The Equality and Human Rights Commission (2011) report[i] indicates that “at least 1.3% of the UK population is in some way transgender or gender variant”[ii]. The significance of this figure is revealing as it shows a less conspicuous element of the already diverse background of the UK population which is often overlooked: gender diversity.
A strong indication of the wide spectrum of gender diversity is given by the online worldwide survey conducted by “Gender Census 2019”. As the graph below shows, the participants “whose gender doesn’t tidily fit into the female/male binary” [iii], described themselves with a multitude of “identity words”.
Within healthcare, awareness about the diverse demographic background of service users is crucial as it demonstrates genuine interest for the individual which is the cornerstone of person-centred care. Ensuring that all people irrespective of their gender are treated equally, is at the heart of the public health strategy to reduce health inequalities [iv].
During their career, staff in healthcare services will come across people who experience emotional discomfort as a result of what is medically called gender dysphoria (GD). GD is the distress a person experiences because of the mismatch between the gender they identify with and the sex they were assigned at birth[v], for instance when a person born female, identifies as a man later on in his life.
Although the causes of gender dysphoria vary, what matters is the person’s mental health and wellbeing. Offering support and signposting people to the right services should be the priority for all healthcare staff.
In the UK there are currently eight gender identity clinics that offer treatment, guidance and help people who wish to proceed with transitioning.
The term transitioning is used to describe the changes that a person undergoes to become closer to the gender they feel comfortable with and eventually “to live full time according to their affirmed gender, in all aspects of their life[vi]”.
Transitioning can be social which means changing how one appears and acts in the world, or medical which in practical terms involves changing one’s physical appearance (including their genitals). Medical transitioning involves hormone treatment and it can be an emotionally challenging experience. Notably, part of transitioning includes changing your name, gender and title on official documents[vii].
The Royal College of Nursing created an “easy to read guide” for everyone who works in healthcare and would like to initiate and encourage positive conversations around gender identity and transitioning.
Mental health and LGBT community
LGBT in Britain – Health Report by Stonewall states that “LGBT people are at a higher risk of experiencing common mental health problems than the general population”[viii]. Sadly, suicidal thoughts among LGBT+ young people are worryingly high according to the “Centre for mental health” [ix]. This evidence highlights the need to adopt a more inclusive and reassuring approach when we look after LGBT people. More training about equality and diversity has also been identified as central in tackling inequalities in healthcare[x].
Clarifying some terms
A common barrier for staff working with trans service users is the confusion caused by some of the terminologies; the Stonewall’s glossary is a great starting point. Here, we will try to demystify some of the most prevalent terms:
Trans/transgender: it’s a broad term that describes people who do not identify with the gender they were assigned at birth. It’s worth noting that, a person is transgender not just because other people assume this based on stereotypes about appearance and gender but because it is the person’s decision to identify with a gender different from the one given at birth.
Binary and non-binary: the binary system classifies people under the main categories of men and women. Anything else between “male” and “female” is non-binary and this can include a variety of gender identities as the graph above shows. (Gender Census 2019).
Cis/Cisgender are the vast majority of the population and their gender identity is the same as the sex they were assigned at birth. Non-trans is also used by some people (Stonewall glossary)
Pronouns: they are the personal pronouns that we use instead of someone’s name such as he/his, she/her and gender-neutral ones such as they/them, xe and ze which are used by non-binary people. For more information about pronouns check out these resources for personal pronouns. An excellent example of best practice is a “pronoun preference” as part of the way people sign off a document or an email -something that you have probably noticed in my signature above.
Gender identity and sexuality
Gender identity should be seen separately from sexual orientation. The latter is an identity on its own with variations and nuances that indicates who we are attracted to. Gender identity and sexuality are distinctive concepts. A person’s gender doesn’t define their sexuality. Have a look at the “genderbread person” below to see how the different identities (gender, sexuality or attraction, biological sex, etc) express different characteristics:
Using the right pronoun
Reflecting on my own experience working in healthcare settings I have observed that the incorrect use of the preferred pronoun has often caused distress to transgender people under our care, for example using he/him to refer to a trans woman and vice versa. This mistake is very significant: it could be a flashpoint for people who struggle with gender dysphoria and subsequently give rise to unpleasant feelings and lead to loss of trust; something that could jeopardize the therapeutic relationship between staff and service users.
