Greetings!
So, I'm going to be talking about the issue of gender binaries and
specifically how some new thinking on
sex, gender, transgender, and non-binary
identities relates to this broader issue
of women's health.
So my goals are to sort of step back and
have us rethink the concept of women's
health and to introduce some of the new
thinking on the gender binary that
changes the way we might view some of
these issues.
I'm going to introduce some
information about the growing population
of individuals who identify as
transgender or non-binary.
And I'm going to talk about why they pose some important
questions that raise implications for
the broader objective of gender-
inclusive approaches to health.
So, many of you (or some of you) might remember
that back in the 1970s was really when
this increased energy and enthusiasm and
activism around women's health really
took place.
This was really
exemplified, I think, in the the book "Our
Bodies, Ourselves" which was written and
distributed by the Boston Women's Health Collective.
And its goal was to really
highlight that women were unique, that
women had unique bodies and experiences
and those unique bodies and experiences
had not been well represented in the
conventional healthcare system and that
there needed to be specific attention to
women with regard to healthcare
provision, with regard to research.
And that is true.
And that movement has
produced really powerful representation
of women's needs and it's
part of the impetus for a conference
like this one, right?
However, there's a
lot of assumptions that go into
even having a conference that talks
about women's health, right?
What exactly makes a woman a woman?
Are we talking
about physical characteristics?
Is it that we're talking about people who have breasts, ovaries, estrogen, and a
uterus and eggs, a vagina, and follicles?
Or are we talking about the broader
experience of being a woman in society?
Which involves exposure to sexism, which
involves coming into maturity and
experiencing menstruation and pregnancy,
your vulnerability to assault and
victimization that certainly is a
worldwide risk that faces women.
And what are the implications of our definition
of "woman" or "healthcare"?
I'm going to pose a couple of examples that
show how tricky these issues can be.
Let's consider Jack. 
Jack is 30 years old
identifies and presents as male, but was
assigned female at birth (AFAB).
Jack has had a
mastectomy, takes testosterone to achieve
a male gender presentation, but still has
ovaries, a uterus, and a vagina.
So, if you want to do outreach about women's health
and women's needs to get screening for
breast and cervical cancer, those
certainly apply to, you know, someone like
Jack, but will that message be effective
if it is framed as a women's health
issue?
In this case, cervical cancer is
not necessarily a women's health issue,
right?
It's an issue for people with with cervixes.
Another example: consider Jane.
60 years old,
identifies and presents as female, was
assigned male at birth (AMAB), takes estrogen,
and has not had genital surgery. 
Jane's family has a history of prostate cancer
and so she should be screened for
prostate cancer, but if Jane receives her
care at a women's clinic that's not used
to treating prostates,
can they really effectively serve her?
And then another example: consider Chris.
Chris is 15 years old, identifies as non-binary or agender--which is a term that is
sometimes used by individuals who don't
identify as either female or male.
Chris uses they/them pronouns--which is
something that is often true of
individuals who identify as non-binary--
and Chris maybe dates both women and men.
Chris goes to the local health clinic for birth control.
The receptionist may have trouble
categorizing their gender if they have an
androgynous gender presentation and
imagine that this receptionist just asks
straight out ,
"Oh what are you? I need to know whether to send you to
someone to give you birth control pills
or someone to give you condoms."
This can be an experience that's
humiliating for anyone in the presence
of an entire waiting room of individuals.
So, the problem here is that our
healthcare system and our entire society
assumes and has long assumed that sex is
a very tidy binary variable. right? 
We all acknowledge that gender is complex and
culturally-constructed, right? 
Gender roles are something that vary from
society to society, but we tend to
presume that there is something
fundamental and essential and permanent
and coherent about "biological sex" and even
when we use the term "biological sex," we
don't often acknowledge that we are
lumping together in that category of
"biological sex" a whole bunch of
different things that aren't the same.
Genes and hormones and body stuff and
body parts and brain anatomy, right?
They're all biological, but they're all
very very different and we tend to sort
of lump them together in this category of
"biological sex."
The problem is that sex is not completely binary.
Even at a biological level, research is
increasingly showing that it's more
accurate to view sex and gender as
mosaics, right?
