Cassie, a 31-year-old transgender woman, had been dealing with persistent skin issues ranging from eczema to chronic dermatitis since childhood. Seeking relief, she consulted a new dermatologist about her symptoms after three years of undergoing hormone replacement therapy (HRT) as part of her transition. But as she described her affliction, listing out the symptoms that had followed her since childhood, the doctor hastily attributed her skin problems to HRT. Cassie was confused since her skin conditions predated her transition by a few decades. But the doctor was unwilling to change their diagnosis. Cassie sought a second opinion, then a third, then a fourth, and so on. This misdiagnosis was echoed by multiple healthcare providers, leaving Cassie feeling frustrated and unheard. It wasn't until she found a healthcare provider who had received education on gender-inclusive health that she finally received the appropriate care she desperately needed. The provider recognized the multifaceted nature of Cassie's health, offering the holistic care she longed for. Cassie's experience is not isolated but reflects the systemic issues that gender-diverse patients often encounter in healthcare. A 2015 U.S. Transgender Survey reported that 33% of respondents who saw a healthcare provider in the past year reported having at least one negative experience related to being transgender. These included being refused treatment, verbally harassed, or having to teach the healthcare provider about transgender care. In addition, nearly a quarter (23%) of respondents reported that they did not seek the healthcare they needed in the past year due to fear of being mistreated as a transgender person. These statistics underscore the urgency of addressing the healthcare inequities that the gender-diverse population faces and advocating for their right to safe, respectful, and competent care. This article aims to shed light on the unique healthcare challenges faced by gender-diverse patients. It also aims to provide healthcare providers with practical strategies to improve their understanding of these issues and their ability to deliver equitable, gender-inclusive care. We hope that through education and empathy, we can ensure that every patient, regardless of gender identity, feels heard, understood, and cared for within the healthcare system. Not As Rare As You May Believe Contrary to prevailing misconceptions, gender-diverse individuals constitute a much larger portion of the population than many believe. In the United States alone, approximately 1.6% of adults, or roughly 5 million people, identify as gender diverse. This prevalence becomes even more significant among younger demographics, with 5% of young adults and 10% of adolescents identifying outside the binary norms of gender. These statistics underscore the importance of gender-inclusive healthcare, given the substantial number of individuals identifying as gender diverse. As Dr. Frederic Ettner, a family medicine physician, aptly points out, "You may be up to speed in rare cancers that you may not see but once in five years. You're seeing gender-diverse people all the time." Understanding Gender Diversity The concept of gender diversity is not new but is often misunderstood or oversimplified. To improve healthcare services for gender-diverse patients, healthcare providers need to understand the complex layers of gender and how they can impact a patient's healthcare. Biological Sex & Gender Understanding the distinction between sex and gender is a cornerstone to providing inclusive and equitable care. Each term represents a unique spectrum of identities and experiences, and both play a critical role in shaping health outcomes. Biological Sex Biological sex is the complex constellation of biological characteristics that typically define humans as male or female. These characteristics include chromosomes, genes, internal and external sex organs, and secondary sex characteristics. Traditional teachings suggest that humans fit neatly into two categories — male or female. However, advancements in biomedical and genetic research have debunked this simplistic understanding. For instance, individuals born with intersex conditions exhibit female and male biological characteristics, challenging the binary notion of sex. Approximately 1-2% of individuals are born intersex, further highlighting that biological sex operates on a spectrum. Yet, standard medical practice assigns sex at birth based on external anatomy — that's what we call assigned female at birth (AFAB) or assigned male at birth (AMAB). Gender Unlike biological sex, gender is a social and cultural construct. It encapsulates societal expectations around roles, behaviors, and preferences typically associated with each sex. In many cultures, gender is perceived as binary, recognizing only two genders: woman (feminine) and man (masculine). However, gender diversity extends beyond this binary framework. Gender Identity is deeply personal and internal. It represents an individual's sense of their own gender, which may be man, woman, both, neither, or a different gender altogether. Gender Expression, in contrast, is external. It is how individuals choose to express their gender identity through dress, hairstyle, body language, and voice. Some conceptualize gender expression as a spectrum, from feminine to masculine, with a multitude of expressions in between.

Jesse, a 27-year-old nonbinary person who doesn’t identify as a man or a woman, had their first seizure at the age of 19. Forced to leave home due to their parents’ lack of acceptance, Jesse sought medical help in their hometown’s emergency department. Despite clearly expressing their non-binary identity and preferred name and pronouns, Jesse faced repeated misgendering and disrespect from the ED staff.

