We are seeing more patients who identify and/or express their gender as something other than the sex on their birth certificate. Medical training is woefully behind at preparing us for treating these patients with dignity and respect. Even with the best intentions many medical students and residents fumble through obtaining a basic history and physical due to stigma and discomfort with the unfamiliar. Some medical providers have deep seeded biases that are very apparent in how they treat members of this community. Transgender patients are some of the most medically underserved because of these types of interactions.
This post covers some basic language choices and definitions for physicians and other medical providers to use and not use when evaluating a transgender patient. Much of this post was adapted from GLAAD Media Reference Guide – Transgender.
Sex – The classification of a person by the appearance of their external genitalia. Usually assigned at birth, either male or female, and determined by genetics and hormones.
Gender – The social and cultural characteristics pertaining to being masculine or feminine. Includes sex but also sex-based social structures and gender identity.
Gender Identity – A person’s deeply held sense of their gender. Most people have a gender identity of either male or female but some people do not identify with either of these two choices. Gender identity is personal and not visible to others, unlike gender expression.
Gender Expression – The external manifestations of gender: name, pronouns, appearance, behavior, voice and body characteristics.
These terms are safe and typically the preferred terms to use.
Transition – The process of changing from the gender expression of their assigned sex to the gender expression consistent with their gender identity. This can range from disclosing to others their transgender status, using a different name or pronouns, changing appearance by altering clothing and hairstyle, using hormone therapy, and/or having augmenting surgery(ies).
Transgender (adjective) – An umbrella term for people whose gender identity and/or expression is not aligned with the sex they were assigned at birth. Transgender does not define if a person is or is not transitioning their bodies to be more in alignment with their gender identity. Many transgender people may describe themselves with a variety of terms, you should use the term preferred by the person. A person who is born male and transitions to become female is a transgender woman. A person who is born female and transitions to become male is a transgender male.
Cisgender – A term used by some to describe people whose gender identity is congruent with their sex.
Gender Non-conforming, Non-binary, Genderqueer – Terms used to describe some people whose gender expression is different from conventional expectations of masculinity and femininity. These are not synonyms for transgender. Many people have gender expressions that are not entirely conventional – that fact alone does not make them transgender. When in doubt use the words preferred by the patient.
Androgynous – Term used to describe an individual whose gender expression and/or identity may be neither distinctly “female” nor “male,” usually based on appearance.
Preferred Gender Pronouns – Equally important as referring to a person by their preferred name, intentionally using the wrong pronouns is hurtful. Many suggest removing the “preferred,” because it indicates flexibility and/or the power for the speaker to decide which pronouns to use for someone else. Zie & Hir are the most common spelling for gender-neutral pronouns. Zie is subjective (replaces he or she) and Hir is possessive and objective (replaces his or her). Some gender non-conforming people will use “they” as a singular pronoun.
Intersex – Describing a person whose biological sex is ambiguous. There are many genetic, hormonal or anatomical variations that make a person’s sex ambiguous (e.g., 5-alpha reductase deficiency). Parents and medical professionals usually assign intersex infants a sex and perform surgical operations to conform the infant’s body to that assignment. This practice has become increasingly controversial as intersex adults speak out against the practice. The term intersex is not interchangeable with or a synonym for transgender.
Cross-dresser – A person who likes to wear the clothing of the opposite sex but who does not identify as that gender or wish to live as the opposite sex. A subset of cross-dressing is drag which is done for performance and entertainment.
Proceed with caution, use these terms only if explicitly told to do so.
Transsexual – An older term that originated in the psychological literature. Refers to people who either have permanently changed their outward sexual characteristics, or want to change, to reflect their gender identity. Not an umbrella term as it defines those using hormones or surgery. Most do not prefer this term but some may.
Trans – Shorthand for transgender or transsexual. Avoid use unless this is preferred by the patient.
Transvestite – A person who dresses in the fashion of the opposite gender but who does not identify with that gender or wish to live as the opposite sex. The new more appropriate term is cross-dresser, some people may still want to use this term.
These terms should never be used. Feel free to correct others if they use these terms.
Tranny – Slang for transgender or transsexual, think of this like the “N-word” some people in the community may still use it but that doesn’t mean you get to.
Transgenders, A Transgender, Transgendered – Transgender should be used as an adjective, not as a noun. It also should never have an extraneous “-ed” tacked onto the end. An “-ed” suffix adds unnecessary length to the word and can cause tense confusion and grammatical errors. Use the word “transgender” as you would use the word “gay”. You wouldn’t say “that gayed man”.
Sex-change – Use gender confirmation surgery or sex reassignment surgery.
Pre-op or Post-op – Not all transgender persons choose to have sex reassignment surgery, some cannot afford to. There are also multiple types of surgeries a person can choose to have to conform to their gender identity and not all of these involve changing primary sex characteristics.
Passing or Stealth – Refers to a person’s ability to go through daily life without others assuming they are transgender. These terms may be used by members of the community but are inherently negative and denote deceit and lies.
She-male, He/she, “It” – Defamatory dehumanizing slang terms. Just don’t.
A tip for charting: It is never appropriate to put quotation marks around either a transgender person’s chosen name or the pronoun that reflects that person’s gender identity. It implies that it is false or an alias.
This is meant to be used as a primer into the basic terms to use and not to use when speaking to or about a transgender patient. As with everything in language the meanings of these words are fluid and constantly changing, and this is by no means an exhaustive list. When in doubt ask the person, in a kind a respectful way, what name, pronouns, or other terms you should be using, and then use them.
Elspeth Pearce is a PGY4 IM/EM resident
Sarah Bunch is a PGY1 EM resident