This post is a part of our Bioethics in the News series
By Jamie Lindemann Nelson, PhD
A little story—it might be called a dramatization—to start: Approaching the third trimester of pregnancy number two, Maria is in for a routine exam. Everything goes as expected until her OB/GYN pauses, gathers herself, and asks, “By the way, Maria … and don’t feel that you have to answer if you don’t want to, but … you do think of yourself as a woman, don’t you … I mean, you … identify as a female gendered person … who … is mainly attracted to men, erotically?”
To say Maria is taken aback by these questions is to say too little; a word like “stunned” comes closer. How to make any sense of this? Has her doctor, who actually attended the birth of her child, had a psychotic break? Is she just trying to be funny? Did Maria just mishear? Or is this some politically correct silliness … does it having something to do with queer people?
Indeed so. The New York Times for this past May 29th reports that LGBT patients are generally willing to disclose their “gender identity and sexual orientation” to their health care providers. Based on research reported in JAMA Internal Medicine, only 10% of a national, randomized sample of lesbian, bisexual, gay, and straight subjects indicated that they would refuse to acknowledge their status; a related study of 101 transgender patients indicated that 90% believed that it was important for primary care providers to know their gender identity.
They are quite right: knowing whether or not a patient is transgender, whether or not they are straight, can sharpen a care provider’s focus. Further, LGBT health care disparities can be spotted and remediated more effectively. Both the National Academy of Sciences and the Joint Commission have endorsed soliciting such information.
Yet, if these results are accurate, LGBT folks should be congratulated not only on their appreciation of quality and equity of care, but also on their bravery. The National Center for Transgender Equality’s 2011 study of 6500 transpeople indicated that 19% were denied access to health care, 28% reported being harassed and disrespected by care providers, and 2% had actually experienced physical assault while seeking care.
Similar perils face LGB patients. A 2010 Lambda Legal study of nearly 5000 respondents roughly anticipated the National Center for Transgender Equality’s results for transpeople, and showed that matters are at least as dire for people with HIV. LGB people who are neither transgender nor living with HIV should not be sanguine—8% report being denied care because of being thought to be otherwise than straight.
Perhaps these data no longer accurately reflect the reception of queer and HIV infected people by health care professionals. Yet there’s still reason for them to be wary—for example, a 2017 Human Rights Campaign Foundation report showing that only 61% of 901 hospitals had nondiscrimination policies that included both gender identity and sexual orientation. The Times piece mentioned “several studies” that say “providers feel uneasy about asking,” out of a reluctance “to make patients uncomfortable.” One hopes that their delicacy is informed by awareness of what LGBT folks might be uncomfortable about—as well as by these recent studies.
But if the studies draw a veil over LGBT fortitude, they also seem insensitive to how “do ask/do tell” policies could leave some cisgender or straight patients feeling deranged. Serious efforts to gather this information will mean that people generally will need to be asked about their sexual preferences and about which (if either) gender they happen to be. Should this become routine, that means that, at least in this particular health care context, queer identities aren’t simply being accommodated: they are being made normative.
We needn’t imagine this inquiry going on just as it did with Maria; her OB-GYN could stand a spot of training. The privacy of these disclosures matters too—it isn’t merely in health care settings that LGBT folks have reason to worry about their safety. Still, however conducted, however safeguarded, routine inquiry destabilizes abiding sources of certainty; neither the fact that Maria’s husband was present as she labored, nor even the fact of her laboring, ground the knowledge of identity a provider needs. Like those who have been relegated to the margins of sex and gender, Maria and all other cisgendered, straight patients will need to abide the question, even if asked discretely, even if they choose not to answer it.
The journalist and historian Elinor Burkett has claimed that unlike progressive movements championing African-Americans, those supporting transgender people have not been content to struggle against violence and discrimination. They have also demanded that women “reconceptualize themselves”—most glaringly by questioning whether having a vagina is necessary for being female. While women born with vaginal agenesis would likely have something to say to her, like Burkett, like Maria, many people will be unsettled by calling old certainties into doubt. But socially advantaged people who oppose injustice cannot simply assume that their world will maintain its proportions and just grow to accommodate those hitherto left out. Those who were excluded will have something to say about the arrangements.
Nor is reconceptualization confined to queer activism. When women’s suffrage was an open question, some women worried that wielding political power would change who women were, how they were thought of, and how they thought of themselves. They were right—and for that, we should all be thankful. Telling your health care provider whether you are cis-, trans-, or non-binary, whether gay, or bi, or straight, may seem a tiny matter in comparison, whose health care benefits may seem not worth the time, trouble, and upset they occasion. Yet in putting the powerful imprimatur of medicine behind the need to respect some of the deepest sources of human self-understanding, the time, the trouble, and the upset might be the most important result of the whole process.
Jamie Lindemann Nelson is a Professor in the Department of Philosophy at Michigan State University. Dr. Nelson is a co-editor of IJFAB: International Journal of Feminist Approaches to Bioethics.
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More Bioethics in the News from Dr. Nelson: Bathrooms, Binaries, and Bioethics
- Grant J, et al. 2011. Injustice at Every Turn. National Center for Transgender Equality. http://www.transequality.org/issues/resources/national-transgender-discrimination-survey-full-report
- Haider AH, et al. “Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity: The EQUALITY Study,” JAMA Internal Medicine. 2017;177(6):819-828. doi:10.1001/jamainternmed.2017.0906 https://www.ncbi.nlm.nih.gov/pubmed/28437523
- Hoffman J. “Gay and Transgender Patients to Doctors: We’ll Tell. Just Ask. New York Times, May 29, 2017. https://nyti.ms/2rgGlRI
- HRC 2017 Health Care Equality Index 2017, p.32. http://www.hrc.org/hei
- Lambda Legal 2010. When Health Care Isn’t Caring. https://www.lambdalegal.org/publications/when-health-care-isnt-caring
- Maragh-Bass AC, et al. “Is it Okay to Ask: Transgender Patient Perspectives on Sexual Orientation and Gender Identity Collection in Healthcare,” Academic Emergency Medicine. 2017 Jun;24(6):655-667. doi: 10.1111/acem.13182. Epub 2017 May 8. https://www.ncbi.nlm.nih.gov/pubmed/28235242