2. GENDER

2.4 Gender: Affirmation History

In some situations, it might be clinically relevant to ask trans and gender diverse patients about their affirmation history. It’s important to create a safe and inclusive clinical environment by using the right language and being mindful of a patient’s experience. Consider the next case.

Khang is an 18 year old man who presented to his GP complaining of nausea”

Sensitive and inclusive practice:

You can use the broad principles you have learned for taking other sensitive histories and examinations

Explain why: It’s a good idea to begin with a short explanation of why you’re asking about someone’s history

Reassure confidentiality: Let the patient know all information will be kept strictly confidential. Although this is an important step for all patients, its importance cannot be overstated to LGBTIQ patients, who could face significant consequences if confidentiality is breached.

Stop signals: As with every sensitive examination and interview, give the patient the opportunity to decline answering any questions they don’t feel comfortable with. Similarly, patients should be given the opportunity to stop at any time.

Check for understanding and consent: Give the patient the opportunity to ask any questions and ask if they are willing to proceed.

We will add a few other guidelines for sensitive history taking with transgender patients

If and only if it’s clinically relevant: You wouldn’t go about asking all your patients about their genitals, the same rule applies about transgender and gender diverse patients! Asking about a patient’s gender identity or transition history when it’s not clinically indicated is considered insensitive and intrusive.

Ask about preferred pronouns, if unsure: Some patients (not necessarily transgender) prefer pronouns other than he or she -such as “they”, “ze”, “xe”- or would rather not use pronouns at all. Ideally, a patient’s preferred pronouns could be denoted on the medical admission forms. Since this is currently not common practice, it might be necessary to ask about a patient’s preferred pronouns if you’re unsure.

Avoid gendered terms: This is particularly important when asking about a patient’s transition or anatomy. Some transgender patients might wish to avoid certain anatomical terms- for example, phrases like “your uterus”, “your vagina” or “your ovaries” might make trans men uncomfortable. Similarly, trans women might wish to avoid phrases like “your penis”, “your testes” or “your prostate”. Create a space for patients to use their preferred terms to describe their bodies. If you’re unsure, asking about which terms to use might be appropriate.

Fertility is still important:  Depending on their transition history, fertility is very much relevant to transgender individuals. Some transgender individuals might have concerns about their fertility or might be at risk of STIs which impact their fertility.

It’s ok not to know!

Queer, transgender and gender diverse patients may identify within a wide range of different gender identities. You’re not expected to be an expert or even have heard about all of them. If you’re unsure about a patient’s gender identity, it’s ok to ask! Transparency is best practice. Your patient will appreciate your effort to be respectful and you’ll give them an opportunity to guide you through what you need to know, in their own terms.

“I’m sorry, I don’t know much about your gender identity, but I’d really like to respectful. Which pronoun would you prefer me to use?”

Many health professionals may not be familiar with working with transgender or gender diverse individuals. As such, it might be challenging for them to navigate with confidence the correct terminology. Gender identity is protected by law and as such discrimination against transgender and gender diverse individuals in clinical setting could be unlawful. It is therefore extremely important for clinicians to have basic communication skills with transgender and gender diverse patients in order for them to provide accessible healthcare.

In the following section, we’ll develop some of your clinical skills when treating trans and gender diverse patients.

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