Introduction
Before a practitioner can begin work with a Transgender Athlete, it is important to be comfortable with a vernacular that is applicable to all individuals, but often exclusively associated with members of the LGBTQ+ community. In modern society, terms like Gender, Sex, Identities, Pronouns, and Sexual Orientation , are often viewed through rainbow-colored glasses, despite the universality of these domains.
Although these topics apply to all persons, they are especially important in establishing trust and building the Doctor-Patient Relationship with members of the LGBTQ+ community. In this chapter, we will be defining terms that will better allow you to serve your patients and larger social communities.
The “Y” in the LGBTQ+?
It is imperative to understand not only know how to use the appropriate language when working with your LGBTQ+ patients, but to also understand why . In the United States, the LGBTQ+ Rights is a prominent conversation in political discourse. Regardless of stance of these topics, the implications for the very real individuals they target are far grander than a conversation about bathrooms. According to the 2022 data collected by GLAAD:
85% of transgender and nonbinary youth, as well as 66% of all LGBTQ+ youth, reported that political discourse of Transgender rights have negatively impacted their mental health.
52% of trans and nonbinary youth considered suicide, with a one in five attempting.
36% of LBGTQ youth reported physical threats or harm due to their sexual orientation or gender identity.
Furthermore, the 2022 National Survey on LGBTQ Youth Mental Health shows clear links between LBGTQ+ identities and mental health risks. The negative mental health outcomes disproportionately affect LGBTQ+ youth when compared to their cisgendered, heterosexual counterparts. Therefore, the need for inclusive language and understanding different patient demographics is not merely about individual preferences and respect—it is about saving lives.
Individuals who identify as transgender or gender diverse report high levels of discrimination when using public transportation, shopping, dining and accessing healthcare. The fear of discrimination may lead an individual to delay or avoid seeking medical care. As medical professionals, it is our duty to educate ourselves to better serve all vulnerable populations if we truly want to make a difference in patient outcomes.
Congratulations, It’s a (?)
From the very early sonograms of pregnancy to the day a baby is born, “male/female” and “boy/girl” are used without truly understanding the impact those terms have. From the moment a parent hears one biological sex versus another, the parents’ perception and understanding of the identity of their child begins to take shape, without regard to what is happening within the child themselves.
Understanding that these classifications are describing the biological sex of the child and not the child’s gender is the foundation of transgenderism. Biological sex is defined by chromosomal analysis determining XX, XY, or other karyotype variation, and assessment of genitalia. The biological sex is then used to distinguish male, female, or intersex. Male , is attributed to those with XY chromosomes with genitalia consisting of a penis, scrotum, and testes. Female , is attributed to those with XX chromosomes with genitalia consisting of a vulva, vagina, uterus, and ovaries. Intersex individuals fall somewhere in between, as the chromosomal assessment may differ from the biological presentation typically associated with those chromosomes.
Though beyond the scope of this chapter, highlighting the intersex experience provides supporting evidence for the transgender cause. Historically, children born with ambiguous genitalia often had their biological sex determined for them by their parents and doctors at birth. It was not uncommon for sex to be determined by the Physician, with or without genital manipulation, followed by parents adopting that sex as the child’s biological sex. In many cases, the presumed sex that was used to determine gender, and therefore gender expression, did not align with the child’s authentic sex. The increasing dissatisfaction with outcomes for these indivduals has largely lead to intersex persons seeking gender affirming care to transition to the appropriate gender that reflects their gender identity. Though intersex individuals who transition are not inherently transgender, as their gender was decided for them by third parties based on perceived biological sex, the commonalities of the lived experiences of these two group only strengthen the argument that sex and gender are not synonymous.
Biological sex is often used in the LGBTQ+ community as “sex assigned at birth,” as this sex may not align with the sex that the individual identifies with. It is important to note that when biological sex and an individual’s gender identity are incongruent, queer identities begins to take shape.
Gender is a social construct that describes the attitudes and beliefs attributed to a biological sex. Gender is entirely based on social ideologies and has no biological or scientific basis. Here is where the distinction becomes important. Gender and biological sex are often viewed synonymously, when in reality, one is rooted in societal norms and expectations, while the other is rooted in genetics.
