Gender and the Medical Cis-tem

Written by Asiel Adan Sanchez as part of the FWF2020 ThinkIn, The Politics of Health.

There are two ways of entering the medical system:

  1. Male
  2. Female

Medicine is not built for bodily and gender diversity. Despite decades of research telling us otherwise, medical systems and ways of thinking are underpinned by the view that a person’s gender reflects their sex and vice versa. This is taught in medical school: in anatomy, physiology, endocrinology, reproductive health, obstetrics and gynaecology (often all placed under the umbrella of ‘women’s health’). This notion is reinforced as doctors progress through their careers: in hospital, in clinics and in healthcare services. Anyone that ticks the ‘female’ box will automatically be assumed to have a uterus and its associated anatomy, use she/her pronouns, and often assumed to have a male partner. In turn, these influence and dictate clinical thinking, physical examinations, tests, scans and medications doctors make available to patients.

This process begins as soon as a baby is born, with the prevailing question ‘is it a boy or a girl?’ It becomes the defining moment where a person’s sex and gender become inexorably reduced to one entity. If the medical professional — and it is often a medical professional — sees a penis and two testes, one is deemed a boy; it is a boy’s body that will grow up to do boy things. A lack thereof then signifies a girl. As such, doctors rarely consider the possibility that a perfectly healthy uterus might belong to a perfectly healthy man. In one swift declaration, the multiplicity of possible experiences is silenced, pathologised and/or deconstructed to reproduce either a male or female physiology.

Of course, the question of what constitutes someone’s sex or gender is never as clear-cut as conventional medicine would like it to be. Wherever medicine attempts to define binary sexual characteristics, there are a constellation of variations that prove otherwise. Genitals and reproductive organs can develop in myriad ways outside of the typical anatomy we come to expect of ‘male’ and ‘female’. Same goes for hormone profile; for example, individuals with congenital adrenal hyperplasia might have testosterone levels similar to those produced by testes, despite the presence of ovaries. These are known as intersex variations, which refer to physical sex characteristics that don’t fit medical and social norms for female or male bodies. This can happen at anatomical, genetic or hormonal levels, and sometimes all at once. Even a person’s chromosomal make-up — long thought to be the basis for binary biological sex categories — exists outside simple dichotomies. Genetic variation allows for myriad configurations of X and Y chromosomes (XXY, XO, XYY), and in rare instances, a person might have a mix of cells across their body that contain either XX or XY chromosomes.   

Likewise, an individual’s relationship with their gendered body is complex. For transgender and gender-diverse individuals, the label given at birth does not match their identity, expression, or sense of self. This can be both deeply personal and heavily influenced by the society we live in. For some, their gendered body becomes an ongoing source of tension, out of an internal sense of distress and/or out of others’ expectations of what it should be. Some seek medical support to be in harmony with who they are; others are content with their physical attributes and affirm their gender in different ways.

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Intersex variations and gender diversity seem to fundamentally be at odds with how doctors practice medicine. To be adequately informed requires clinicians to unlearn years of training and foundational knowledge. All those hours in medical school — memorising anatomy, reproductive health, gendered differences — have to be revised through a new lens and re-considered in a new language. Doctors have to be comfortable with challenging the binary framework of western medicine they were brought up with, and extend that understanding to their clinical practices and the healthcare system they are working in. Anything from intake forms to reference ranges to clinical reasoning are thrown into question, often with little guidance on how to go about doing it.  

At present, there is no formally recognised pathway for doctors to upskill themselves on gender affirming care. A 2017 survey of medical school curriculum administrators in Australia and New Zealand indicated that 60 per cent of medical schools only dedicated up to five hours of study to LGBTIQ health in pre-clinical years. What’s more, most of this content focused on same-sex sexual activity, with nearly half of all curriculum administrators being unsure if trans and gender-diverse sexual activity was covered at all. Similarly, a 2019 survey of endocrinologists (medical specialists who typically manage hormone replacement therapy for trans and gender-diverse individuals) suggested only 19 per cent felt confident providing clinical care to trans and gender-diverse individuals.

So while it is safe to say that the vast majority of doctors practice medicine with the patient’s best interests at heart, the nuances of people’s lived experiences often fall outside the scope of their clinical training. The number of health professionals who practice with outright bigotry are, for the most part, a rarity. Rather, their prejudices are a reflection of societal ignorance and wider systemic issues in medical systems. For example, until very recently, common medical administration software was unable to differentiate between sex assigned at birth and gender. This meant that even well-intended doctors could not distinguish between the two, and would often need to use a patients’ dead name in medical forms or referrals.

Even open-minded health professionals who wish to create a welcoming environment struggle with the practicalities. Though they may understand the concept in theory, very few know what inclusive practice actually looks like. Do I ask every single patient about their pronouns? How can I best support my patients through their gender affirmation? The function of the status quo means that doctors are trained to assume everyone is straight and cisgender. This seemingly innocuous assumption can have a detrimental impact on access to healthcare.

Undoing the impact of these beliefs involves restructuring years of training and unlearning deeply ingrained habits. And it is only in recent times that the medical profession is coming to realise that their teaching frameworks come from a white, colonial, patriarchal, cisgender and heteronormative lens. Until these aspects of a flawed medical system are actively questioned as part of a human rights-based approach to medicine, doctors will continue to be inadequately prepared to deal with the diverse lived experience of their patients.

