You are a passionate advocate for gender equity. You believe in empowering women and in dismantling the patriarchal norms in the surgical institution that hinder the progress of women in the field. We hear you and are completely with you. Here, we want to bring your attention to how we can make our advocacy for gender equity more inclusive and supportive of not just women but all historically marginalized gender groups.
This requires us to acknowledge and expand beyond the gender binary and gender essentialism which use the familiar “man/male vs. woman/female” framework that recognizes the two birth-given options as the only legitimate gender identities. Most of us have been socialized into the gender binary but we can educate ourselves to assist our peers who may not fall under the binary construct of gender in breaking barriers set against them and help empower their leadership. It’s especially important for us to proactively learn about how people with gender identities that don’t fit into this strict gender binary have been marginalized and oppressed in society.
Guidelines for the Primary and Gender-Affirming Care of Transgender and Non-binary People, published in 2016 by the Center of Excellence for Transgender Health at UCSF (Editor: Dr. Maddie Deutsch), is an incredible resource. It focuses on how health care providers and students can provide gender inclusive patient care, in addition to offering vital information on gender inclusivity 101. This information is useful for anyone who is passionate about gender equity, regardless of your familiarity with gender identities outside of the gender binary. Most of the information in this post is from this document.
First, let’s talk about terminology. Many often ask, “what is the difference between gender and sex?” These terms are distinct yet often used interchangeably; the academic literature is no exception and in fact perpetuates this error. But it’s really important to understand and acknowledge the difference as conflating these terms can be oppressive to many. The definitions below, directly quoted from the aforementioned 2016 UCSF Guidelines, will help clarify these distinctions and also help you understand other terms you may have heard before but weren’t sure about:
Gender / Gender identity: A person’s internal sense of self and how they fit into the world, from the perspective of gender.
Sex: Historically has referred to the sex assigned at birth, based on assessment of external genitalia, as well as chromosomes and gonads. In everyday language is often used interchangeably with gender, however there are differences, which become important in the context of transgender people. Although sex is generally assigned at birth as male or female, it is important to acknowledge that the biological sex binary is also a social construct. Science tells us that biological sex is a spectrum.
Gender expression: The outward manner in which an individual expresses or displays their gender. This may include choices in clothing and hairstyle, or speech and mannerisms. Gender identity and gender expression may differ; for example a woman (transgender or non-transgender) may have an androgynous appearance, or a man (transgender or non-transgender) may have a feminine form of self-expression.
Transgender: A person whose gender identity differs from the sex that was assigned at birth. May be abbreviated to trans. A transgender man is someone with a male gender identity and a female birth assigned sex; a transgender woman is someone with a female gender identity and a male birth assigned sex. A non-transgender person may be referred to as cisgender (cis=same side in Latin).
Gender nonconforming: A person whose gender identity differs from that which was assigned at birth, but may be more complex, fluid, multifaceted, or otherwise less clearly defined than a transgender person.
Genderqueer is another term used by some with this range of identities.
Nonbinary: transgender or gender nonconforming person who identifies as neither male nor female.
Trans-masculine/trans-feminine: Terms to describe gender non-conforming or nonbinary persons, based on the directionality of their gender identity. A trans-masculine person has a masculine spectrum gender identity, with the sex of female listed on their original birth certificate. A trans-feminine person has a feminine spectrum gender identity, the sex of the male listed on their original birth certificate.
They/Them/Their: Neutral pronouns used by some who have a nonbinary or nonconforming gender identity.
Transsexual: A more clinical term which had historically been used to describe those transgender people who sought medical intervention (hormones, surgery) for gender affirmation. Term is less commonly used in present day, however some individuals and communities maintain a strong and affirmative connection to this term.
Cross dresser / drag queen / drag king: These terms generally refer to those who may wear the clothing of a gender that differs from the sex which they were assigned at birth for entertainment, self-expression, or sexual pleasure. Some cross dressers and people who dress in drag may exhibit an overlap with components of a transgender identity. The term transvestite is no longer used in the English language and is considered pejorative.
Sexual orientation: Describes sexual attraction only, and is not directly related to gender identity. The sexual orientation of transgender people should be defined by the individual. It is often described based on the lived gender; a transgender woman attracted to other women would be a lesbian, and a transgender man attracted to other men would be a gay man.
Collecting Gender Identity Data
In any health-related research, collecting gender identity data is important because how our society perceives and interacts with different gender identities has a significant and differential impact on the health and healthcare of individuals based on their gender. Collecting gender identity data in an accurate and inclusive manner is even more important. Fitting people with diverse gender identities into the strict binary that conflates sex assigned at birth and gender is not only inaccurate but can exacerbate the invisibility of marginalized gender populations to researchers and policy makers. So how to ask about gender? Here are our recommendations:
What is your gender? [options listed in alphabetical order]
Cisgender man
Cisgender woman
Genderqueer / Gender nonconforming
Transgender man / transman
Transgender woman / transwoman
Additional identity (fill in: ___ )
Decline to state
Finally, I’d like to introduce a concept called “cultural humility.” It is a concept developed by Drs. Melanie Tervalon, MD, PhD and Jann Murray-Garcia, MD, MPH. It refers to an attitude – of humility, self-reflection, self-critique, and lifelong learning – with which healthcare providers should treat their patients, colleagues, communities, and with themselves. Cultural humility is recognizing that “our own experiences and identities may not project onto the experiences or identities of others” (UCSF Guidelines). That means avoiding judging or editorializing other people just because their experiences, identities, or preferences are different from one’s own. The lived truths of anyone with any gender identity are completely valid and must be treated with dignity and respect.
I encourage all of us to approach this topic of gender inclusivity with cultural humility. We must also have structural humility – acknowledging and proactively educating ourselves on the systems and structures in society that have historically oppressed individuals of certain gender identities such as cis-women and individuals in the transgender umbrella including binary trans men and women, and of gender identities outside the gender binary including non-binary, agender, genderfluid, and genderqueer.
Let’s remember that our collective movement for gender equity and justice would only be complete when we center the voices of all genders who are systemically discriminated against and thus historically excluded in surgical fields.