As a fairly out and open queer person, I’ve been getting a lot of questions about trans* healthcare. So I decided (with the help of some anonymous trans* pals) to make a few posts to do some explaining en masse…
This post will give a few explanations and definitions that may help to initiate (or refresh) some learning. After that, there’s a section of (anonymised) questions from healthcare professionals and students, and finally a few quotes about healthcare from some of my trans* pals.
The words in bold type are the ones thrown about a lot by people that I will (hopefully) explain in this post. If you have any questions (or additions, or edits that you’d like making) please let me know. This post is a bit dry and mostly definitions, but possibly something to keep coming back to! I’ve tried to keep it short and concise to avoid complete brain-melt…
This is number 1 of a series of posts on trans* issues. Later on, links will appear to posts about Management and Treatment Options, Sexual Health for Trans* Patients, Legal & Ethical Obligations (and anything else that crops up along the way!). Please feel free to comment/Facebook/Tweet any questions or suggestions.
Terms and Definitions
First things firstː gender and sexuality are two separate and distinct entities.
Sex is a biological definition and categorises us as male, female or intersex. This distinction is generally made based on a number of features; including internal and external reproductive organs and sex chromosomes. Sex is often (and frustratingly) confused with gender.
Gender is the association of the way a person feels, acts or behaves to a biological sex, as determined by a given culture or society. In Western culture it is often considered in terms of masculinity and femininity. Generally, gender has been broadcast as a binary system (one which has only two distinct options; male and female). It is becoming an increasingly popular belief that gender lies upon a spectrum; the term non-binary is used to describe people who identify and/or present somewhere along the spectrum.
Gender consists of gender expression and gender identity – two things which can be very different. Gender identity describes how a person feels inwardly and their perception of themselves; gender expression is the gendered image of ourselves we communicate to society (in the way we dress, our haircut etc.).
Sexuality describes who we are (or are not) attracted to romantically and/or sexually. There are many different terms one can use to describe their sexuality (and if anyone would like me to, get in touch and I’ll speak about several at length…). Some more common minority sexualities are lesbian, gay, bisexual, asexual, pansexual.
Gender assigned at birth – this is decided when we are born and it is boldly proclaimed “It’s a boy!” or “It’s a girl!” based on the genitalia seen by the healthcare professional, and after that there is a flurry of pink or blue…
Cis – remember that pre-med school chemistry? Cisgender people are those whose gender identity matches up to the gender they were assigned at birth. This accounts for the vast majority of people.
Trans – a prefix used to denote that a person has adopted a gender role different to that which was assigned at birth. Often when trans is mentioned in the media or in discussion it is directly in relation to a person who has undergone (or plans to undergo) treatment and/or surgery to change their image from one binary gender to the other, in order to match their gender identity. Trans* is the term used (and the one I will use) to refer to all people and identities which come under the “trans” umbrella – including non-binary identities, genderqueer, genderfluid, trans men, trans women etc. Using the asterisk at the end recognises that there are many different gender identities in existence and that the term aims to be representative of these identities too. (It can be a bit confusing and take a while to get used to…If it helps, it took me about a year to stop looking for a footnote when someone wrote “Trans*”)
Trans man and trans woman: a trans man is a person who was assigned female at birth but now presents as male (sometimes referred to as FtM). A trans woman is a person assigned male at birth, but now presents as female (sometimes referred to as MtF).
A lot of people I’ve spoken to get a bit confused about which is which, so I’m going to use hair colour as an analogy to try and help here (bear with me, I know gender and hair colour aren’t really comparable issues…).
Two people are born – one with brown hair and one with blonde hair. They grow up and the person with brown hair starts to dye their hair blonde people may say the person has “Dyed-blonde hair”. They were born with different coloured hair, but we use the colour they currently have to describe them, with a prefix. Similar goes for trans men and trans women. As time passes other people (including friends and strangers) may point out the two people together as ‘blondes’, dropping the prefix (because it is either not known about, is not recnognisable or is unimportant). When this kind of thing happens to trans* people, this is called stealth.
Dysphoria is a term used to describe severe distress and discomfort caused by the mismatch of sex and gender identity. The levels of dysphoria vary hugely from person to person and may also change day-to-day.
Non-binary and genderqueer are terms used to describe a person whose identity or expression of gender does not reflect traditional gender distinctions, or who identifies with neither, both or a combination of male and female genders. For some people this may involve changing and evolving feelings of gender identity and expression (often referred to as genderfluid), for others there is just no clear affiliation with either binary gender. Non-binary people may experience dysphoria, or they may not. They may or may not feel the need for medical and/or surgical management.
Pronouns – the words we use when we talk about someone – he/she/they etc.
A couple of definitions and words I want to clear up before I finish:
- Transvestite: someone who cross-dresses for any of a number of reasons (fun, sexual pleasure etc.) but generally identifies as the gender they were assigned at birth.
- Transsexual: an older term used for people who have a gender identity different to that which is assigned at birth who may go through (or have gone through) medical or surgical therapy to rectify the disparity.
- Drag queen/king: these terms are usually used to label a person who dresses up and performs an act as a gender other than that which they identify/were assigned at birth. (Drag queens: men who perform drag acts as women – think Lily Savage, RuPaul and such).
Questions You Asked Me (and I took anonymously to a panel of me and some of my pals)
“What pronouns/name am I meant to use?”