Where you can imagine
different pieces--like different pieces
of tile--they fit together to produce
something that is understandable as an
entire image, but the little pieces are
not uniform, right?
The extent of sexual
dimorphism--in other words, the existence
of two different forms (male and female)--
that you find in one
biological domain like prenatal hormones,
and adult hormone levels, neurobiological
anatomy, brain structure, brain function.
Dimorphism that you find in one domain
doesn't always correspond the degree of
dimorphism in others.
Basically, this
means that you can be highly female-
typical in one domain, right?
For example: some structure in your hypothalamus that
is typically different in males and
females, but you can actually be more
male-typical in other domains of brain
structure, brain function, hormone
exposure, right?
Now, you see this
mosaicism most clearly in the cases of
intersex individuals who are born with
ambiguous genitalia as a result of
differences in their sexual development.
The most common form of intersex--and
another term for intersex is "differences
of sex development"--is congenital adrenal
hyperplasia, in which babies with an XX
karyotype (so they are
genetically female) have a misfunction
in the adrenal gland that causes them to
be exposed to male-typical forms of
androgens in the womb.
As a result, they are born with genitals that look more
male-typical: an enlarged clitoris, other
forms of variation.
So, you have a mismatch between the genes, the hormone environment, and then the
genitalia, right?
So ,that's a perfect
example of a mosaic: where you have
differences. 
These are individuals that are assigned female at
birth (AFAB) and are raised as girls, but there
are aspects of their development that
are more male-typical.
This mosaicism, although it's most extreme in those
cases, really we're finding that it
extends very broadly to individuals in
the brain and in the body.
And what this means is that 
when we use "biological sex"
to categorize individuals, when we think
of someone as "male" or "female," we're
really using those terms and those
categories as proxy variables or a whole
host of other things in the brain in the
body that usually, but don't always, hang
together in a coherent way, right?
Usually, we can assume that someone categorized
as female has a uterus and follicles and
ovaries and female-typical brain
structure and female-typical
socialization, but that isn't always the
case, right?
So, we're used to treating
"women" as a group and in regard to
"women's health,"
we might say, "oh, women as
a group have a different level of risk for
breast cancer and depression."
And then we lump
that together as a female-typical risk.
But, using sex as a proxy in that way
risks drawing our attention away from
the actual and diverse biological and
cultural causal mechanisms that might
actually be involved in different mental
and physical health conditions, right?
Women may have a higher level of risk for
both breast cancer and depression, but
the mechanisms that confer that risk
might be different, right?
One might be
more biological or might focus
specifically on genetic risk with the
BRACA gene and levels of estrogen
exposure while the other, the depression risk,
have more to do with culture, right?
So, we're better off focusing on the actual
mechanisms--hormone exposure versus
societal exposure say to sexism--than
using sex as a proxy variable that kind
of combines all those needs.
The additional problem with focusing so much on the gender binary is that it leaves a
lot of people out.
A growing number of
individuals and especially, increasingly,
teenagers and young adults, more directly
challenge the gender binary by
identifying as transgender or non-binary.
So, transgender is usually
used to refer to individuals who feel
that their psychological sense of gender
(their gender identity) doesn't match
their birth-assigned sex, a sex to
which they were assigned at birth. 
That's typically what transgender refers to.
Other individuals, some of whom
will identify as transgender and others
may not, may feel that they are both male
and female, neither male or female.
These individuals often identify as genderfluid or agender or non-binary.
Now, you may be assuming this is a
really tiny part of the population and
so, do we really have to overhaul the way we think about gender and healthcare system
for such a small population? 
It's a larger population than many people
realize.
We now have good, representative
data on this and in the United States,
the overall prevalence of transgender
adults is about 0.6% (so less than 1%), but
that equals over 1 million individuals,
about 1.5 million adults.
The prevalence for youth is even higher.
Representative surveys of youth have
found that among individuals between 18
and 24, prevalence rates are 7%, sometimes 8%,
depending on the state.
Among those aged
55 or older, the prevalence is lower: 0.5%.
