Sex & Gender 101: The First Steps to Creating Trans Inclusive Care

Sex & Gender 101 is a gender-inclusive series designed to show learners how to take the first steps to providing care that addresses the specific needs of LGBTQI+ patients. This series includes a glossary of terms, resources for further study, and a “cheat sheet” for providers interacting with patients across the gender spectrum.

You can find the glossary for this course here and in the dropdown at the bottom of the page.

Sex and Gender

Learning Objectives

At the end of this video learners will:

  • Define gender and sex and describe their differences
  • Understand that human sex diversity goes far beyond the binary of male and female
  • Identify ways in which the socially constructed binaries of sex and gender are damaging

Reflection Questions:

  • How do you relate to gender outside of your assigned sex at birth?
  • What is your earliest positive memory of a trans person? What is your earliest negative memory of a trans person?
    • How do you think these memories shaped your views of trans people?

Gender Beyond the Binary

Learning Objectives

At the end of this video learners will:

  • Understand that gender is experienced in a spectrum of ways and not simply as one of two check boxes
  • Become familiar with the historical context and implications of colonization on the idea of a strict gender binary in the US
  • Name other cultures from around the world that acknowledge more than 2 genders

Reflection Questions:

  • How have you reinforced the idea of a gender binary in your own life and in the lives of people around you? (Ex. attending a gender reveal party, encouraging someone to “man up” or “be more ladylike”, etc)

Understanding Identity: The Gender Opossum

Learning Objectives

At the end of this video learners will:

  • Understand the importance of using the pronouns people ask you to use for them
  • Describe the difference between gender identity and gender expression
  • Understand that it is not our place to hold trans people to standards of being “man” or “woman” or “nonbinary” enough
  • Avoid making assumptions about someone’s sex or gender
  • Avoid putting gender assumptions, expectations, or beliefs on other people

Since recording, Eddie Izzard’s pronouns have changed. She uses she/her pronouns.

Gender Opossum Worksheet

Reflection Questions:

  • Fill out the gender opossum PDF based on your identities. How did that activity feel? Did you find anything challenging?
  • In what ways have you adhered to gender roles and expectations at different points in your life? How have you benefited from adhering to these gender roles/expectations? 
  • In what ways have you deviated from gender roles and expectations at different points in your life? Did you ever experience consequences for violating the rules of the gender binary?

Spectrums of Identity

Learning Objectives

At the end of this video learners will:

  • Understand that identity labels are personal and can mean different things to different people
  • Remember that almost all elements of identity, including gender, exist on a spectrum, and there’s no one right way to do it
  • Understand it is not our place to police how other people exist in their gender and that we should appreciate all the human diversity that exists

Reflection Questions:

  • Do you make assumptions about a person’s gender identity or place gendered expectations on them based on their race, ethnicity, sexual orientation, socioeconomic status, ability, body size, religion, clothing, makeup, etc?
  • What thoughts and feelings come up for you when you cannot easily determine the gender of a person? Do you find yourself trying to determine the person’s sex assigned at birth? Why do you think that is?

Language and Impact

Learning Objectives

At the end of this video learners will:

  • Accept that changing our language is something that is essential and necessary to provide competent care to trans people
  • Have the tools they need to change language in clinical encounters that excludes trans people
  • Remember that language changes all the time and we need to remain flexible and willing to change

Reflection Questions:

  • When someone calls you out for saying or doing something hurtful or harmful, do you feel compelled to quickly defend yourself and your intentions? Why is that?
  • Do you feel attached to using the word “women” to describe people who are or who can become pregnant? What are some benefits transgender people might experience from the widespread use of inclusive language? How are cisgender women harmed by equating womanhood to pregnancy?
  • How do you feel about “women only” spaces? Do you believe they should be for all women? How do cisgender women benefit from a less restrictive definition of womanhood?

Do's and Don'ts

Learning Objectives

At the end of this video learners will:

  • Ask people for their pronouns when it’s safe and appropriate to do so
  • Use neutral language when talking about someone if they do not know how the person identifies
  • Apologize in a healthy way if they misgender someone or mess up in another way
  • Thank people who correct them on pronouns, and work to do better
  • Understand that if they misgender someone and the person corrects them, that correction is an opportunity to change language and behavior to be more inclusive

Do’s and Don’ts Cheat Sheet

Additional Don’ts

  • Don’t assume the pregnant person is the mother or that the other person/partner is the father
  • Don’t assume the number of partners a person has
  • Don’t assume that a pregnant person has a partner at all

Reflection Questions:

  • How do you feel about being asked to use or corrected to use they/them pronouns for an individual? What about ze/zir pronouns? Do those two pronoun sets feel different to you?
  • Can you think of a time when your implicit bias affected your interaction with a patient?
  • Have you witnessed the impact of implicit bias during a patient encounter? How did it make you feel to witness that?
  • Can you think of a recent patient interaction in which you would have been able to use the strategies you learned in this course if you had known them beforehand? If so, please describe.

