Module 204 Symposium: Sex and Gender PDF

Module 204 Symposium: Sex and Gender Dr Duncan Shrewsbury (they/them) Reader in Clinical Education & Primary Care [email protected] Learning objectives By the end of this session, learners should be able to 1.Differentiate what sex and gender are 2.Use the different terminology used when refer...

Module 204 Symposium: Sex and Gender Dr Duncan Shrewsbury (they/them) Reader in Clinical Education & Primary Care [email protected] Learning objectives By the end of this session, learners should be able to 1.Differentiate what sex and gender are 2.Use the different terminology used when referring to diverse communities and genders 3.Manage scenarios in which sex and gender are important to health 4.Articulate the barriers affecting trans and gender diverse people when accessing healthcare 5.Examine the health issues that disproportionately affect trans and gender diverse people 6.Adapt practices to be more inclusive In covering these objectives, we will explore The classification of gender and gender diversity Children, development, sex and gender Gender diversity in clinical communication and practice Genetics and sex Rough timings: Time 9am 9:05 9:25 9:40 9:55 10:15 10:30 10:50 11:10 11:30 Thing Intro etc Gender, construction and diversity Introducing sex and gender in clinical contexts Gender identity and pronouns Barriers faced by transgender people Inequalities in health BREAK (20 mins) Experiencing barriers and inequity – patient voices Queer healthcare – a patient’s story Inclusive practices: hints and tips 🚨 Content Warning 🚨 In this session, we will draw on data that speaks to violence and hatred towards marginalized groups, including women, trans and gender diverse people, and the LGBTQIA+ community. Sexual wellbeing, and practices, feature in discussion. I want everyone to feel safe to learn and grow in this space. I invite respectful questioning, challenge and discussion of everything I bring to this symposium. Acknowledging context This is a contested space Fears and concerns Polarized views and discourse Valid concerns about safety of vulnerable groups 1 in 4 women experience gender-based violence In 2017 5.1 million women in UK experience before age of 16 48% homicides perpetrated in relationship Estimated 75% rate of non-report Embarrassment Wouldn’t be believed Violence, abuse and trauma normalized Women systematically and structurally disadvantaged in society Androcentric Heteronormative Binary norms Hierarchical Easier to ‘other’ and ‘abnormalize’ Rise in anti-trans/LGBT crimes (2018 – 2021) 41% transgender + 31% NB people faced hate crime in 2017-18 25% TGD youth experience homelessness 28% experience intimate partner violence (EVAWG, 2021; ONS, 2021; McLean, 2021; Galop, 2021; Stop Hate, 2021; TransActua Gender Construction & Identity Sex and Gender in Clinical Contexts Sex, gender and biology The concept of gender identity confused and conflated ‘biology’, sex and gender used interchangeably as all being fixed and binary immutable and unchangeable Chromosomal sex usually XX or XY >1/500 have a variant of this: Turner’s (X), Klinefelter's (XXY, XYY) mosaicism 1-2/10,000 Biological sex comprises more than just chromosomes, though: genetic expression, hormones, gonadal development and appearance, secondary sexual characteristics https://www.youtube.com/watch?v=pFHVV_GcykI Sex throughout the body 'Brain’ sex: Total brain volume is greater in men Percentage grey matter is greater in women Blood flow greater in women Regional differences less consistent The developing brain has an immense capacity of neuroplasticity Psychological sex: Is this the way we think of ourselves, or the way we think of others? Is this to do with the way brains work differently to men from women? Or the way that men think differently from women? Or is this referring to internralised construct of gender identity? ‘neurosexism’ - different genders are treated differently, on the basis of assumptions of how their brains may work, which in tern lead to learned behaviours which do impact on brain activity and development Sex throughout the body ‘Hormonal sex’ / Primary sexual characteristics: Appearance of genitals from birth Secondary sexual characteristics: Pubertal development of Hair (growth and loss) Breast tissue Voice, larynx Fat distribution Muscle Hormonal profiles