Addressing Cisgender Bias in Health Care to Improve Services for Transgender Youth

In Canada and most other Western societies, cisgender bias often goes unnoticed, which holds true in health care services for people of all ages. To overcome the problem, we can begin by understanding some of the ways that cisgender bias impacts children and youth in the health care system.

Drew Clark, PhD Candidate in Interdisciplinary Studies

What does cisgender mean? People whose sex assigned at birth is congruent with their gender are referred to as cisgender. Trans is often used as an umbrella term for people whose gender does not align with the sex they were assigned at birth. Many trans people have a binary experience of gender and identify as girl/woman or boy/man. However, children, youth, and adults may also be non-binary – an experience of gender that is neither exclusively boy/man nor girl/woman. Cisgender bias refers to the effects of making assumptions that a person’s gender is the same as the sex they were assigned at birth.

Cisgender bias in health care

In pediatric care, gender-based assumptions can be found in many places, from washrooms to toys, from intake forms to patient-family-doctor interactions. These assumptions can result in erasure, enacted stigma, and disconnection from health care providers and institutions. Unconscious cisgender bias happens when people don’t make the needed effort to consider how their actions affect trans people, whereas conscious bias occurs when trans identities are recognized, but intentionally discounted. On a larger level, cisgender bias within health care systems replicates stigma found in society at large, contributing to compromised wellbeing of trans people and communities.

Erasure

Whether unconscious or intentional, both structures and interactions can lead to erasure of trans identities – the failure to acknowledge or represent the existence of trans people. What structural cues in a pediatric health care setting signal cisgender assumptions? Boys’ and girls’ washrooms, gendered toys, and intake forms that do not collect information about gender identity are all examples of ways that the existence of trans people has not been adequately recognized. In contrast, gender-inclusive washrooms, literature on trans resources, rainbow and trans flag symbols, and intake forms that ask about sex, gender, pronouns, and name used are all indicators that a setting may be a safer space for trans people.

Cisgender bias can also be found in everyday interactions among health care providers, families, and patients. Consider this recent experience of a parent and non-binary child. “Everyone is so great so far, except for the pediatrician at the end who said ‘you’re a healthy boy’.” The parent responded that their child was, in fact, healthy. This may seem like a small – and perhaps insignificant – act to people who don’t understand what it means to be trans or to raise a trans child. However, this kind of erasure can be deeply felt and lead to lack of trust and comfort with health care providers. This was seemingly an oversight of a busy doctor who did not check the chart for name, pronouns, and gender, but it shows how unconscious cisgender bias can have negative effects. Fortunately, in this setting, all other staff had been positive about this child’s gender identity, using correct name and pronouns, and open to the parents’ suggestions of how to best support this child while in their care.

Enacted bias

Enacted bias can take multiple forms, and be conscious or unconscious. Microaggressions are small (passive-aggressive) acts that indicate a person is not supportive of trans people. For example, a health care provider could be aware that a client uses they/them/their pronouns, but decides it is just too difficult to use them. This act signals that the professional – someone who holds a great deal of power and authority – may believe that there is something wrong with being trans. For the client, this can undermine their sense of self, make them feel less safe in the world, and question where they can go for support.

Consider these more overt forms of enacted bias. Providers may tell patients that they do not believe in trans identities, refuse to provide them with medical care, or even refuse to refer them to another health care provider who will help them. Perhaps one of the most extreme examples is a health care provider telling parents that they should try to change the gender identity of their child through punishing them for expressing their true gender. This approach, often called conversion or reparative therapy, is considered unethical by major medical organizations and is now illegal in several places. It is an extreme form of enacted stigma, an overt act that can have lifelong consequences for the child, the parents, their relationship, and relationships with future health care providers.

Impact on youth and families

The cumulative effects of erasure and enacted stigma can have significant consequences for children, youth, and families. If a young person’s gender is not supported by their family or their health care providers, where else can they turn? If families are unsure of what to do when their child comes out and health care providers fail to provide support, what happens within that family? When a young person is experiencing stigma related to multiple parts of their identity – for example race, class, and gender – the impacts of these oppressions can be magnified. On a positive note, our research at UBC shows that trans youth with strong parental support and family connectedness report more positive health outcomes, including better mental health and lower rates of considering suicide. This confirms what other researchers in Canada, the US, and Europe have found: when youth have family support and access to needed health care they are more likely to lead healthy lives.

Opportunity

All children, youth, and families deserve access to health care services without encountering bias, erasure, and enacted stigma. Unfortunately, current research indicates that there is much work to be done before all trans people in all communities can receive the health care they need. Health care providers have an opportunity to make a significant difference in the lives of their trans patients and clients by taking a steps toward recognizing the impacts of cisgender bias and changing the practices and policies in our systems of care.