Transgender individuals have made strides forward in societal acceptance in recent years. However, they still face significant barriers. Healthcare providers have a duty to provide care that meets individual patient needs. People who identify on the transgender spectrum experience a unique set of challenges. Many clinicians are, in turn, looking to understand how to provide inclusive care in transgender gynecology.
Gynecologic care for transgender individuals
Issues surrounding gender identity can impair patients access to gynecologic care. We explore the issues that face transgender patients and suggest ways in which clinicians can provide more compassionate care.
We spoke with LGBTQ activist Chen Malchut, a practicing psychologist who offers inclusivity training for organizations looking to ensure that LGBTQ individuals receive sensitive and culturally aware interactions with their staff. Malchut shares some of the transgendered experience and suggests concrete ways that clinicians can be inclusive of trans experience.
What do all the terms mean?
When a person’s gender experience is different than the gender assumptions that were assigned to them at birth (based on their physical sex), they can be said to fit somewhere on the ‘transgender spectrum.’ That means their gender experience exists outside of the binary male born in a male body and female born in a female body.
Malchut explains that once you allow for more expressions of gender than the binary male/female, a whole spectrum of possibilities exists.
“Many people assume that ‘trans’ means someone in a male body who identifies as female or visa versa. But there are so many more experiences.”
“There are many terms that people use to describe their experience,” Malchut shares. “From, gender queer, a-binary, gender fluid, trans… the list is long and can be confusing for people from outside the community.” Very often the term queer is used as a blanket inclusion of all those people who fall outside of the binary gendered, heterosexual experience.
Malchut defined some of the most common terms found in discussion around transgender experiences:
|Male to female transgender (MtF)||Someone whose gender experience is female, although she was born in what our culture considers to be a male body|
|Female to male transgender (FtM)||Someone whose gender experience is male, although he was born in what our culture considers to be a female body|
|Gender queer / non binary||Someone who does not subscribe to conventional gender distinctions but identifies with neither, both, or a combination of male and female genders.|
|Genderfluid||Someone who does not identify themselves as having a fixed gender, but rather their gender experience is fluctuating and dynamic.|
|Cisgender||Someone whose gender experience is the same as the gender they were assigned at birth.|
Malchut is quick to stress that ‘getting the words right’ is not the most important thing, “Treating people with respect is far more important than worrying about the correct modifier.”
Because trans awareness is relatively new in the wider medical world, there are many common misconceptions to address.
Trans does not necessarily mean surgery
While many trans individuals do have gender reassignment surgery (GRS), it is not always the case. Also, the process of GRS is long, so a patient who identifies as trans may still have all of the same sexual organs they were born with. This is particularly relevant for gynecology. A transman might still need cervical cancer screening as with any person who has a cervix.
Gender queer people have a range of sexualities
“Because we talk about the LGBTQ community, people can have the impression that trans gender identity means queer sexuality,” Malchut explains. In fact, gender expression and sexuality are different issues. Sexuality relates to which other people an individual is sexually attracted to and is a stand-alone topic, not necessarily related to an individual’s gender identity.”
“You can have a transman who is sexually attracted to women and would identify as having heterosexual sexuality. Or you could be a transman who is attracted to men and so is homosexual. You can even have a transman who identifies as a lesbian. Gender and sexual orientation are up to each person to define for themself,” Malchut says. Gender identity and sexuality are not automatically correlated.
Transgender experience of the healthcare system
Bodies are complicated
Inherently for trans-people, their body is likely to be a complex issue. “Just growing up in a body that may not quite feel ‘right’ causes trans people to have complicated feelings when it comes to their physicality and subsequently their healthcare,” Malchut explains. Dysmorphia is common among non-cisgendered individuals.
Transmen can have a particularly difficult experience in certain respects, Malchut says. “Living with a female hormonal system, including menstruation, can be traumatic. Imagine knowing you’re a man but having a period! Every month you are reminded that there are aspects of your body that are viewed as female that are out of your control.”
Lack of trust in the healthcare system
Struggling to regain control is pervasive for many in the trans community. Many have had negative healthcare experiences. “Medicine is based in biology as fact,” Malchut outlines.
“It can be extremely hard for healthcare providers to ‘wrap their heads around’ queer gender. This can lead to gender queer people having very negative experiences.” These negative experiences can be so damaging that many trans individuals simply refuse to seek medical care.
For transmen who still have female reproductive organs, gynecologic care is particularly challenging. “What man wants to go to the gynecologist?!” Malchut asks. “Needing to receive gynecologic care for their bodies only reemphasizes the ‘female-ness’ of their bodies.”
Studies have shown that understandably Pap test uptake among female-to-male trans patients is lower than cis-gendered women, even after adjusting for individual and provider-level factors. Research into forms of cervical cancer screening that would be more accessible for transmen has found that HPV testing, as opposed to Pap test, received more uptake. Participants found HPV testing to be less invasive than Pap, making it more accessible.
How gynecology clinicians can ease the healthcare experience for transgender individuals
Malchut offered a number of practical suggestions for clinicians in treating members of the trans community.
Put your own feelings and beliefs aside
The trans community is not always visible. Healthcare providers have a unique intimacy with their patients as they are required to be familiar with them on a more personal level than other public service providers. “You don’t have to tell your bank manager that your trans,” Malchut compares, “but you do need to tell your primary care doctor. It means that automatically you need to open up a topic that can leave you feeling super vulnerable.”
How any clinician personally feels about the trans community does not change their patient’s need for quality healthcare. The more comfortable a trans individual feels with their clinician the more likely they are to adhere to medical recommendations and to return in the future. Therefore, making them feel at ease is a vital component of their care.
“Clinicians need to leave aside their own feelings or opinions on the trans community,” Malchut says. “All you need is compassion and sensitivity towards another human being, and respect for their lived experience.”
Never assume gender
“Being mis-gendered is a common experience for gender queer individuals,” Malchut explains. “Having someone show the care to ask about your gender orientation, and your preferred pronouns is a game-changer.”
“You can just ask directly – which pronouns do you use?” It shows an understanding and respect for a range of gender experience.
“You can always ask,” Malchut says. “Ask about gender identity. Ask about past medical experiences. Ask before you perform any exams.” The goal is to reassure patients that all of their experiences are valid and respected. “Most gender queer people are open to answering questions that are asked with sensitivity and respect. It’s always best to ask open questions when it comes to sexual and gender experience. Closed questions don’t allow for the variety of experience that exists, and therefore are by nature, exclusive.”
Reach out to the trans community
“Many trans people will only see doctors they know to be trans-friendly,”
Malchut explains. “You need to let them know they will be safe, respected and not challenged about their gender and sexual life.” This could be as simple as adding a line to your practice website saying that your practice is LGBTQ friendly (assuming of course that it is).
There are teams that offer inclusivity training to help organizations ensure that all members of their staff are aware of the unique trans sensitivities. “There needs to be some discussion about how to create a safe space and how to best reach out to the community,” Malchut suggests.
The bottom line
“Transgendered people frequently do not feel safe in the world. Even walking down the street can be frightening. Having a positive experience within the medical system can be deeply healing,” Malchut says.
By extending our understanding and learning about unfamiliar communities, we can deepen our connection with our patients, make our practices more inclusive and improve the healthcare outcomes for those patients.