By: Renee Dumaresque, MSW, Ph.D. Student
You may already be dedicated to building a gender inclusive pelvic pain practice, and, perhaps, have your own ideas about how to provide safe and accessible care for transgender and gender diverse patients. This post is not meant to be exhaustive, and, of course, I am unable to speak on behalf of every transgender and gender diverse person living with pelvic pain. Hopefully, this piece can provide an entry point into learning more, or will contribute a thing or two to your existing knowledge about gender-inclusive healthcare. Based on my lived experience as a gender non-binary person with vulvodynia, and my professional experience as a social worker who is pursuing their Ph.D. in relation to queer and trans healthcare, I hope to offer some thoughts that may be helpful in making your practice more inclusive for transgender and gender diverse folks.
Chronic pelvic pain impacts people across the gender spectrum, but, for many transgender people, healthcare is not safe or accessible. Too often, this results in patients being denied appropriate care, withdrawing from care, or not engaging with healthcare at all. Healthcare holds the potential to be a transformative space of healing, support and affirmation, and there are initiatives all over the world that model dedication to gender-inclusive healthcare. What’s important, is your desire to learn, the courage to make mistakes, apologize, and try again.
Dominant understandings of health, pathology, and treatment, as well as the delivery of healthcare services, are often approached and practiced based on mainstream ideas about gender as binary and as biological. Within “women’s health”, for example, research, diagnostics, and treatment equate gender identity with biological ideas about sex. Gender does impact a person’s health and health care, but gender identity does not determine a person’s body parts or the health issues that lead a person to seek health-related support. There is no such thing as a “woman’s body” or a “man’s body”. For example, a man can have a uterus, a vulva, or breasts; and, a woman can have a prostate and testes.
A person’s gender identity relates to the way that they perceive their own experience of gender, which may or may not correlate to the sex that they were assigned at birth, for example, male and female. Mainstream ideas about gender suggest that there are only two genders and that a person must identify as a man or as a woman. However, gender exists on a spectrum, meaning that there are many ways that a person might experience gender, and for lots of people, gender is fluid throughout the course of their life.
Everyone has an experience of gender, not only transgender and gender diverse folks. For cisgender people, too, gender can shift and be extremely nuanced. When a person identifies as cisgender it means that their gender identity corresponds to gender norms associated with the sex that they were assigned at birth, for example, a person who was assigned male at birth and identifies as a man. Transgender or ‘Trans’ is an umbrella term to describe the many ways that people identify and experience gender that differs from societal norms regarding gender and gender identity.
The term ‘Trans’ does not suggest that all Trans people identity in the same way and it is not meant to erase the differences that exist between people’s unique experiences and understandings of gender. Trans includes transgender men and women, but it also includes people who don’t necessarily identify as either a man or a woman, and who may or may not identify as transgender, for example, non-binary, agender, gender fluid, and Two-Spirit folks, etc. Ideas about gender also vary within and between cultures, where people may or may not identify with Trans identity.
Transgender identity is not dependant on physical transition, for example, hormones or surgery. Gender transition may or may not involve physical aspects, but it can also include emotional, spiritual, and many other shifts. Be mindful of the language that is used by your patients to describe their bodies and experiences. For some patients, labels such as “pre-operative” and “post-operative” will be problematic because of the assumption that transition must include physical change, but for others, these terms might feel right. It is important to remember, for both cisgender and transgender individuals, that the words people use to describe their experiences and their identities can mean many different things for different people. There are no generalizable rules about gender.
You cannot assume a person’s gender by looking at them. Gender expression is different than gender identity - it relates to the way that a person presents, such as masculine, feminine, androgynous, etc. Like gender identity, gender expression is often fluid, it might change day to day, and it is not dependent on gender identity.
With respect to pelvic pain healthcare, consider who is currently left out of the conversation? Which bodies and identities are not included in research, treatment, and support? What assumptions exist related to gender? Although there are many structural barriers to gender-inclusive healthcare, there is a lot that you can do to make your practice safer and more accessible to transgender and gender diverse folks. Increasing access and inclusivity does not mean implementing special practices for Trans patients that differ from the practices that you use with cisgender patients. By providing gender-inclusive care, to all patients, you will contribute to the development of new norms in mainstream healthcare. You will help to address the structural issues that result in marginalization and erasure of transgender and gender diverse patients.