Among teens, representative surveys have
found a prevalence rate of 1.8%, which is
over twice the rate of young adults 18
to 24 and, if you ask a teenager
specifically whether they
identify as transgender or genderfluid or
non-binary, the prevalence rate gets even
higher (up to 3%).
So, this is a far larger
population than most people think
especially among youth.
Just to give folks a sort of primer with regard to
terminology, because a lot of people are
like, "I don't even know what terms to use
and terms keep changing" and it's true
terms keep changing.
Generally,
"transgender" is used to refer to the
entire spectrum of individuals who
experience some sort of difference
between their internal, psychological
sense of gender and the sex to which
they were assigned at birth.
That term
"assigned at birth,"
is what is typically
used instead of the term "biological sex"
because, as we now know, biological sex is
not so unitary--it's kind of a complex
construct--and so instead of saying
"biological sex", we say "sex assigned at birth"
and, typically when doctors say
"it's a boy or it's a girl,"
they don't know anything about that
child's prenatal hormone exposure or
brain structure.
They're looking at one thing--typically the genitals--so that
assignment is made on a relatively
limited piece of information.
Instead of biological sex, it's now more
common to talk about a birth assign sex
or sex assigned at birth.
Trans (adj.) is a
shorthand for "transgender" that's often
used as well when someone has a female
or feminine gender identity, they will
often identify as trans feminine so when
you hear something like trans female or
trans male, that term is referring to
their gender identity not the
sex to which they were assigned at birth.
So, someone who transitioned from a
male to a female identity would be
called trans female or trans feminine.
I really already covered why do
you talk about sign sex rather than
biological sex.
Then there are intersex
conditions that I mentioned, like
congenital adrenal hyperplasia, those are
sometimes called "intersex", sometimes
called "differences of sex development"
(which is often abbreviated as DSC).
Then
there's a growing population of
individuals who identify as non-binary,
agender.
Sometimes they call it "genderqueer," meaning that they
don't identify with either male or female. 
Some of those individuals would count
themselves among the larger trans
population, others would not, so there's a
lot of variability there.
And then the term "cisgender."
(and cis female and cis male)
are now used to refer to what used
to be considered "normal" men and women.
We want to question the whole
notion of "normality," but someone whose
gender identity fits the sex to which
they were assigned at birth would be a
cisgender individual.
So, I am a cis female. I was assigned female at
birth (AFAB); I have a female gender identity.
I'm a cis female.
So, with regard to healthcare, one thing that is
sort of important to keep an eye on is
is the growth in efforts to
provide gender-affirmative care.
In other words, healthcare that treats someone
with respect to their preferred, chosen
gender identity, so that instead of
having a transgender individual come in
and saying, 
"I don't care what you call yourself,
what are you biologically?" 
That would be, obviously, not a very hospitable healthcare
interaction for a
transgender individual.
So, instead
there's a movement to really try to
provide gender-affirmative care that
affirms individual, psychological sense
of gender and that can provide hormones and
interventions that can help them achieve
their desired a gender identity presentation.
We used to talk about "sex reassignment
surgery," in which individuals underwent a
whole host of medical procedures to
switch from one gender to another.
The problem there is that there are many
trans individuals who don't necessarily
want to go all the way from one end of
the gender binary to the other.
They may have a more nuanced sense of gender.
They may not feel strongly about altering
their genitals, but they may want to
alter their appearance with hormones.
So, gender-affirmative healthcare
usually involves an interaction with the
individual to figure out what their
preferred gender presentation is and
what are the best means to achieve that
gender presentation.
So, instead of "sex reassignment" as a unitary set of
procedures, there's a broad range of
interventions that a trans individual
may want to pursue.
Then, there's treatment for intersex individuals.
This is an area
that, over the years, has been
really controversial because there was a
lot of surgery done on infants that
parents didn't necessarily know a lot
about and the infant' is obviously not
consenting and there has been a movement
to really be a little bit more patient
and conservative about genital surgeries
on infants to obviously promote
effective urinary function and
things like that, but to be a little bit
more conservative and patient about
doing any surgery that is intended to
simply change the appearance of genitals
in order to satisfy sort of cultural
norms about what females and males look like.
So, there's been I think a
greater sensitivity to non-binary
notions of gender when it comes to
treating those differences of sex
development.
