Gender and sex are complicated, and yet are often treated as though they are neat and simple
Oversimplifying the complicated factors of sex and gender often results in intersex, trans, non-binary and Two-Spirit people being altogether erased from curriculum in medical education, or being treated as rare exceptions whose health care needs are limited to a few specific fields.
Let’s Talk About Sex (and Gender) was presented as part of the It Starts With Us series. In this session, Dr. Mei-ling Wiedmeyer and Dr. A.J. Lowik shared some background learnings that set the stage for an ongoing curriculum audit funded by the UBC Faculty of Medicine Strategic Investment Fund. The audit is assessing ways to better equip future generations of doctors with the language, skills, values, and knowledge to better serve the needs of all patients, especially intersex, trans, non-binary and Two-Spirit patients.
This topic identifies some of the important concepts for faculty, staff, tutors, preceptors, and others to understand, and to continue UBC’s leadership in equity-oriented care and education.
Discover more about the Let’s Talk About Sex (and Gender) session.
What is cisnormativity?
Cisnormativity is when individuals, institutions, or processes assume cisgender people are the norm and fail to acknowledge the existence and address the unique needs of intersex, trans, non-binary, and Two-Spirit people. Cisnormativity involves a series of assumptions:
- That sex is a fixed, purely biological reality and that knowing something about a person’s physical body tells you something unchanging, knowable, and fundamentally important about that person’s biology
- That sex is a binary and that all bodies will fit neatly into the categories of male or female
- That gender is a binary and that all people will identify as a man or woman
- That these binary sexes and genders will, or should, align in predictable ways according to dominant cultural and social values: that ‘alignment’ between sex and gender (called cisgender) is taken as the ‘natural’ and ‘normal’ default
- That trans, non-binary and Two-Spirit identification are recent novelties, when in fact genders other than man or woman and movement between lived genders are traditional in many world societies
What do we know about medical education?
Intersex, trans, non-binary and Two-Spirit people experience systemic barriers to quality health care. Literature suggests an overall lack of medical education curricula focused explicitly on gender and sex diversity. If present at all, curriculum focused on intersex, trans, non-binary and Two-Spirit people is often superficial, optional, and largely focused on improving attitudes rather than building and practicing clinical skills.
Tips for intentionally creating space for intersex, trans, non-binary, and Two-Spirit people
- Avoid relying on intersex, trans, non-binary and Two-Spirit medical students to fill in the gaps of your knowledge; these students need to feel that they are represented in the curriculum, without having to be the ones educating you and their peers
- Remember that intersex, trans, non-binary and Two-Spirit people have all kinds of health care needs – they have primary, reproductive, sexual, special, mental health, and emergency health care needs. No matter what your point of care or interaction is, these populations must be considered
- When researching, teaching about, or discussing the influence of sex or gender, be clear on whether you mean gender identity, sex assignment, or some specific sex-based variable (e.g., hormone level, having a prostate, having a uterus), as these are often conflated and treated as interchangeable. Instead, each may have unique and specific impacts on health and wellness
- Familiarize yourself with the historical and ongoing racist and colonial roots of sex and gender binaries. We often take the binaries of male/female and man/woman for granted, but these binaries are deeply entangled with Anglo-Western culture and ideology, colonialization, and white supremacy
- Work to create a learning environment where learners feel like they can ask questions and make mistakes. This involves being able to model humility if there is something that you don’t know or if you get something wrong and are corrected
- Avoid deficit-focused framing. While it is true that some intersex, trans, non-binary, and Two-Spirit people experience negative health outcomes, remember that this is often the result of oppression rather than a defining characteristic of these populations and that stories of joy, resilience, happiness, and good health are relevant to health and well-being
- Don’t assume that someone else is teaching and addressing the unique needs of these populations, so you don’t have to. Ensuring that the students are exposed to these populations often, across their degrees, and in diverse ways, is crucial
Guidelines for gender-affirming primary care with trans and non-binary patients by Sherbourne Health Centre (free downloadable manual)
Primary health care for trans clients by Sherbourne Health Centre (free online interactive tool)
Transgender primary medical care: Suggested guidelines for clinicians in British Columbia by VCH, Transcend Transgender Support and Education Society and the Canadian Rainbow Health Coalition (free downloadable manual)
Our relatives said: A wise practices guide, voices of Aboriginal trans people by the 2-Spirited People of the 1st Nations (free downloadable manual)
Gender-affirming care for trans, Two-Spirit and gender diverse patients in BC: A primary care toolkit by Trans Care BC and the Primary Care Working Group (free downloadable manual)
Developing inclusive primary care for trans, gender diverse and nonbinary people by Riki Lane (commentary)
Transgender health in primary care: Initial assessment by Toward Optimized Practice (practice guidance tool)
Gender-affirming primary care by Trans Care BC and UBC CPD (online learning module, free with UBC CPD account)
Improving care for transgender patients: An introduction to gender-affirming primary care by Dr. Marria Townsend for Trans Care BC and UBC CPD (webinar recording over slides)
Trans patient care guide for health care professionals by Trans Equality Society of Alberta (free manual)
Providing diversity competent care to Two-Spirit clients by Fraser Health Authority (free handbook)
Gender dysphoria: Information for primary care by eMentalHealth.ca (informational website)
Providing primary care for gender diverse clients by Trans Health Connection (slides from in-person training session)
Addressing gaps in physician knowledge regarding transgender health and healthcare through medical education by McPhail, Rountree-James and Whetter (article in the Canadian Medical Education Journal)