dr. Bahng reported no financial disclosures.
1. Lancet. 2016 Jul 23;388(10042):390-400.
2. www.genderbread.org/resource/genderbread-person-v4-0.
3. Obstet Gynecol. 2011 Dec;118(6):1454-8.
4. Curr Opin Endocrinol Diabetes Obes. 2016 Apr 1;23(2):168-71.