There were a few variations on this theme, so I put them all together for ease of my workload. Be led by your patient. Ask them (discretely) if you’re not sure. A simple “Which pronouns do you prefer?” will suffice. It may seem a bit strange but from the consensus people would much rather you asked!
Most people for whom gender is not an issue will shrug off the question, and for the people it really matters to it is likely to only strengthen the relationship you are forming.
A useful thing to note here is saying something gender neutral, for example “Which pronouns would you prefer?” is much less likely to be triggering than asking about affiliation to a particular gender. “Can I say ‘he’?” etc.
It’s useful to “check-in” with names and pronouns from time to time too, if you feel it’s appropriate.
“What if I’m not sure about pronouns but I don’t feel confident in asking?”
If you’re not keen or confident in asking and you need to refer to the person in the third person, you can use gender neutral pronouns. An example of this is to use “they”. It can feel strange to use ‘they’ in a singular sense, but it doesn’t sound as jarring to hear as it may do to say.
The last time I went to the supermarket, the person on the checkout said they really liked my t-shirt…
Reading the above sentence, I’d imagine that you weren’t too weirded out by the fact I had not alluded to gender at all. I’d recommend trying it out in other circumstances if you’re wary!
“What about pronouns and names in letters?”
So this is a bit more difficult (and hopefully something I’ll cover in a later article around legal and ethical bits and bobs). It involves an open conversation with the patient about what will be going into letters and a real consideration of who else is at home or others who may see the letter. The risk of ‘outing’ someone as trans* early on may be such that a joint decision is made between yourself and the patient to retain their birthname and pronouns for some documentation. Warning the patient that this is what will be written in letters they may receive is incredibly useful in reducing the risk of triggering a patient, or leading them to feel misunderstood and misrepresented.
Please also note that it is an offence to disclose someone’s transgender status (other than for ‘medical purposes’.) More on this later!
“When does a preferred name become their real name?”
A person’s name changes from their birth name when they formally change their name and terms of address (this doesn’t have to be in the form of a Gender Recognition Certificate nor is it necessary for them to change their name by deed poll).
A general etiquette note that popped into my head after reading this question is just to say that the accepted term for a person’s name prior to transition is ‘birth name’. Several of my trans* friends have experienced being asked what their ‘real name’ is or was, and this carries many negative connotations and can be triggering to individuals.
“Do non-binary people need hormones or other treatments?”
Non-binary people (and binary transgender people) are all different in management needs and goals.
Some non-binary people will need hormones; some non-binary people will want gender confirming surgeries, some may desire both. Others may just require an outlet to verbalise and rationalise their feelings.
In response to this and a few other questions I’m in the process of making a post which outlines the different types and variety of management options used (psychological, medical and surgical).
“What’s the algorithm for treating people for gender dysphoria?”
There are no hard and fast rules or algorithms for which treatments are used or necessary. The patient needs to lead management and treatment decisions in line with what they want. There is no set checklist to tick off to ‘treat’ gender issues (though I will explain general pathways in a later post).
Some patients are content with having validation and discussion with a healthcare professional, some require hormones, some require surgeries. Not every experience is the same, and treatment ideals and goals may evolve in time.
“Can I use the term ‘transsexual’?”
As a general rule, I would avoid the word ‘transsexual’ if not used by the patient themselves, as it is often used in a derogatory sense and is somewhat outdated – more often nowadays the term transgender is used.
A note here too though, that using the language a person uses to define themselves can be incredibly therapeutic and validating. The words to describe and define trans* people are still developing, and people use a variety of terms for their identity.
Ask people what the label means to them instead of what it means in general.
In my experience, people love self-identified labels and hate other-imposed labels. Know basic terminology (transgender, transsexual, cisgender, genderqueer, non-binary etc.) but remember that the nuanced meaning behind these labels varies.
“Can I ask questions about genitals, or other possibly upsetting/controversial questions?”
Do you need to? If so, then yes. Treat tackling sensitive issues with trans* people in the same way you would with cis people. If you need the information then (tactfully) ask any questions. It may be useful to signpost the person to the fact you’re about to ask some sensitive questions, and why this information is required.
A Few Trans* Voices on what they wish healthcare professionals knew or did
- “Understand that [we] may be struggling with dysphoria, rejection, fear, or any number of other things surrounding being trans or transition, but [we’ve] got other stuff going on and it’s not always about being trans*.
- “I wish they’d be careful about ‘back-handed compliments’. I’m a transwoman and I’ve had healthcare professionals tell me “I can’t believe you were a man!…”
- “My dysphoria makes me depressed. Changing the dysphoria will change my mental health. Saying I need to be perfectly mentally healthy to get treatment isn’t helpful, and isn’t going to happen.”
- “Spend time in the community.” Browsing some internet forums and reading up does wonders! (See some of the links I’ve included at the end of the piece)
- “Don’t be gate-keepy…for some people long delays can be literally a matter of life and death. As soon as you can place a diagnosis with certainty, discuss therapy and their future plans.”
- “Be open minded – there is no single trans story and there is such a huge vairety [sp]. Accept everyone and make sure to do your best in helping them.”
- “Most importantly, don’t treat [trans* patients] any different than your other patients. The best therapists I’ve gone to always saw me as a person first, like everyone else”
WPATH Standards of Care for Transgender People http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351