In practice, and to keep in line with an open, holistic and person-centred approach, it is best to ask a transgender person which pronoun they would prefer to use when we refer to them[xi]. Patient information forms across healthcare should include more options for gender identities and pronouns. A small change like that would have a huge impact on our service users as it would show that we are aware and we genuinely care about them.
UK LGBT+ history month
February is the UK’s LGBT+ history month. Let’s see this month as an opportunity to learn more about both the history and the needs of the LGBT+ community. We aim to create respectful and caring relationships with service users and this can be achieved only when we fully understand their needs and what matters to them. Our hope is that this blog will add a little to everyone’s knowledge about gender identities and you will go on to explore the rich history of the LGBT+ community. A little goes a long way!
RCN trans easy guide
Mental health org: https://www.mentalhealth.org.uk/statistics/mental-health-statistics-lgbt-people
Human rights campaign foundation: https://suicidepreventionlifeline.org/wp-content/uploads/2017/07/LGBTQ_MentalHealth_OnePager.pdf
LGBT in Britain – Health: https://www.stonewall.org.uk/lgbt-britain-health
Guidelines for Psychologists Working with Gender, Sexuality and Relationship Diversity: https://www.bps.org.uk/news-and-policy/guidelines-psychologists-working-gender-sexuality-and-relationship-diversity
[i] Meera Balarajan, M., Gray, M. and Mitchell, M. (2011). Monitoring equality: Developing a gender identity question. 1st ed. Equality and Human Rights Commission.
[ii] Practical Androgyny. 2019. How many people in the United Kingdom are nonbinary? – Practical Androgyny. [ONLINE] Available at: https://practicalandrogyny.com/2014/12/16/how-many-people-in-the-uk-are-nonbinary/#ehrc-gender-identity. [Accessed 09 December 2019].
[iii] Gender Census. (2019). Gender Census 2019 – The Full Report (Worldwide). [online] Available at: https://gendercensus.com/post/183832246805/gender-census-2019-the-full-report-worldwide [Accessed 28 Jan. 2020].
[iv] GOV.UK. (2018). Health equity. [online] Available at: https://www.gov.uk/government/collections/health-equity [Accessed 21 Jan. 2020].
[v] Vincent, B. and Lorimer, S. (2018). Transgender health. JKP, pp.17-37.
[vi] Vincent, B. and Lorimer, S. (2018). Transgender health. JKP, pp.17-37.
[vii] Transgender an easy read guide. (2018). [ebook] Royal College of Nursing. Available at: http://Vincent, B. and Lorimer, S. (2018). Transgender health. JKP, pp.17-37. [Accessed 29 Jan. 2020].
[viii] LGBT in Britain health report. (2018). [ebook] Stonewall. Available at: https://www.stonewall.org.uk/system/files/lgbt_in_britain_health.pdf [Accessed 21 Jan. 2020].
[ix] Children and young people’s mental health: the facts. (2018). [ebook] Available at: https://www.centreformentalhealth.org.uk/sites/default/files/2018-09/CentreforMentalHealth_ChildrenYoungPeople_Factsheet.pdf [Accessed 28 Jan. 2020].
[x] Hunt, R., Bates, C., Walker, S., Grierson, J., Redsell, S. and Meads, C. (2019). A Systematic Review of UK Educational and Training Materials Aimed at Health and Social Care Staff about Providing Appropriate Services for LGBT+ People. International Journal of Environmental Research and Public Health, 16(24), p.4976.
[xi] BBC. 2019. BBC Radio 1 – BBC Advice – Trans People On Pronouns. [ONLINE] Available at: https://www.bbc.co.uk/programmes/articles/1GBpnZrhLNpVwYcTxlTyS5L/trans-people-on-pronouns. [Accessed 09 December 2019].