These painful experiences left Jesse feeling unsafe, anxious, and disrespected, leading them to avoid seeking care altogether. The consequences were dire, as the frequency of their seizures increased and they were eventually suffering from dozens of seizures daily. Jesse eventually lost their home and job, and found themselves living in their car for three years. 

Jesse’s experience is not isolated but reflects the systemic issues that gender-diverse patients often encounter in healthcare. A 2015 U.S. Transgender Survey reported that 33% of respondents who saw a healthcare provider in the past year reported having at least one negative experience related to being transgender. These included being refused treatment, verbally harassed, or having to teach the healthcare provider about transgender care. 

In addition, nearly a quarter (23%) of respondents reported that they did not seek the healthcare they needed in the past year due to fear of being mistreated as a transgender person. These statistics underscore the urgency of addressing the healthcare inequities that the gender-diverse population faces and advocating for their right to safe, respectful, and competent care.

This article aims to shed light on the unique healthcare challenges faced by gender-diverse patients. It also aims to provide healthcare providers with practical strategies to improve their understanding of these issues and their ability to deliver equitable, gender-inclusive care. We hope that through education and empathy, we can ensure that every patient, regardless of gender identity, feels heard, understood, and cared for within the healthcare system.

Not As Rare As You May Believe

Contrary to prevailing misconceptions, gender-diverse individuals constitute a much larger portion of the population than many believe. In the United States alone, approximately 1.6% of adults, or roughly 5 million people, identify as gender diverse. This prevalence becomes even more significant among younger demographics, with 5% of young adults and 10% of adolescents identifying outside the binary norms of gender.

These statistics underscore the importance of gender-inclusive healthcare, given the substantial number of individuals identifying as gender diverse. As Dr. Frederic Ettner, a family medicine physician, aptly points out, “You may be up to speed in rare cancers that you may not see but once in five years. You’re seeing gender-diverse people all the time.” 

Understanding Gender Diversity

The concept of gender diversity is not new but is often misunderstood or oversimplified. To improve healthcare services for gender-diverse patients, healthcare providers need to understand the complex layers of gender and how they can impact a patient’s healthcare.

Biological Sex & Gender

Understanding the distinction between sex and gender is a cornerstone to providing inclusive and equitable care. Each term represents a unique spectrum of identities and experiences, and both play a critical role in shaping health outcomes.

Biological Sex

Biological sex is the complex constellation of biological characteristics that typically define humans as male or female. These characteristics include chromosomes, genes, internal and external sex organs, and secondary sex characteristics. Traditional teachings suggest that humans fit neatly into two categories — male or female. However, advancements in biomedical and genetic research have debunked this simplistic understanding.

For instance, individuals born with intersex conditions exhibit female and male biological characteristics, challenging the binary notion of sex. Approximately 1-2% of individuals are born intersex, further highlighting that biological sex operates on a spectrum. Yet, standard medical practice assigns sex at birth based on external anatomy — that’s what we call assigned female at birth (AFAB) or assigned male at birth (AMAB).

Gender

Unlike biological sex, gender is a social and cultural construct. It encapsulates societal expectations around roles, behaviors, and preferences typically associated with each sex. In many cultures, gender is perceived as binary, recognizing only two genders: woman (feminine) and man (masculine). However, gender diversity extends beyond this binary framework.

  • Gender Identity is deeply personal and internal. It represents an individual’s sense of their own gender, which may be man, woman, both, neither, or a different gender altogether. 
  • Gender Expression, in contrast, is external. It is how individuals choose to express their gender identity through dress, hairstyle, body language, and voice. Some conceptualize gender expression as a spectrum, from feminine to masculine, with a multitude of expressions in between. 

Cisgender, Transgender, and Nonbinary

A comprehensive understanding of gender diversity necessitates understanding terms like cisgender, transgender, and nonbinary. These terms help define and recognize the spectrum of gender identities that individuals may identify with.

Cisgender

‘Cisgender’ is a term used to describe individuals whose gender identity aligns with the sex assigned to them at birth. For example, someone who is assigned female at birth (AFAB) and identifies as a woman is cisgender. 