Glossary and Resources

Resources

Fausto-Sterling, Anne. 2018. “Opinion | Why Sex is Not Binary.” The New York Times, October 26. https://www.nytimes.com/2018/10/25/opinion/sex-biology-binary.html 

Roughgarden J. 2013. Evolution’s rainbow: diversity, gender, and sexuality in nature and people. University of California Press. https://www.ucpress.edu/book/9780520280458/evolutions-rainbow 

Karkazis, Katrina, Rebecca Jordan – Young, Georgiann Davis, and Silvia Camporesi. 2010. “Out of Bounds? A Critique of the New Policies on Hyperandrogenism in Elite Female Athletes.” The American Journal of Bioethics: AJOB 12(7):3-16. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5152729/ 

Richardso, Sarah S. 2013. Sex Itself: The Search for Male and Female in the Human Genome. Chicago. https://scholar.harvard.edu/srichard/publications/sex-itself-search-male-and-female-human-genome 

Intersex Justice Project. https://www.intersexjusticeproject.org/ 

“Beyond the Gender Binary” by Alok Vaid-Menon https://alokvmenon.myshopify.com/products/beyond-the-gender-binary-book 

“Seeing Gender: an Illustrated Guide to Identity and Expression” by Iris Gottlieb https://www.irisgottlieb.com/books 

“What does “Two-Spirit” Mean?” by Inqueery and them. featuring Geo Neptune. https://www.youtube.com/watch?v=A4lBibGzUnE

What Does Intersex Mean? By InQueery and them. Featuring Maria Tridas. https://www.youtube.com/watch?v=n_5l2fwWGco 

“Gender Variance Around the World Over Time” by Lucy Diavolo for Teen Vogue. https://www.teenvogue.com/story/gender-variance-around-the-world

“82: The Public Universal Friend (P.U.F).” Your Queer Story. https://yourqueerstory.com/the-public-universal-friend/ 

Public Universal Friend. Throughline, NPR. https://www.npr.org/2020/03/04/812092399/public-universal-friend .

Disclaimer: Many historians use exclusively “she/her,” exclusively “he/him,” or a mix of “she/her and he/him” pronouns for the Public Universal Friend (PUF), along with using the PUF’s assigned name at birth when referring to them. Please note that this explicitly goes against the PUF’s stated wishes to not be referred to with gendered language or by the name given at birth. It is very common even today for out transgender people to be misnamed and misgendered both in life and in death, and so while disappointing, it is unsurprising to see historians fall victim to implicit bias around a historical figure who broke social rules of gender. While Aspen does often use “they/them” pronouns in reference to the PUF, it is good to point out that there are many individuals who do not use any pronouns at all.

A genderless prophet drew hundreds of followers long before the age of nonbinary pronouns. The Washington Post. https://www.washingtonpost.com/history/2020/01/05/long-before-theythem-pronouns-genderless-prophet-drew-hundreds-followers/ 