Trans patients live whole lives that don’t always center their gender identity. For the most part, people want to visit their healthcare provider and be treated just like everyone else – to feel included, considered, and like their experiences and bodies are equal to other patients. Below are some ideas about how you can increase accessibility within your pelvic pain practice.
- Consider the advertisements, signage or other materials that you display in your clinic.
Avoid placing material in your clinic that equates specific experiences and medical issues with a specific gender. For example, frameworks of women’s health often exclude and erase transgender and gender diverse people and their experiences. Consider displaying a sign or a poster in your clinic which communicates to patients that your clinic values transgender and gender diverse patients. Remember that signage, alone, is not helpful and must be accompanied by a thoughtful practice dedicated to gender inclusivity.
- Understand that building trust takes time.
Recognize that patients are often coming into your practice having had negative experiences in healthcare. It is normal and reasonable that Trans patients might enter from a place of distrust. In fact, for a lot of people, having their guard up is a safety precaution that has been both smart and necessary. For this reason, be patient, avoid making judgments, and understand that you are in a unique position to provide a different and positive experience of healthcare. Communication and transparency is key to building trust. Always communicate what you intend to do, check in with patients about their comfort level, and ask for consent along the way.
- Respect patients chosen name.
Ask patients to share their name and don’t assume that the name they provide will be the same as what you see listed on their health identification. Safety concerns, legal and financial barriers, social and family issues, and personal choice are some of the many reasons that a patient’s name might differ from their legal name or the name that appears on their health identification. Ask patients what name appears on their health-card, and also ask patients if they prefer a different name be used in your clinic. If so, make sure to document their chosen name.
- Ask all patients to share their pronouns.
Like gender identity, you cannot assume a person’s pronouns based on how they look or based on their gender identity. For example, some gender non-binary people choose to use she/her or he/him, and some people use different pronouns in different settings. By asking all patients what their pronouns are you will avoid making assumptions and it will quickly feel like your new norm. Start by introducing yourself and sharing your own pronouns, then you can ask your patient if they feel comfortable sharing theirs.
- Ask about body parts instead of assigned sex.
Within society, gender and sex are often conflated, meaning that ideas about sex are hardly ever gender neutral in social institutions. Many people do not identify with the sex that they were assigned at birth. Instead of asking people about their assigned sex, ask people to identify the specific body parts that they have or that are relevant to their healthcare.
- Don’t make assumptions about sexual orientation or sexual practices.
Sexual orientation is different than gender identity. A persons gender identity does not dictate or limit a person’s sexual orientation. Knowing a person’s sexual orientation does not tell you what sexual practices that they engage in, just as knowing what sexual practices that a person engages in does not tell you their sexual orientation. Avoid making any assumptions about a patient’s sexual orientation and their sexual practices. If having this information is necessary for providing certain aspects of health care, then, inform patients as to why having the information will be helpful and ask them if they are comfortable sharing.
- Review (and possibly revise) your patient intake form.
Your intake form is one of the first interactions that a patient has with your practice. Thoughtful design can ensure that you share and obtain the necessary information that you need to run your business and provide quality, gender-inclusive healthcare. Review your intake form in relation to the information and the suggestions listed above. Do the questions that you ask on your intake form make assumptions about gender identity or equate gender with certain body parts? What questions might you consider adding? Are there questions that can be removed or rephrased? Reflect on the reasons that you ask each of your questions and consult with others if you need advice or if you are struggling with revisions.
Like any big change, moving toward gender-inclusive pelvic pain healthcare will come with lots of learning and you may have lots of questions. Changes in your practice might also come with questions from others, including patients and colleagues. Taking a few moments to explain your approach to providing care or to clarify the questions that you ask in your intake form shouldn’t take long, but it will make a big difference for Trans people who engage with your practice and who see themselves reflected in your day-to-day operations. Many people and organizations have put tons of thought into developing gender-inclusive healthcare - you do not need to reinvent the wheel! Remember that not everything that you do will work for every patient - be open to feedback, try new things, and know that you are engaging in life-saving and life-affirming work. More resources must be put into learning more about the unique ways that pelvic pain impacts Trans folks, about effective treatment, and effective support. People with pelvic pain carry huge amounts of knowledge related to health, survival, coping, healing, and resistance. Within your work, centre the knowledge of people living with pain. Continue to acknowledge that we all have something to learn from one another as we reimagine what it means to live with pelvic pain, and in some cases, how to live without it.