Transgender

‘Transgender’ refers to individuals whose gender identity differs from the sex assigned to them at birth. For instance, a person who is assigned male at birth (AMAB) but identifies as a woman is transgender. 

Nonbinary

‘Nonbinary’ is an umbrella term that describes gender identities that do not fit within the traditional binary of man or woman. Nonbinary individuals may identify as having a gender that blends elements of both masculinity and femininity, or they may reject these concepts altogether, feeling that their gender identity is fluid or outside the binary spectrum.

Key Terms Related to Gender Identity:

  • Transgender Man: A man who was assigned female at birth. Similar terms include trans man, trans masculine, and trans male.
  • Transgender Woman: A woman who was assigned male at birth. Similar terms include trans woman, trans feminine, and trans female.
  • Nonbinary: A person who does not identify exclusively as a man or woman but as neither or somewhere in between. Sometimes shortened to enby. Similar identities include gender non-conforming and genderqueer.
  • Bigender: A person who identifies as having two or more genders. Similar identities include pangender, omnigender, and multigender.
  • Genderqueer: A person who does not identify exclusively as a man or woman but as neither or somewhere in between. Similar identities include nonbinary and gender nonconforming.
  • Agender: A person who does not identify as having a gender identity or who experiences their gender as neutral. Similar identities include gender-free and gender-neutral.
  • Genderfluid: A person who identifies as having two or more genders and experiences their gender as varying or shifting over time.
  • Two Spirit: An umbrella term adopted by many Native North American peoples to communicate a broad range of identities used in indigenous communities. Different indigenous cultures have their own specific terms and nuanced cultural meanings. People who are not indigenous, Native, or First Nation should not call themselves Two Spirit.

Healthcare Disparities Experienced by Gender-Diverse Individuals

The unfortunate reality is that gender-diverse individuals face considerable disparities in healthcare access and quality. Often, gender-diverse individuals must deal with bias, misunderstanding, and even outright discrimination from healthcare providers. This results in lower rates of care, misdiagnosis, and detrimental impacts on health outcomes. 

Poor-Quality Care

Many healthcare providers are not adequately trained or educated on the unique health needs and concerns of gender-diverse individuals. This lack of knowledge can lead to poor-quality care and ineffective treatment plans. 1 in 2 gender diverse patients report they had to educate their healthcare providers about gender diversity to receive appropriate care. Such educational gaps in the healthcare system exacerbate health disparities.

Mistreatment and Discrimination

Research shows that 1 in 2 gender-diverse patients report experiencing some form of mistreatment or discrimination from their healthcare provider in the past year. This mistreatment may come in the form of derogatory comments, abuse, or refusal of care because of their gender identity. The fear of facing such prejudice often discourages gender-diverse individuals from seeking healthcare.

Assumptions About Gender Identity

A common complaint from gender-diverse patients is that healthcare providers often make assumptions about their identity, leading to discomfort, misunderstanding, and misdiagnosis. Some providers, based on a patient’s appearance or a superficial understanding of their gender identity, may make harmful assumptions about the patient’s health behaviors, risks, or needs, thereby leading to inappropriate or ineffective treatment.

Misgendering

Misgendering is the use of incorrect pronouns or gendered language that does not align with a patient’s gender identity. Misgendering can make gender-diverse patients feel unseen, disrespected, and unwelcome, creating an uncomfortable and unsafe healthcare environment for them. It can also contribute to the delay of care, as 1 in 4 gender-diverse patients have reported avoiding or delaying necessary medical care due to fear of being misgendered or experiencing other forms of discrimination.

Delays in Seeking Care

A consequence of the above disparities is that many gender-diverse individuals delay or avoid seeking healthcare. For instance, nearly half of all gender-diverse patients have reported avoiding preventative screenings in the past year, likely due to past negative experiences or fear of future mistreatment. The reluctance to seek timely care and preventive services can lead to late diagnosis of diseases and poorer health outcomes.

