Columbus Medical Association - CMA's Blog

By Columbus Medical Association - CMA posted 07-15-2021 03:00 PM


I am a medical student interested in LGBTQIA+ (lesbian, gay, bisexual, transgender, queer or questioning, intersex, and asexual) competent family medicine. With that, there’s always a particular conversation I have with healthcare providers who haven’t had a lot of experience with LGBTQIA+ communities. I’m asked things like, “why does it matter if I get this person’s pronouns wrong?” and “it’s so confusing, they have these ovaries and I’m looking at their pap smear but they’re telling me they’re a man”. These are often well-intentioned, and are usually from people looking to know more and learn, but can be very difficult questions to answer as an LGBT-identifying person. So where do you start if you don’t have that experience? Why is asking a problem? How do you learn what to do if asking directly isn’t always appropriate? 

As is indicated in the definition above, there are a broad spectrum of people encompassed within the label “LGBTQIA+”. The first thing to be conscious of is that identifying as such doesn’t remove other socio-economic labels that are associated with difficulty (such as “woman, person of color, poor, rural”), and each individual’s experience is going to differ wildly from another’s. However, there are some shared experiences, and, unfortunately, they’re usually negative. These negative experiences are especially common with LGBTQIA+ patients seeking healthcare, which has been repeatedly documented by facilities like Fenway Health in Boston, MA and Equitas in Columbus, OH (both of which are very vocally LGBTQIA+ friendly healthcare centers). While each identity in the LGBTQIA+ alphabet has its own difficulties with healthcare, here I want to address specifically the “T” in this case, transgender (trans) patients.

In my opinion, it’s our most basic responsibility as healthcare providers to be conscious of how we talk to patients: in this case, trans or gender minority (GM) patients. As a very broad definition, it’s generally accepted that sex is biological and gender is the social identity a person uses to interact with the world. If your gender is associated with your sex, you’re considered cisgender. If not, you’re GM. GM patients, on average, are considered incredibly high risk - not because of their identity inherently, but because of how they are treated by society. Being GM significantly increases your risk of mental illness, family rejection, homelessness, abuse of any kind, bullying in school, and decreased access to healthcare and other social services.

GM patients are aware of this pile of difficulties, and, being the incredibly adaptive folks that we are, we figure out how to survive and protect ourselves. What this usually looks like is being hyper aware of language. Language is a tool that people use to communicate intent and action before it happens. No matter who the patient is that you’re seeing, how you talk about or to them when you walk into the room shapes the encounter. If you connect with a patient they’re more likely to trust you and work with you for their healthcare. If you don’t click then it’s a little more difficult, and it’s easier to miss something in their care. When you walk into the rooms of your GM patients, if you misgender or misname them and don’t respond respectfully when corrected, you’re telling them right off the bat that they don’t know themselves as well as you know them; that they don’t have the same right to self-identity as your other patients, and you aren’t willing to respect them as they are. Why, in lieu of that, should they trust you with their health? 

So, pronouns matter. They seem like such small things, but I’ve had numerous strangers stress out over my dog’s pronouns while he has his pale purple collar on, and no pants, so there’s clearly some societal weight to these tiny words. Basic trust starts with obvious respect, and verbal denial of a person’s identity interferes with that. Asking a GM person to explain to you why they deserve to have their identity respected is like a cartoon villain asking a starving villager to explain why they deserve food. Patients shouldn’t need to defend their basic self-determination to their provider. They have an awareness of their own needs, and a physician is a person in the uniform of a profession that has repeatedly disrespected and denied them their humanity because of their identity. We have an absolute responsibility to be conscious of ourselves while wearing our white coats. 

What does that mean in a medical setting? Primarily, you should explicitly confirm with new patients, prior to them revealing anything at all about their own identity, that your office is a non-judgemental place where your primary interest is in their health and wellbeing. Science has been used as an argument against the validity of GM identities and so speaking to a patient’s health is a more accessible phrasing than speaking to the ideals of science. Next, you have to be aware of your own use of gendered terms. Would what you’re saying be appropriate when addressing any patient, independent of gender? Ask physiology-specific questions in the context of their specific physiology, not gender. Don’t be afraid to ask clarifying questions and readily admit your own shortcomings of knowledge in this regard. If your patient has specific needs and concerns they will be able to tell you, and that’s much easier than making incorrect assumptions. 

The most important parts of addressing patient care are establishing trust, and maintaining an environment of healing while they are in your care. With GM patients, consciousness of language and non-judgemental acceptance of identity are essential cornerstones to building that trust.

Frequently, the difficulty that people experience when approaching GM identities is just being unclear on how to open that conversation. There are some amazing resources available with some quick searching, but there are a few cardinal rules that I try to stick to when meeting someone, particularly if I notice something that tips me off that they might be LGBTQIA+.

  1. Be contextually aware - don’t assume they want to tell you their gender or sexuality in a crowd or when being put on the spot. If they say something about their identity, believe them, and if you know it’s different than what they’ve confided in you previously, don’t correct them and pull them aside to ask them what they want you to do for them in private when convenient for them. This is a safety issue! 

  2. Create space - It can be including your pronouns in your email signature (especially if you’re cisgendered!), wearing a pronouns pin, having the trans or LGBT flag visible, or just straight up saying your pronouns to everyone you introduce yourself to. There’s lots of ways to tell people “Hey! I will do my best to respect your identity!” Without putting both of you on the spot.

  3. Assume neutrality - if you’re not clear on what someone’s gender is, use the gender neutral singular “they”! To borrow an example from Equitas’ own Ramona Peel, we already use it if we’re talking about an unknown assumed gendered person while they’re out of the room (“oh no, they left their phone!” “I hope they come get it soon!”). 

  4. Ask!!!! - not everyone has the same boundaries and not everyone has the same relationship with pronouns and gender. If one person is ok with you correcting other people who misgender them, another person might not be! This is a very personal subject and it really will go a long way if you just ask the person in question what their boundaries are. Be respectful, but ask if you don’t know - If you’re not given an answer, let it go and move on.

    Bea Carbone is a first year medical student at The Ohio State University College of Medicine. They're interested in family medicine with a competency in LGBT healthcare and can be found at @beacarbone on twitter.



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