Are these distinct and rigid? ‘normal’ exists on a spectrum itself Chromosomes, genes and expression… What chromosomes you have does not necessarily always determine your ‘sex’ Sex is determined by appearance of external genitalia at birth No routine karyotyping at birth Gene expression affects appearance and development CYP21A2 gene mutation: 21-hydroxylase deficiency (1 in 15,000) AR gene mutation (1:20,000) SRD5A2 gene mutation: 5-alpha-reductase deficiency (unknown) AMH / AMHR2 gene mutation Guthrie test does not detect any of these conditions Ambiguity in sex and sexual development Intersex 2-4% of live births Usually arising from one of the genetic mutations above resulting in differential expression in utero ‘hermaphroditism’ or ambiguous external genitalia Turners (X0), androgen insensitivity syndrome, Kleinfelters (XXY), CAH Uncommon, yes, but not insignificant For comparison: 1-2% of human population have red hair Gender Identity & Pronouns Microaggressions Are verbal and nonverbal behaviours Communicate negative, hostile, and derogatory messages to people Rooted in marginalized group membership Occur in everyday interactions Can be intentional or unintentional Are often unacknowledged Brief, everyday exchanges that send denigrating messages to certain individuals because of their group membership (Wing-Sue, 2010) Deadnaming… Referring to someone (usually a trans person) by their former name, rather than their chosen name No requirement for Gender Recognition Certificate, or to prove ‘trans enough’ Risks ‘outing’ or disclosure Gender Recognition Act (2004): ‘it is an offence for a person who has acquired protected information in an official capacity to disclose the information to any other person’ Exceptions for clinically and legally relevant reasons exist Barriers and Inequalities What does it mean to transition or be trans? Trans = gender identity other than Social transition: that aligned to sex as assigned at birth Separate from sexuality Can involve efforts to align appearance with internal sense of gender identity: Social Medical name, pronouns appearance and sound affirming hormonal treatment ‘blockers’ pausing puberty Surgical ‘top’ and ‘bottom’ surgery facial feminization surgery Cass review interim report: ‘not a neutral act’ In the context of heavily loaded cultural norms May have implications on physical health, e.g. Binders: can cause pain, and damage to skin best to limit to 6-8hrs a day specifically designed garments Tucking: tape or garments, again can damage tissue – impact on bottom surgery options (Cass, 2021) How is this relevant to us? 1) Our profession has been implicated in the pathologisation of difference and diversity in terms of gender and sexual identity note 1 in 20 people who underwent socalled ‘conversion therapy’ had it done by a healthcare professional 2) Our language alludes to our beliefs and assumptions These can influence the relationships we build with our patients and communities We need to be conscious of our position of power and privilege Our practices shape what is and isn’t socially acceptable Specific healthcare needs 2-5x increased rates of depression 10x rates of suicidality and suicide Mental health and trauma-aware approaches Tissue-based screening initiatives Awareness of diverse forms of family and relationship Avoid being (unintentionally) exclusory or prejudicial Transgender patients Estimates around 6-400/100,000 Likely massive under-estimate Depends on how (and who) defined Specific healthcare needs Greater rate of trauma Transgenderism is not itself a mental illness Often occurs alongside gender dysphoria Other mental health morbidity alongside is greater Potential for missed tissue screening Trans men with a cervix or endometrium No national strategy to mitigate risk Hostility of UK towards trans community Safety, holistic wellbeing, community support (Trans Lives Survey, 2021 Gender Identity Services Multidisciplinary team Psychiatry, psychology, endocrinology, surgery, SALT Direct referral from GP to GIC / GIDS No other opinion needed beforehand 13 in UK: 7 in England 4 in Scotland 1 in NI (Belfast) 1 in Wales (Cardiff) “18-24” month wait for first appt www.gic.nhs.uk Not a one-way street! The process of transitioning involves exploration of identity and what supports and affirms a positive sense of self, and what does