Is it a boy or a girl? This burning question surrounds babies starting before their birth, and it has always been answered by a brief assessment of physical traits. If the baby has a penis, it’s a boy, and if the baby doesn’t have a penis, it’s a girl. The baby enters a binary gender system based on the sex assigned at birth.
What is a binary gender system?
According to the Human Rights Campaign, a national LGBTQ+ advocacy organization, “the binary gender system is the notion that only two genders exist, male or female, each solidly fixed, biologically based and attached to various expectations for behavior, appearance and feelings.” These various expectations revolve around the belief that there’s a correct way to be a man and a correct way to be a woman — e.g., men are masculine and women are feminine — and sex assigned at birth is unchangeable.
The gender binary system is such a well-accepted concept in our society that we expect everyone to naturally fit into one of these boxes: male or female. Much of the world around us reinforces this binary gender system through social norms. We see this in binary bathrooms, locker rooms, barbershops/hair salons, health care settings, etc. It’s also seen in the clothes we wear, the products we buy, the language we use and the traditional roles we are expected to follow based on our sex assigned at birth. These social norms make it incredibly difficult for gender expansive people to navigate a world that doesn’t accommodate their gender fluidity.
Health care systems across the U.S. are notorious for reinforcing the binary gender system and using the sex assigned at birth concept in the care provided. Practitioners typically offer services that are focused on men’s health or women’s health, and are usually located in settings geared toward either men or women. This approach to health care doesn’t leave space for gender expansive people to easily access services in a way that feels safe, and with practitioners who are well informed on gender affirming care. We, as a society, need to better understand what “gender expansive” means before we can really affect change.
Gender Expansive Defined
So, what is “gender expansive”? The Human Rights Campaign surveyed more than 10,000 LGBTQ+-identified youth in 2012 in order to examine their experiences in the U.S. Of the respondents, 9% identified their gender as “other,” sparking the conversation that the gender spectrum is significantly more expansive than as defined by the gender binary system that is so well anchored in our society.
People who are gender expansive use terms such as “nonbinary,” “genderqueer,” “gender fluid” and “androgynous” to describe their gender. This challenges the long-standing notion that a person is transgender if their gender identity or gender expression doesn’t align with their sex assigned at birth. Our society needs to recognize that gender is an internal sense of self that is influenced by our sex, gender expression and gender identity.
This shift beyond the binary makes health care designed for only men or women incredibly difficult for gender expansive people to access. For example, a nonbinary identified person who was assigned as female at birth but appears androgynous would feel completely out of place during a Gyn/Ob appointment for a well woman exam. The waiting room, language and services are all presented in a way that says: We serve women. Health care systems need to adjust to delivering care across the gender spectrum.
What is gender expansive health care and how do we make space for it?
Gender expansive health care is a delivery model that is inclusive and affirming, and that normalizes gender care as basic health care. To implement this model, health care organizations must address the people, spaces and technologies that contribute to the marginalization of genderqueer patients. This approach can be accomplished by focusing on 1) growing the base of clinicians who serve the gender expansive patient population by expanding clinical skills related to gender affirming care, 2) creating a framework for patient access that includes an affirming web presence, gender neutral facilities/settings and well-coordinated pathways to primary and specialty care 3) using appropriate sexual orientation and gender identity (SOGI) wording (such as self-reported pronouns, gender identity, etc.) in electronic health records, as well as features such as organ inventories to trigger preventive care reminders.
These are the building blocks needed to help ensure psychological safety and high quality, unbiased health care for patients everywhere along the gender spectrum.
The Johns Hopkins Center for Transgender and Gender Expansive Health is on a mission to build a health care delivery model at Johns Hopkins Medicine that embraces diversity, inclusion and respect for autonomy by providing affirming care across the life span. Our focus is on normalizing gender affirming care as basic health care. Our health care professionals accomplish this by providing culturally competent, evidence-based care that advances the human condition through medical knowledge, research and education, in a space for everyone — including those beyond the binary — to access the health care they need.