The “gender binary” of Male and Female does not account for the variations to identity that exist in this world and often is the root cause of confusion when trying to comprehend this topic. A person’s gender identity is an inner sense of where on the gender spectrum they feel is most applicable to them. The spectrum includes but is not limited to male, female, genderqueer and agender identities.
Individuals who identify as nonbinary or gender non-conforming have gender identities that do not unambiguously conform to conventional notions of male or female. These individuals may identify as neither male nor female, both male and female, or fluctuate between the two. This can also be termed gender fluidity, genderqueer, or gender diverse.
While gender identity encompasses someone’s inner sense of gender, gender expression is comprised of the characteristics of an individual’s appearance, personality, speech and behavior to embody their outward perception of their identity. It is important to note that both gender expression and gender identity may change over time.
When an individual’s gender identity is incongruent with societal expectations on the basis of their sex assigned at birth, this is termed transgender . For example, an individual who is assigned Female at birth, but identifies completely as Male, may be classified as Transgender Male . Individuals assigned Male at birth and identifying completely as Female, may be classified as Transgender Female . These classifications are only applicable the gender binary, but the trans identity extends beyond this scope. Identities of transmasculine (transmasc) and transfeminine (transfem) fills in the gaps for individuals who do not fully identify the identities discussed.
There are varying degrees to which this misalignment can impact the transgender individual. When someone experiences discomfort or stress caused by the discrepancy between their gender identity and sex assigned at birth, it is referred to as gender dysphoria. Like many other concepts discussed, the severity of gender dysphoria also falls on a spectrum. Individuals can experience dysphoria for varying reasons, such as if they were born with a uterus and have their period, if they were born with a penis and experience an erection, or if their voice is too high or too low for their desired gender expression. The degree to which this impacts this populations lives can vary as well, which ultimately contributes to the higher levels of depression, anxiety, and suicidality of the LGBTQ+ population.
As discussed, the spectrum of expression and identity is vast and patients will continue to explore different avenues to find what works best to affirm their gender and challenge their gender dysphoria. Not every transgender individual may experience dysphoria, nor do those that do experience dysphoria experience it to the same degree. Some persons may feel completely affirmed with changing their clothing to express their identity, while others may require medical intervention. When medical intervention is required, gender affirming care from medical professionals comes into play.
Gender Affirming Care is any intervention that allows an individual to better align with their gender identity. This can include, but is not limited to, hormone replacement therapy, voice training, chest binding, or gender affirming surgeries such as vaginoplasty, metoidioplasty, phalloplasty, tracheal shaving, or mastectomy. These are all procedures and treatments that patients may be actively participating in or seeking when you provide them care.
When providing medical care for transgender and genderqueer patients, it is important to understand that patients may change their name, pronouns, and/or physical appearance to affirm their gender identity between visits. The complexities of gender affirmation are evident on for both providers and patients, but when open dialogs are shared, drastic positive changes for these patients are possible.
Gender identity versus sexual identity
Distinct from someone’s gender identity is their sexual identity or orientation . This reflects how we classify our attraction to different genders. There are several subclassifications of sexual orientation:
Gay: an individual who identifies as male, who is attracted to males.
Lesbian: an individual who identifies as female, who is attracted to females.
Bisexual: an individual who is attracted to both males and females.
Heterosexual: an individual who is attracted to someone of the opposite sex or gender.
Pansexual: an individual who is attracted to someone regardless of sex or gender identity, which can include those who identify as nonbinary.
Asexual: an individual who does not experience sexual attraction.
Sexual attraction on the other hand, while related, defines the nature of the gender identity one is attracted to, but does not necessarily have to play a role in one’s sexual identity.
Sexual behavior differs from both sexual identity and sexual attraction. Sexual behavior is the pattern of sexual or romantic activity one engages in, regardless of sexual identity or orientation. This includes men who have sex with men (MSM), women who have sex with women (WSW), men who have sex with women (and vice versa). It is important to note that sexual behavior does not always reflect an individual’s sexual attraction or identity. An individual’s sexual orientation should not be assumed based on their sexual behavior and vice versa.