Best Practices That Healthcare Providers Can Implement To Promote Gender-Inclusive Care:

  • Reflect on and center your core values as a provider
  • Communicate that your priority is to provide the best care possible
  • Signal a gender-inclusive clinical environment with clear policies and visible symbols of support, such as rainbow flags and pins
  • Avoid making assumptions about a patient’s gender identity, sex assigned at birth, or anatomy
  • Collect information about gender identity, sex assigned at birth, and clinically-relevant anatomy through patient intake forms or clinical examinations
  • Ask only clinically relevant and necessary questions, avoiding invasive or unnecessary inquiries
  • Create a safe space for patients to share openly by demonstrating inclusivity and using respectful language
  • Mirror the language patients use to describe themselves
  • Be open to adjusting your language based on patient feedback
  • Avoid burdening patients with having to educate you on gender diversity during appointments
  • Always protect patient privacy and confidentiality of gender-related information, and inform patients that their privacy is protected by federal law

We highly encourage healthcare providers to take our course “Caring for Transgender and Gender Diverse Patients” to gain a deeper understanding of the best practices mentioned above. This comprehensive course offers valuable insights, practical strategies, and resources to enhance your knowledge and skills in providing gender-inclusive care. By investing in further education, you can strengthen your ability to deliver compassionate and equitable healthcare to transgender and gender diverse individuals.

Embracing Gender Inclusive Care: The Path Forward

Jesse, the 27-year-old non-binary individual mentioned earlier in this article, did eventually find the care they needed. They were eventually referred to a provider whose own child was gender diverse, which led them to seek GIC training. This provider offered the competent and compassionate care that Jesse desperately needed, but hadn’t received elsewhere. Eventually, Jesse’s seizures became manageable, and they have since found a job and are no longer houseless.

As Jesse’s story shows, understanding and promoting gender inclusive care within healthcare is not merely a matter of political correctness or social justice but a fundamental necessity to ensure quality, personalized, and effective care for all patients. The scope of healthcare extends beyond merely treating illness—it involves actively working to eliminate disparities, ensuring equitable access, and fostering an environment of inclusivity and respect.

The strategies outlined in this article offer a starting point for implementing gender-inclusive care. However, continued education and evolving practice are necessary to keep up with the nuanced needs of gender-diverse patients. To aid in this endeavor, we recommend our course, “Caring for Transgender and Gender Diverse Patients.” This course provides in-depth information and tools to improve the quality of care provided to gender-diverse individuals.

The healthcare field is ever-evolving, mirroring the diversity and complexity of the human experience. By continuously learning, reflecting, and adapting, healthcare providers can ensure they are prepared to deliver high-quality, respectful care to all patients, regardless of their gender identity. It is in these concerted efforts that we can create a healthcare system that truly acknowledges, respects, and caters to all, promoting health equity for everyone.

 

Sources:

  1. Brown, A. (2022, June 7). About 5% of young adults in the U.S. say their gender is different from their sex assigned at birth. Pew Research Center. https://pewrsr.ch/3Qi2Ejd
  2. Elk, R., & Kallio, J. (2016). Barriers to cancer care and treatment as a transgender Man: Jay Kallio’s personal journey. LGBY Health, 3(1), 3-6. https://doi.org/10.1089/lgbt.2015.0146
  3. Buxton, R. (2016, February 2). This trans man’s breast cancer nightmare exemplifies the problem with transgender health care. HuffPost. https://www.huffpost.com/entry/transgender-health-care_n_7587506
  4. James, S. D. (2012, August 7). Trans man denied cancer treatment; now feds say it’s illegal. ABC News. https://abcnews.go.com/Health/transgender-bias-now-banned-federal-law/story?id=16949817
  5. Hanson, B. (2021, September 13). The pervasiveness of transgender health care discrimination. NPR. https://www.npr.org/2021/09/09/1035457004/the-pervasiveness-of-transgender-health-care-discrimination
  6. Yurcaba, J. (2021, August 19). Nearly half of trans people have been mistreated by medical providers, report finds. NBC News. https://www.nbcnews.com/nbc-out/out-health-and-wellness/nearly-half-trans-people-mistreated-medical-providers-report-finds-rcna1695
  7. Meda, K., & Williams, C. (2020, December 7). Shedding light on the experiences transgender and non-binary patients face in the doctor’s office. Thomas Jefferson University. https://nexus.jefferson.edu/category/science-and-technology/
  8. Ainsworth, C. (2015). Sex redefined. Nature, 518, 288-291. https://doi.org/10.1038/518288a 
  9. The Editors (2017, September 1). The new science of sex and gender. Scientific American. https://www.scientificamerican.com/article/the-new-science-of-sex-and-gender/
  10. The Report of the 2015 U.S. Transgender Survey (2016, December). https://transequality.org/sites/default/files/docs/usts/USTS-Executive-Summary-Dec17.pdf
Category: Perspectives