- [Instructor] Welcome to the CREOG modules
on caring for transgender and gender non-conforming patients
for the obstetrician-gynecologist.
This module is the first of several modules
that will introduce you to the role
of the obstetrician-gynecologist
in providing care for this patient population.
These modules were created with the support
of the CREOG empower award,
and with the support of the University of Michigan.
Through all these modules,
any hormones mentioned for gender affirmation are off-label.
Module one: an introduction to gender,
gender identity, and the role of
the obstetrician-gynecologist in the care of transgender
and gender non-conforming people.
After completing this module,
you should become familiar with correct terminology
regarding transgender and gender non-conforming patients,
and understand some of the specific issues
pertaining to the health care of these patients.
Please pause the video and take a minute
to answer the following questions.
Differences between sex and gender.
The terms sex and gender are often used interchangeably
in both lay and medical texts, but have distinct meanings.
The term sex is commonly defined as the reproductive,
genital, and biological characteristics of an individual,
including the anatomy of their genitalia
and reproductive organs, concentrations of sex hormones,
and the genetic makeup of their 23rd set of chromosomes.
These can align as typically male,
with a karyotype of 46 XY,
typically female, with a karyotype of 46 XX,
or a host of other combinations of genitalia
and chromosomes that fall under the category of intersex.
Where useful to distinguish biological characteristics
of natal sex, we will use the term sex at birth,
which relates to the sex determined,
usually by rapid examination of
the genitalia when one is born.
In contrast, the term gender relates to the social
and cultural roles and characteristics
associated with a certain sex.
For example, masculine refers to the roles
and characteristics that are often associated
with having a male body,
and these are culturally and historically variable.
So, what is gender identity?
Gender identity is a person's internal,
deeply felt sense of being male, female,
or somewhere in between.
Gender identity can correlate with sex assigned at birth,
or it can differ from it completely.
Everyone has a gender identity.
When a person's gender identity aligns
with their sex assigned at birth,
we say that a person is cisgender.
For example, a person who understands themselves
as a woman and who was assigned female
at birth is a cisgender woman.
When a person's gender identity differs
from their sex assigned at birth,
we say that a person is transgender.
For example, a person who understands themselves as a man,
and who was assigned female at birth, is a transgender man.
Some people may identify as non-binary,
gender non-conforming, gender queer,
or use other terms that best capture
a gender identity that does not fall squarely
into a male or female category.
Gender dysphoria, in a medical context,
we may use the term gender dysphoria.
This is a diagnostic term based on the DSM version five,
which refers to the distress a transgender
or gender non-conforming person experiences
in relation to their birth sex.
Sexual orientation, it is important to note
that sexual orientation is different from gender identity.
Sexual orientation is a person's sense
of gender-based attraction to other people.
People use words such as gay, lesbian,
bisexual, straight, queer, pansexual, asexual,
and other terms to describe their sexual orientation.
Everyone has a sexual orientation,
including transgender people.
For example, a transgender woman may be primarily
attracted to women, and identify as lesbian.
Or she may be primarily attracted to men
and identify as straight.
A transgender person may decide to transition
to living outwardly in a way that corresponds
with their gender identity.
There is no best way to transition,
and the journey looks different for many people.
Transitioning can include several dimensions,
including legal, or changing the name and gender on identity
documents such as driver's license, passport, et cetera.
Social, or coming out to people in one's
life as transgender, and letting people what name
and pronouns they use for themselves.
Psychological, or adjusting to changes in thinking,
emotions, behavior, and relationships resulting from
the mental shift of accepting one's gender identity.
And medical, or accessing transition-related
health treatments such as hormone therapy or surgery.
Affirming care, many transgender, or gender non-conforming
people may seek care from an OBGYN.
They may have gynecological concerns
such as vulvar pain, or abnormal bleeding,
need obstetric or fertility-related care,
present for routine screening,
or request gender affirming care,
including hormones and surgery.
We will go into each of these in more
detail in the upcoming modules.
The term affirming care relates to care
that is respectful, acknowledging,
and supportive of one's gender identity.
Our role as physicians is to care for all of our patients
in the most respectful, knowledgeable way,
and to ensure that their specific needs
and concerns are addressed.
Recent national estimates suggest that .5 to .6%
of the adults living in the United States,
or one in 200 people identify as transgender.
This comes out to about 1.5 million people.
The transgender population is diverse,
spanning across age categories, races,
urban, and rural locations.
Overall, the transgender population
is more likely to attend college,
yet have higher poverty rates when compared
to the general population.
These higher poverty rates are likely related
to employment discrimination and loss of social networks
that many transgender and gender non-conforming people face.
We should note that higher educational rates
are common in internet-based surveys.
In our survey, trans people who have attained
a college education may be more likely
to come out and identify as such
than those who have not attained a college education,
skewing the survey population.
Health risks and disparities.
Transgender and gender non-conforming people
face significant health disparities due to discrimination.
