Finding the right words: Talking about sex and gender in general practice
I know nothing in the world that has as much power as a word. Sometimes I write one, and I look at it, until it begins to shine.
– Emily Dickinson1
Sexology is a broad field encompassing all areas of sexual heath, sexuality, gender identity and forensic medicine including care for those affected by sexual violence.2 Aspects of sexology incorporate biological, psychological and social aspects of health, emphasising the sexual history as an important part of holistic care.
Early in medical school, we learn the importance of language. This spans from precise anatomical terms that allow surgeons to discuss intricate parts of the human body, to respectful language that opens up communication in a doctor–patient relationship. Various tools help to guide our communication with both peers and patients. An example is the PLISSIT model (Permission, Limited Information, Specific Suggestions and Intense Therapy) discussed by Ramanathan and Redelman in their primer on sex therapy.3 The model begins with ‘permission granting’, in which the practitioner can indicate to a patient their openness to discussing sexual concerns.
Language is again important when responding to any sensitive disclosure, such as when treating a patient presenting after sexual assault. Freedman provides guidance on psychological first aid in the initial response, as well as emphasising the importance of clear and precise documentation that may be required for legal proceedings.4
The labels used by the medical profession have their own impact, and diagnoses may be modified or abandoned over time for a variety of reasons. Terms may be recognised as medically inaccurate or increase harms such as stigma. A notable example is the removal of ‘homosexuality’ from the Diagnostic and statistical manual of mental disorders in 1973.5
In the 11th edition (2018) of the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (ICD), the new chapter ‘Conditions related to sexual health’ was created. Old terms related to gender identity were replaced with ‘gender incongruence’ and moved from the mental health chapter to the new sexual health chapter.6 This change signals recognition by the medical profession that the diversity of people includes transgender, gender diverse and non-binary (TGDNB) identities.
In this issue of Australian Journal of General Practice, we present two articles relating to the general practice care of TGDNB patients. Strauss et al explore how to promote an inclusive environment within the general practice setting.7 The language used by the clinician and practice is an important part of providing inclusive care. A general principle is to ask patients in an open-ended manner for their preferred language, including name, pronouns and gender identity. This can be formalised through practice forms and medical records. Cundill discusses key aspects of prescribing medication for gender affirmation and further resources to upskill in this area.8
An area as fundamental to the human experience as sexology must be considered when providing whole-person care. As practitioners caring for patients across the diversity of the population and their lifespans, we must engage in respectful discussions of sex and gender identity with our patients to address their needs.
The rainbow is a part of nature, and you have to be in the right place to see it. It’s beautiful, all of the colors, even the colors you can’t see.
– Gilbert Baker9