not. This can mean: Trying one form of treatment Realising this doesn’t contribute to identity Discontinuing this treatment This is not the same as detransitioning or transition regret Medical interventions: Suppress biological-sex hormone function ‘Blockers’ GnRH analogues Finasteride or spironolactone ‘Cross Affirming hormones’ Follows pubertal sequence Can take years to see some effects Not accelerated by higher doses Considered largely reversible (90%) Limited data, but experience suggests Less so with breast tissue Uncertainty around fertility Only small proportion seek surgery Some concerns re: bone mineral density Of this, even fewer seek ‘bottom’ surgery Contraception! Don’t assume sexual orientation or practices Wide variety Not all have surgery Amenorrhoea does not guarantee anovulation! If they retain uterus and have receptive penetrative sex with people who have a penis: Offer coil (lowest dose) or depot Progesterones don’t ‘counteract’ T Not known to feminize trans men Important opportunity to consider Sexual wellbeing as well as sexual health Sexual health screening Greater rates of undiagnosed HIV (~30%) Pre-exposure prophylaxis Truvada, licensed for daily dosing Vaginal tissues take 7 days to achieve therapeutic concentrations! Event-based dosing not appropriate Worth noting… Non-binary: Are included within the transgender definition Unknown with regards to risks and where they ‘fit’ in the data No evidence relating to hormonal treatment and physical or mental health Children and adolescents: Some data linking blockers to improved mental health In the UK, NHS practice takes a very long time, and begins with complex MDT assessment and input from psychologists Blockers ‘press pause’ on puberty Some concerns about impact on bone mineral density Believed to be reversible when discontinued, although long-term data missing, and concerns about impact on fertility Other healthcare considerations: National cancer screening programmes May be lost to recall if change gender marker Change in gender marker can be achieved by applying directly for a new NHS number Do not need GRC Practice manager in GP surgery can help NHS numbers are gendered and linked to screening programmes Minimal evidence in this area, but guidance on likely best practice informed from specialsit experience Trans women: Mamography after 5yrs on hormonal Rx Programme >50yrs Also consider DXA after 60yrs Trans men: May still have breast tissue even after surgery, so consider mamography If retains uterus and cervix Cervical screening May need assistance (e.g. diazepam + lidocaine ointment) 2 to 3-yearly USS of uterus DXA after 60yrs Break! Experiencing Barriers and Inequity Inclusive Practices Inclusive care Inclusive practices Consider environment What implicit signals of heteronormativity are there Allyship Active bystander Reflective of privilege Use it to support and platform others Inclusive clinical practice Pronoun awareness She/her/hers He/him/his They/Them/Theirs Xe/Xem/Xyrs Environmental cues Unnecessary gendering Single-occupancy bathrooms Language: Instead of Ladies and Gents  Hello Everyone Mistakes, microaggressions and miscategorisations: It is easy to make mistakes. ‘Honest’ mistakes come with a desire to repair and improve, an openness to feedback Microaggressions are brief, everyday exchanges that send denigrating messages to certain individuals because of their group membership (Wing-Sue, 2010) Miscategorisation is wrongly assigning something (e.g. gender identity / sexuality) to someone, and is often met with ‘passing’ responses Check out: GenderedIntelligence.co.uk, and MyPronouns.org Intervening Recognizing a potentially harmful situation or interaction and choosing to respond in a way that could positively influence the outcome Being an ally does not mean jumping in at the heat of the moment The psychological and physical safety of yourself and victim is paramount What action would be helpful? When would it be most constructive? The aim of action is generally to be: supportive, restorative to victim, and to initiate a change in behaviour in system Start with understand yourself better: 1. your own sense of identity 2. your own beliefs and values, and how these may impact on your practice 3. work out what you feel awkward or inexperienced about, and actively practice vocabulary and approaches to topics