Simply navigating hospital admin is ridden with many structural violences which actively work against patients who don’t fit the ‘default’ experience. Inconsistencies between Medicare records and patient charts can lead to double-ups, errors, misgendering, awkward questions and inappropriate remarks. For trans and gender-diverse patients, getting the care that they need might mean outing themselves to the rest of the hospital staff, restricting access to services or having their gender repeatedly questioned. It requires a type of self-advocacy and resilience we should never expect of patients in need of care. With the amount of doctors involved in a patient’s care, confidentiality is never fully guaranteed. It is simultaneously invalidating and riddled with scrutiny.

When I asked one of my good friends, who is trans-masculine, about how he went about navigating all the barriers set in place at the hospital, he laughed and rolled his eyes.

‘If the place has only two options for sex or gender, I disengage,’ he said. ‘You’ve lost me already.’

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The function of the status quo means that doctors are trained to assume everyone is straight and cisgender. This seemingly innocuous assumption can have a detrimental impact on access to healthcare.

It’s impossible to isolate medical practices from the wider society it operates in. If society continues to prioritise whiteness, cisgenderedness and heteronormativity, then the medical system will continue to regard them as the default experience. Creating lasting change in any area of social inequity is difficult: getting such an interlaced system of knowledge practices, legalities and services to transform in a way that benefits trans and gender-diverse people takes tremendous effort and patience. The pace can be frustratingly slow; doing so requires multiple moving parts to shift.

Despite these hurdles, there have been relentless work from the intersex, trans and gender-diverse community to make their voices heard. Currently, there are a number of initiatives centering trans and gender-diverse voices in shaping the care that they receive. One such example is Equinox, a gender-diverse health centre in Fitzroy. They recently released a new update of the Informed Consent Guideline, which was created with significant input from members of the trans and gender-diverse community, and seeks to transfer medical support for gender affirmation from specialists to general practitioners. This is a huge step forward in terms of improving access to healthcare for trans and gender-diverse individuals – it not only minimises wait times in terms of accessing medical affirmation, but also steps away from a pathologising narrative around gender identity.

It is only in recent times that the medical profession is coming to realise that their teaching frameworks come from a white, colonial, patriarchal, cisgender and heteronormative lens. Until these aspects of a flawed medical system are actively questioned as part of a human rights-based approach to medicine, doctors will continue to be inadequately prepared to deal with the diverse lived experience of their patients.

Thanks to the advocacy efforts of the wider trans, gender-diverse and intersex community, the next generation of doctors is becoming increasingly aware of the gaps in the curriculum. Medical students are beginning to recognise that medicine goes beyond bodies, treatments and diseases. For example, a policy document from the Australian Medical Student Association — the peak representative body for medical students in Australia — suggests that students think LGBTIQ health is important and would like more education on the topic than they are currently receiving. Similarly, medical students are taking self-education into their own hands by creating community-led resources and educational opportunities.

In order for this progress to have the reach and impact it deserves, medical schools need to make space in their curricula for a human rights-based approach to medicine – in particular, one that gives significant weight and focus to marginalised communities and populations, recognising the impacts of structural violence on the health of individuals. This curriculum must be constructed from the ground-up in collaboration with members of each community. It involves a certain humility, a coming down from the ivory tower of academia, not to mention placing value in lived experience. This means inviting community to the table and allowing them to shape the healthcare they are to receive. While in the process of learning about the underlying scientific principles behind disease and treatment, medical schools must acknowledge that when it comes to care and communication, our patients are our best teachers.  

Through a number of national programs that work with existing clinical practices to help provide better healthcare, it has been shown that efforts from community members in educating health professionals have led the way in medical reform. LGBTQIA doctors and medical students themselves are opening up spaces, re-educating their peers and challenging the systems they work in, whether that’s through informal peer networks, self-education, trial-and-error or self-advocacy from community groups and organisations. Health professionals who are intersex, trans or gender-diverse are calling out both direct and indirect discrimination. Medical students are organising their own educational initiatives and pushing for the addition of inclusive training into their medical schools.  

While in the process of learning about the underlying scientific principles behind disease and treatment, medical schools must acknowledge that when it comes to care and communication, our patients are our best teachers.

If equality in healthcare is to be achieved, this kind of widespread systemic change needs to happen across all healthcare sectors. Each one is its own battle, but small, quiet milestones will be reached: clinics will allow patients to define their own gender on their intake forms; intersex will stop being treated as a disorder and more as a variation of bodily diversity; trans and gender-diverse patients will be able to get the care they need regardless of the service they walk into. There might not be a parade to celebrate, no float in Mardi Gras, no speech by Penny Wong. In time though, these little victories will add up and sex and gender will have little to do with the quality of care one receives.

Asiel Adan Sanchez (they/them) is a doctor, writer and academic working in Naarm/Melbourne. Born and raised in Mexico, their work explores the intersection between gender, culture, sex and identity. Their work has been featured at the Emerging Writers’ Festival and in Archer MagazineVoiceworks and Rabbit Poetry, among others.

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