These may range from violence and social isolation,
leading to loss of social networks,
to unemployment, lack of insurance,
and lack of financial resources.
Because of these, transgender people
are at a high risk for homelessness,
which may cause them to engage in survival sex,
and are also at a higher risk for depression and anxiety,
substance abuse, and other consequences
of discrimination and isolation.
Family acceptance is a significant
protective factor with each of these outcomes.
It is important to note that many of the barriers
to care are from within the health care system.
19% of transgender people report being refused
medical care due to their gender identity.
28% report experiencing harassment within a medical setting.
And 50% of transgender and gender non-conforming
people had to teach their providers
about care for transgender people,
and this lack of knowledge correlated with
an increased propensity to delay needed care.
Best practices, because of these experiences
of discrimination, a patient may feel
anxious in clinical settings,
even if you have expressed no ill will.
To maximize safety and reduce risk,
you should utilize some of these best practices
to ensure the safety and comfort
of transgender and gender non-conforming patients.
Use correct patient identifiers,
both in the chart and in person.
Being addressed in a way that is congruent with,
and respectful to who they are is vital for all patients,
and shows patients that we respect them.
For transgender patients, this is of particular importance.
Be particularly aware in waiting rooms and public spaces.
Addressing a patient incorrectly in public
can lead to outing, or publicly exposing the person,
which can lead to unsafe situations.
In some clinics, all patients are called by their last name.
This eliminates the need to make decisions about prefixes
such as Mr, Mrs, and Ms.
Some health systems have locations
in the medical chart for gender pronouns.
It helps when they are easily found,
such as in the headline,
and can allow patients to tell their first provider,
or fill it out in their forms,
and not need to continue to correct people.
Many EMR systems are moving to enable this.
When writing in the chart, some providers note trans status.
For example, transgender man in the first line.
And then write their note using the appropriate pronouns,
such as he, him, or his.
When asking about patient sex and gender on intake forms,
a simple two-step question relating to sex and gender
ensures that all patients are respected,
and that you can get the range of information
you need to treat your patient.
When discussing this with patients in person,
start by asking how a person would like to be addressed,
and what pronouns they use.
You may feel awkward asking the question,
but skipping that step and assuming
incorrectly could be much worse.
An interaction may go as such.
Hi, I'm Doctor Stroumsa and I'll be seeing you today.
How would you like me to address you?
My name is Mike, I use he, him, or his pronouns.
If asking detailed questions about
trans-related health information,
it is important to provide your patient with rationale
around why this information is medically relevant.
As always, when interacting with patients, don't assume.
If you're unsure, clarify.
You can say something like,
I noticed you filled out a different name
than is in your chart.
Which name would you like me to use?
Refrain from asking people and patients
about their genitalia unless it is medically relevant
to the care you are giving them today.
You can learn about their medications
and any relevant surgeries when you obtain
the past medical history and past surgical history.
Mistakes happen, even with the best of intentions.
If you mis-gender a patient,
or unintentionally address them by the wrong name,
simply acknowledge your mistake, apologize, and move on.
Ensure that all staff, not just clinical workers,
have appropriate training.
Since the frontline staff are often the first people
to encounter our patients in clinic,
and often do so publicly,
such as when calling a patient in from
the waiting room to their appointment,
these staff have a particularly important role
in ensuring the privacy and safety of patients.
For transgender patients,
calling them by a name or title that does not align
with how they would like to be addressed,
may inadvertently out them publicly.
For example, a transgender woman may have
a male gender marker on her insurance card.
If she's addressed as Mr. So-and-so in the waiting room,
that may cause significant discomfort,
may make her less likely to disclose health concerns,
and may even endanger her safety.
Be sure to educate your staff on these issues pertaining
to transgender and gender non-conforming patients.
Having non-gendered single stall bathrooms,
or family all gender bathrooms,
ensures that everybody can use the bathrooms,
and sends a welcoming message.
Additionally, a small placard stating the location
of the nearest all-gender restroom
located under the signs for the gendered restrooms
can allow people to find these locations
if they are not readily apparent.
If your clinic is a standalone women's health clinic,
consider placing signs that clarify that
they are affirming of all patients.
Some examples are demonstrated here.
To conclude, in this module,
we learned key terms such as sex,
gender identity, transgender, and cisgender.
We also learned that transgender individuals
face many barriers to care.
However, simple measures can facilitate creating
a welcoming environment for all of our patients.
Let's review the self-assessment questions
that you saw earlier in this module.
Number one: a transgender man is someone who was assigned
female at birth, but identifies as male.
This is true.
Number two: the best way to assess which pronoun to use
when addressing a transgender patient
is to use the sex listed in their medical record.
This is false, the best way to know what to call a patient,
and what pronouns they use, is to ask them.
Thank you for viewing module one,
which provided a basic introduction
to the care of transgender and gender non-conforming people.
For more information, you might consider
reviewing the following sources.