Cis, Trans, Gay, Straight: Being Called Out by the Doctor

Bioethics-in-the-News-logoThis 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.

This “Transgender-Affirming Hospital Policies” document is available for download on the Human Rights Campaign website.

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 Nelson photoJamie 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.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, July 6, 2017. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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More Bioethics in the News from Dr. Nelson: Bathrooms, Binaries, and Bioethics

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Bathrooms, Binaries, and Bioethics

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series. Visit this page for more information.

By Jamie Lindemann Nelson, PhD

Bioethicists typically deal with the moral complexities that emerge when social institutions—the clinic and the lab, chiefly—try to fend off our bodily vulnerabilities or ease their physical and social consequences. Recently, however, major social institutions have acted to make some people’s bodily vulnerabilities harder to deal with, hampering their access to means of coping with them that otherwise are publicly available.

The vulnerability I refer to is the regular need to eliminate the waste our bodies generate; “some people” are transgender women and men, boys and girls; the culprits are a wide selection of American state legislatures. Spring 2016 may go down in the annals of infamy as the season when lawmaking bodies across the country became fixated on the subject of bathrooms. The South Dakota House of Representatives narrowly sustained the governor’s veto of a measure passed by large majorities in both legislative houses that would have forbidden transgender students to use bathrooms, locker rooms, and showers designated for use by members of the gender with which they identify. In Tennessee, a bill that extends the bathroom ban to public universities as well as middle and high schools unanimously passed out of committee. Briefly stalled due to public hearings at which transgender high school students eloquently testified, the bill was quickly revived and sent on, only to stall again; its future remains uncertain. Unwilling, perhaps, to encounter eloquent North Carolinian trans students, the legislature there called a special session to ram through a sweeping bill that undercut the ability of local governments to extend anti-discrimination protections to LGBTQ folks generally; this haste was prompted, apparently, by the specter of trans people being expressly welcome to gender-concordant loos in Charlotte. Unimpeded by vetoing governors or eloquent students, this measure is currently the law in North Carolina. Nor is this all. According to the Human Rights Campaign, 44 anti-trans measures are under consideration in 16 states.

The typical rationale for barring trans people from their lavatories is to protect privacy and safety. To speak gently, this is ill-considered: there is no reason to regard a transwoman as a particular threat to any other woman occupying the next stall. No cisgender man standing at a urinal has any special cause to fear the transman washing his hands at the sink. Any heightened danger of being menaced would run in the other direction: a transwoman forced to use accommodations designated for men might well have good reason to be concerned about her safety. Privacy is a more amorphous notion, but however it is meant, it seems unlikely to be furthered by forcing transmen to enter women’s lavatories, or forcing transwomen to use the gent’s.

Bioethicists, who generally favor clarity about risks and benefits as they concern bodies, should be among those pointing this out. They might also help spread the word that enforcing such measures heightens risks of pain, distress, and ill health to those who, during the course of a long work shift or school day, can’t bring themselves to use discordant facilities, or fear making themselves conspicuous by using whatever alternatives might be present. There is also disturbing evidence that barring trans people from facilities matching their gender identification contributes to their strikingly elevated suicide rates (Seelman).

But the matter doesn’t end with getting clear about who is more at risk than whom—if that were really at issue, none of these bills would have taken up any legislature’s time and money. What then is behind these efforts to crimp transpeople’s access to concordant lavatories, and thus to hamper their access to much of social life generally? A clue was provided by South Dakota state representative Stephen Haugaard. In a bravura performance of metaphoric derangement, Representative Haugaard called transgender a “virus that has broken out” across the nation, while also asserting that being transgender is a matter of decision. “When you feed the fire of this kind of confusion,” Haugaard said, “you’re going to add to the number of people who are going to make this choice.”

Not that these bills—which frequently stipulate that sex is determined by anatomy at birth, by chromosomes, or in accord with original birth certificates—need such dicta to reveal their intent; they do a pretty good job speaking for themselves. The language that blocks recognition of any kind of gender crossing makes it clear that the real target isn’t preserving anyone’s safety or privacy. The drive is to use the law, not only to limit trans presence in public spaces, but to fight the uptake and circulation of how transpeople understand themselves—in short, to delegitimize transgender people as such.

Anti-transgender laws are part of a general reactionary effort to hold certain people in the subordinate or frankly abject positions in which social traditions have assigned them—forced to give way on same-sex marriage, the imagined immutability of the gender binary is the new line in the sand. As bioethicists have noted, medical practices that engage trans people have played both sides of that line—both pathologizing and affirming the distinctive ways in which transgender constitutes an invitation to respond more richly to reality’s complexities. A challenge now for bioethics is to nurture the affirmative side of this legacy, helping to clarify for medical personnel and the public how what has been fancied a natural binary in fact is maintained by intricate expressions of social power. If bathroom access is where those who still root for reaction draw today’s line, let’s be sure that it is drawn in beach sand, and welcome the incoming tide.

jamie-nelsonJamie Lindemann Nelson, PhD, is a Professor in the Department of Philosophy at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, May 5, 2016. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

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