Understanding Gender-Affirmative Care Beyond Women’s Health

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In recent years, there has been increasing awareness and understanding of gender as a fluid social construct that differs from biological sex. While sex is defined by physical characteristics, such as chromosomes and reproductive organs, gender refers to how individuals perceive and express themselves. Gender-affirmative care (GAC) is a holistic approach to health care that supports individuals’ expressed gender identity. Understanding gender identity, implementing inclusive language, and creating welcoming health care environments are essential steps toward ensuring that all individuals, regardless of their gender, receive the care they need.

Gender vs Sex

Gender is a social construct. As an expression of their gender identity, an individual may identify as cisgender, nonbinary, transgender male or female, genderfluid, or genderqueer.^1,2 Sex, on the other hand, is defined as biological characteristics at birth, such as reproductive, chromosomal, and hormonal characteristics. The sex of a baby at birth is often categorized as either male or female, although intersex is also a category.¹

Further, gender identity pertains to a personal self-identity that may or may not align with a person’s dress code, facial and body hair grooming, or how they speak. On the other hand, the manner with which a person externally expresses themselves, such as through their clothing, hairstyle, facial grooming, or behavior is called their gender expression.1 The ideal way to know a person’s gender is to ask them, while also keeping in mind that gender identity may not be permanent; basically, asking an individual about their gender identity at their first appointment while establishing care may not be sufficient, as this question can remain a relevant component of care into the future.

What is GAC?

GAC is defined by the World Health Organization as a type of health care that includes one or a combination of social, psychological, behavioral, or medical interventions that are intended to support and affirm one’s gender identity.³ GAC is applicable for individuals of all ages (ie, children, adolescents, and adults).⁴

Transgender and nonbinary individuals often experience gender dysphoria, which the Human Rights Campaign defines as “clinically significant distress caused when a person’s assigned birth gender is not the same as the one with which they identify.”^2,4,5 When health care providers deliver GAC in a manner that is age-appropriate and evidence-based, individuals can interact with health care providers as their authentic and true selves, which supports trust within the relationship.

To understand GAC beyond women’s health, a working knowledge of appropriate terminology is a crucial step (Table).² The 2021 edition of the “Inclusive Language Guide” by the American Psychological Association provides guidance that supports person-first language infused with cultural humility to promote gender-inclusive and affirming language for gender-diverse individuals.⁶

What Does It Mean for Someone to Transition?

Gender transitioning is the process by which an individual (transgender or nonbinary) actively takes steps to live their authentic life in their true gender identity. The transition process is a personal one and is different for each individual. Gender transitions may be social, medical, legal, or surgical.

Social transitioning refers to when a person uses reversible and nonmedical steps, such as adopting a new name and pronouns, a new hairstyle, different clothes, and/or sharing their gender identity. Medical transitioning is when individuals use sex hormones, such as androgen inhibitors or estrogen, to develop secondary sex characteristics. Legal transitioning involves elements of social transitioning and name change on legal documents such as driver’s licenses. Surgical transitioning includes a broad range of procedures, such as plastic surgery to change features to appear either more masculine or feminine. Categories of surgeries may be referred to as top surgery or bottom surgery. Top surgery creates the desired gender chest or torso shape, and bottom surgery creates changes to the reproductive organs.⁵

Does GAC Matter?

Outside of the relevance of GAC in health equity, decreasing disparities in care, and supporting patient trust in their health care providers and the health care system at large, Title VII of the Civil Rights Act of 1964 also prohibits discrimination in the workplace on the basis of sex. For this reason, there is a legal liability component to the importance of GAC.

Bostock v Clayton County: A Landmark US Supreme Court Civil Rights Case

In a case brought forward in Georgia, Gerald Bostock was fired for “conduct unbecoming of its employees” after he joined a gay softball league in 2013. Bostock sued because he alleged he was protected under Title VII on the basis of sexual orientation. Clayton County argued that Title VII does not prohibit such discrimination. It did not argue that sexual orientation played any role in his being fired. In 2017, a decision in the federal appeals court in Georgia stated that Title VII did not protect LGBTQ workers and as such did not have a case in Georgia. The case was then taken up by the Supreme Court. In 2020, the Supreme Court’s decision in Bostock v Clayton County ruled that Title VII of the Civil Rights Act of 1964 also extends to discrimination based on sexual orientation and gender identity because Title VII protects individuals, not populations.^7,8

“The Supreme Court has made clear that people have a right not to be discriminated against on the basis of sex and receive equal treatment under the law, no matter their gender identity or sexual orientation. Fear of discrimination can lead individuals to forgo care, which can have serious negative health consequences,” said US Department of Health and Human Services (HHS) Secretary Xavier Becerra in an HHS statement. “It is the position of the Department of Health and Human Services that everyone—including LGBTQ people—should be able to access health care, free from discrimination or interference, period.”⁷

GAC Beyond Women's Health

Traditionally, the term women’s health has centered around the care of cisgender women (who are assigned the female sex at birth and identify as female). However, there are individuals of different genders, such as genderqueer, nonbinary, and others, who can and do carry pregnancies. A transgender woman and nonbinary individuals may require obstetric and gynecological services such as contraception, fertility care, estrogen treatment, and surgical care. When seeking appropriate care, these individuals often experience stigmatization, verbal harassment, fear of discrimination, and refusal of care, which contributes to social and health inequities in gender-diverse populations.^9-11

Overcoming Barriers to Care for All

Changes in language and environments can provide a welcoming and safe platform for the gender-diverse population in clinical settings. Further, some changes are simpler than others to achieve. To foster gender-diverse care that is psychologically safe, staff education is an important step in ensuring that everyone has a working knowledge of inclusive terminology and environmental considerations for gender-diverse individuals.