Many, especially youth who
are questioning their gender identity
and who see a therapist, will often be
diagnosed with gender dysphoria.
This was
a big change in the Diagnostic and Statistical
Manual of Mental Disorders.
It used to be
that there was something called "Gender
Identity Disorder of Childhood" and that
was replaced by a diagnosis of "gender
dysphoria" and one of the reasons for
that change was to move away from
pathologizing gender identity issues and
to have a way to describe this
experience of a conflict between the
sex to which we were assigned at birth
and our psychological sense of gender,
but to allow for the fact that some
individuals are distressed by that and
some individuals are not.
The mismatch itself need not be
disruptive or causing any sort of
distress, but for the individuals for whom it
does cause distress, that's what can
provoke a diagnosis of gender dysphoria.
One of the, sort of, paradoxes here (as
with all diagnosis) is that although
being diagnosed with a mental health
condition has the sort of smell of
pathology in our healthcare system,
that's often what provides a rationale
for insurance coverage for therapy and
treatment.
So, we see that paradox, I think,
in a lot of mental health conditions and
it's definitely one that's relevant to
the area of healthcare for trans and
non-binary individuals.
A lot of controversy exists regarding
the treatment of youth with transgender
or non-binary gender identities.
You often hear in the media this sort of
sense that, "oh my god,
doctors are pushing young children to
transition at very early ages!"
That is certainly not the case.
Pediatricians who treat children who are experiencing
gender dysphoria tend to be extremely
conservative with regard to treatment
because many of those children will
experience changes in their sense of
gender as they get older.
It's only among
children who have a pervasive and
consistent and distressing experience of
dysphoria that doctors
typically think about transition.
And transition is usually the last resort
and something that's not typically
undertaken until older ages.
A more common approach that's taken with such
children is to administer hormones that
will delay the experience of puberty
right.
If you've got a child who is
persistently experiencing gender
dysphoria from a very early age ,as they
approach puberty, you can administer
hormones to slow down that process, to
give the child and the family more time
to think and consider gender issues.
That's a reversible treatment. 
So far, the studies have found it to be safe but,we
don't have a lot of long term follow-up
studies, which is why it continues to be
controversial.
I should note that there
are currently 6 states that are trying
to ban all gender-affirmative care for
minors, even if their parents consent, so
there is a lot of public health
controversy regarding the treatment of
these youth and it gets wrapped up in a
lot of political domains and that's
something to keep in mind.
So, I think the implications of all of this
is that there are really two big
problems when we apply apply a binary
approach to healthcare.
The first is, obviously, that we're failing to serve a
large and growing population of
transgender and non-binary individuals.
But the second is more subtle: that
relying on the gender binary
leads to habits of mind that force us to
prioritize gender categories over other
things that may be going on with a
particular person's health and that
doesn't always lead to effective healthcare and effective policy.
So what should we do?
I think one thing that all
healthcare providers can do is take a
second look their own forms and
procedures and materials and practices
to make sure that they're inclusive.
To imagine how the transgender
or non-binary individual
would experience them.
And to really ask,
"what aspect of sex or gender really
matters to the healthcare that I'm
providing?"
"Is it calling my attention to
something relevant? Is it distracting me
from other causal mechanisms that I
should focus on? Is there a way that I
can be more specific in my language,
instead of referring to women? To just
focus on what exactly am I looking at? Am
I looking at individuals
with with a cervix and a uterus?" 
Things like that.
I think another example is family
violence; typically primary care
providers are accustomed to asking women if
they've experienced violence in their
home.
Well, why aren't we
asking men that question?
Are we making some some inappropriate
assumptions about who is even exposed to
violence and who should be asked about it?
So, the conclusion...
I'm not here
to say that we shouldn't even talk about
women's health anymore.
There's a broader
role for this attempt to really
focus on what sex and gender do in
someone's life to change their health
risks and their health experiences, but
we need a more gender-inclusive approach.
One that really takes a critical look,
meaning at the mechanisms of gender in the mind in the body.
And *that* will provide
more affirmative care for trans and
non-binary individuals and it will
also provide better healthcare for all
individuals.
Thank you so much.
I greatly look forward to your questions.