Case Studies

Case Studies

  1. You have a new patient named Alex who is in for a prenatal checkup, and the front desk staff lets you know that Alex has a support person named Beth, and both are in the exam room waiting. You walk into the exam room to see Alex (short brown hair) wearing the exam gown and sitting on the exam table, and Beth (long blonde hair) wearing a dress and sitting in the extra chair. You greet the two and say, “Hello! You must be Alex, it’s great to meet you. You must be Beth. It is always so nice to see sisters supporting each other, especially for something as exciting as pregnancy. Before we get started, are there any burning questions you have for me?”
    Beth, the support person at the appointment, says, “We’re not sisters. He is my husband. I’m a little confused–when Alex called to set up the appointment, he was told that this office had experience with trans people.” You apologize profusely for the mistake and continue with the appointment. A few times, you stumble over your language, as you are used to saying things like, “When a woman is in the first trimester,” and, “many women have these symptoms,” though you do try to correct yourself. Even with your apology, correcting yourself, and using the correct language to refer to the patient and his wife throughout the rest of the visit, it is tense. Later that day, the front desk staff asks if anything odd happened in the visit, as Alex asked if he could see a different provider going forward, or to have his records so that he could go to a different office.
    • How could you have greeted the patient/support person differently? [“Hi, my name is _____, you must be Alex and you must be Beth, unless you decided to sit in the wrong spots haha. I’m excited to get started, but how about you tell me a little more about you.”]
    • If the patient had been a woman, why might the greeting that was used still be offensive and alienating? [Bisexual and lesbian women have babies.]
    • Even though you apologized and made corrections, it was still a tense appointment that the patient did not feel good about. Why might an apology not be enough? [Apologizing is important, but it does not undo the harm that was done.]
    • Aside from being alienated by the language that you used, why might the patient seek out a different provider for their pregnancy care after this experience? [Beth specifically mentioned that the couple was looking for a trans competent provider. Alex may have pregnancy-related questions that are specific to being trans.]
  2. You have a new patient come in for abortion care named Scout. The patient’s pregnancy has been confirmed at 6 weeks, and the patient has opted for medication abortion. You go in to the room to meet with the client, give them information about how medication abortion works, answer any questions, and give them the medication. When you enter, you introduce yourself and say, “Sometimes women can have complicated feelings about accessing abortion. I just want to let you know that you know best what you need, and we support you no matter what.” Scout says, “I’m not a woman, I’m agender. I thought I put that on the intake form with my pronouns?” You look at the chart to see a sticky note that says, “agender, they/them pronouns.” Confused, you say, “I’m sorry, I didn’t see that. What’s agender? And I guess I’m a little confused why you’re here for abortion care if you’re not a woman?” Scout sighs and says, “I don’t really want to get into it. I’d really like to just get this over with. The chart confirms I’m pregnant. I have the required parts.”
    You want to ask more questions about this “agender” thing, but as the schedule is tight today and the chart does confirm that Scout is pregnant, you go into your regular spiel of explaining how the medication abortion works and the instructions for the patient to follow. You notice that as the appointment goes on and you explain what symptoms most women have and concerning symptoms to look out for, that Scout looks increasingly upset. You ask, “Sweetie, are you okay? If you’re having second thoughts or you’re feeling scared, I’m here to help.” Scout replies, “I’m just not having a good day. I’d like to get this over with. I know that I don’t want to be pregnant anymore.”
    You finish the appointment. Later that day, the front desk staff who checked out the patient approaches you and says, “What happened in that appointment? When I asked Scout if they wanted to schedule an appointment for birth control, they said ‘only if it wasn’t with you,’ but I didn’t see anything in the chart from you about them being difficult, and otherwise they were nice as could be.” You reply, “That’s weird. She said some confusing stuff during the appointment, but I thought maybe it was just stress? She mentioned that she wasn’t having a good day.” The front desk staff member replies, “Ahh, that would be why Scout was upset. They’re trans, they use they/them pronouns.”
    • What could you have done differently to not alienate the client? [Used inclusive language, not continuously misgender them.]
    • What are some negative outcomes that Scout may experience because of how they were alienated in this appointment? [Lack of continued access to all healthcare, lack of access to contraceptives, lack of access to safe abortion care if it is needed in the future.]
    • Why would it be inappropriate to ask Scout about “that agender thing” in an abortion appointment? [While it is good to verify with patients what language is affirming for them, it is not appropriate to ask invasive questions that do not relate to the appointment. Ex: it is appropriate to ask what pronouns a patient uses and what medications they take, including gender-affirming hormones, to check for negative medication interactions. It is not appropriate to ask the patient what their gender “means” and if they have plans to have gender-affirming surgeries if it is not pertinent to know for the care you are providing.]

The following case scenarios come from “Learning to Address Implicit Bias Towards LGBTQ Patients: Case Scenarios” from the National LGBT Health Education Center, The Fenway Institute. Additional cases can be found here.

  1. Celina is a transgender woman being examined for an infection in her hand. The nurse has never taken care of a transgender person before and finds himself very curious about Celina. He repeatedly catches himself staring at her. While taking Celina’s vitals, the nurse asks, “You know, at first I thought you were a real woman. Do you take hormones? Have you had the surgery yet?” Celina angrily responds, “I don’t think that has anything to do with my hand.”
    • Why did the nurse upset Celina?
    • What could the nurse have done differently?
    • How could the nurse practitioner apologize?
  2. Carmen is having her annual physical exam with Dr. Jones, an openly gay physician. Dr. Jones recently skipped his health center’s training on LGBTQ care because he believed he already knew everything about LGBTQ health. Dr. Jones asks Carmen, “Are you sexually active with men, women, or both?” Carmen says, “I am sexually active with one woman.” Hearing this, Dr. Jones skips the questions about condom use. Unbeknown to Dr. Jones, Carmen’s partner is a transgender woman.
    • How does this case demonstrate the importance for every team member to receive training in LGBTQ health care delivery?
    • How could the doctor rephrase his question to ensure effective communication?
  3. Dawud is meeting his pregnant wife, Imran, at the health center for a prenatal appointment with the midwife. Dawud is transgender and is in the process of transitioning from female to male. The midwife, along with a midwife in training, enters the room and sees Dawud. The midwife says to Dawud: “Hi, you must be Imran’s sister, it’s nice to meet you!” Dawud, upset, responds, “No, I am her husband.” The midwife looks startled and mumbles “Oh, sorry.” The trainee notices that Dawud and Imran are visibly uncomfortable, but does not say anything.
    • Why are Dawud and Imran upset?
    • What could the midwife have said instead?
    • How can the midwife in training talk to the midwife preceptor about the interaction?

Sex & Gender 101 Webinar