Language/Communication Considerations

• Changes in language is a simple way for all health care workers (including pharmacists and pharmacists’ technicians) to be gender-inclusive in clinical care, health policy, and patient advocacy. A shift to more gender-inclusive language among all health care workers can decrease stigmatization and fear, supporting a psychologically safe environment for gender-diverse individuals.
• All patients should be asked about their pronouns in a manner that makes them feel more comfortable. Pronouns can be stored in their medical record in areas visible and accessible to all staff (clinical and nonclinical) to foster appropriate communication.
• When working through insurance claims, both gender identity and gender at birth may be helpful components to note for benefits.
• Patient education materials should be created to include gender-diverse populations and language for all patients to feel a sense of belonging.
• Use gender-neutral terminology for examinations and procedures, such as preventive care visits instead of well-woman visits.

Environmental Considerations

• Bathroom/changing room signage for a gender-specific bathroom creates an environment that is gender-inclusive. A transgender woman may be more inclined to get a mammogram screening at a facility where a gender-specific bathroom is available.
• Office color and decor may impact one’s sense of belonging. For example, signage designating “women’s space” using the color pink or lots of butterflies may be considered gender-exclusive. Office design schemes can be modified to be more gender-inclusive.
• Signage on rooms for infant feeding can be modified to say “infant feeding room” instead of “mothers’ room” to foster inclusivity.

Fostering an inclusive and affirming health care environment for all individuals, regardless of their gender identity, is crucial for promoting health equity and reducing disparities. By understanding the differences between gender and sex, embracing GAC, and incorporating inclusive language and practices, health care providers can create spaces where individuals feel respected and supported, which can influence various aspects of health care outcomes. As society continues to evolve, it is essential that health care systems adapt to meet the needs of gender-diverse populations, ensuring everyone has access to compassionate and non-discriminatory care. Through education, understanding, and empathy, we can work toward a health care landscape where all individuals can thrive.

REFERENCES

1. Bhatt N, Cannella J, Gentile JP. Gender-affirming care for transgender patients. Innov Clin Neurosci. 2022;19(4-6):23-32.

2. Glossary of terms. Human Rights Campaign. Updated May 31, 2023. Accessed November 21, 2024. https://www.hrc.org/resources/glossary-of-terms

3. Gender incongruence and transgender health in the ICD. World Health Organization. Accessed November 21, 2024. https://www.who.int/standards/classifications/frequently-asked-questions/gender-incongruence-and-transgender-health-in-the-icd

4. Gender-affirming care and young people. US Department of Health and Human Services. March 2022. Accessed November 21, 2024. https://opa.hhs.gov/sites/default/files/2022-03/gender-affirming-care-young-people-march-2022.pdf

5. Get the facts on gender-affirming care. Human Rights Campaign. Updated July 25, 2023. Accessed November 21, 2024. https://www.hrc.org/resources/get-the-facts-on-gender-affirming-care

6. Inclusive language guide. American Psychological Association. Updated 2023. Accessed November 21, 2024. https://www.apa.org/about/apa/equity-diversity-inclusion/language-guidelines

7. Protecting the rights of lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI+) people. US Department of Health and Human Services. Updated June 28, 2024. Accessed November 21, 2024. https://www.hhs.gov/ocr/lgbtqi/index.html

8. Fawbush J. Bostock v. Clayton county case summary. FindLaw. Updated February 28, 2022. Accessed November 21, 2024. https://supreme.findlaw.com/supreme-court-insights/bostock-v--clayton-county-case-summary-.html

9. Moseson H, Zazanis N, Goldberg E, et al. The imperative for transgender and gender nonbinary inclusion: beyond women’s health. Obstet Gynecol. 2020;135(5):1059-1068. doi:10.1097/aog.0000000000003816

10. Stroumsa D, Wu JP. Welcoming transgender and nonbinary patients: expanding the language of “women’s health.” Am J Obstet Gynecol. 2018;219(6):585.e1-585.e5. doi:10.1016/j.ajog.2018.09.018

11. Douglas M, White RT, Sankey K, Gallegos Aragon K. Pharmacist guide for providing gender-affirming care: dispensing and beyond. J Am Pharm Assoc (2003). 2023;64(1):212-217. doi:10.1016/j.japh.2023.10.004