Terminology
Language surrounding lesbian, gay, bisexual, transgender, and queer (LGBTQ) identities is constantly evolving. However, there are some basic terms that may aid in communication with patients and clients.
The term sex is generally used to refer to the physical attributes of a person at birth, including their chromosomal makeup, internal and external genitalia, and reproductive organs. Most people consider sex to be binary – either male or female. However, depending on what definition is used, studies show that up to 2% of people are born intersex, meaning that their physical bodies differ in some way from stereotypical male or female bodies (Blackless et al., 2000). Examples of intersex conditions include congenital adrenal hyperplasia, where an increased level of androgens leads to masculinization of the genitals in a person with XX chromosomes, and androgen insensitivity, where the androgen receptors are partially or completely unable to respond to androgens in a person with XY chromosomes.
Gender identity refers to a person’s self-identified gender, as distinct from their sex assigned at birth. While the majority of people assigned male at birth identify as men and the majority of people assigned female at birth identify as women, studies show that 0.6% of the United States population, approximately 1.4 million people, identify as transgender (Flores et al., 2016). Transgender, or trans for short, is an umbrella term that describes a diverse group of people who have in common that their gender is different than that which they were assigned. Conversely, cisgender, or cis, describes people for whom there is no discrepancy between their gender identity and sex assigned at birth.
Most intersex people are assigned a gender at birth and some undergo early surgeries to match their bodies to their assigned genders, although this practice has been decreasing in frequency as intersex advocates work to convince providers and new parents to delay any non-emergency surgeries until the affected individual can participate in the decision making. . Helpful resources for intersex people and their families include InterACT: Advocates for Intersex Youth and AIS-DSD Support Group. Some intersex people come to understand their gender identities as different from those they were assigned at birth. They may transition from one gender to another in a similar fashion to transgender people. However, they may or may not consider themselves to fall under the trans umbrella.
Trans men are assigned a female sex at birth and identify as male (sometimes referred to as female-to-male or FTM), whereas trans women are assigned a male sex at birth and identify as female (sometimes referred to as male-to-female or MTF). The abbreviations FTM and MTF are not generally used as self-identities, but may be helpful to include in medical charts to make a patient’s identity clear to colleagues.
Others who may consider themselves as falling under the trans umbrella include people who identify as genderqueer or nonbinary. The gender binary refers to the system of classification that separates people into binary genders – male and female. Some people consider themselves to be between genders, to have aspects of both genders, or to be nongendered.
The phrase gender nonconforming is sometimes used as an umbrella term to describe a diverse group that may include transgender but also genderqueer, nonbinary , or even cisgender people. As opposed to gender identity, which describes a person’s internal self-identified gender, gender nonconforming typically describes the external appearance or behaviors that may be seen as being outside the traditional norms for their assigned gender. For example, a person may identify as a cisgender male but may consider themselves as presenting as gender nonconforming due to adopting clothing or engaging in activities typically not associated with cisgender male norms. Children may also be referred to as gender nonconforming, especially when it is not yet clear how a child identifies on the gender spectrum. Other terms used to describe children include gender variant and gender creative.
Whereas gender identity refers to a person’s sense of their own gender, sexual orientation refers to the gender or genders of those to whom a person is attracted. Heterosexual and homosexual are more academic terms that some find offensive when used in a personal setting. Common terms for sexual orientation in colloquial language include: gay (attracted to people of the same gender), straight (attracted to people of another gender), and bisexual (attracted to both men and women). Some women who are attracted to other women describe themselves as lesbians, while others use the more generic term gay. Researchers may use the terms androphilic (refers to a person who is attracted to men) and gynephilic (refers to a person who is attracted to women), though these terms are not commonly used colloquially.
Recently, newer terms for sexual orientation identities have emerged. Pansexual refers to someone sexually attracted to people of multiple genders. People who identify as pansexual sometimes feel that the term bisexual is limiting, as it may not convey an openness to attraction to transgender or nonbinary people, although many people who identify as bisexual feel that this term can be used similarly to pansexual and can indicate attraction to multiple genders. Asexual individuals identify as not experiencing sexual attraction, though they may choose to form intimate or romantic relationships. Queer is a term often used to describe non-straight sexual orientations and non-cisgender gender identities, and those who identify as queer may vary considerably in their attractions and in their gender identities. Queer is a word that was initially derogatory and has been reclaimed by LGBTQ communities, so it may also have political connotations. Someone who identifies as queer may be expressing an anti-establishment stance toward heterosexism, the system that privileges heterosexual people, and homophobia, the system that discriminates against non-heterosexual people.
It is important to note that transgender people can have any sexual orientation, and that sexual orientation terminology, when used to refer to transgender people, is based on the person’s self-identified gender. A transgender woman, for example, who is attracted to other women, may describe herself as a lesbian. Some researchers do not use self-identified gender to describe participants. Many people find it offensive when their sexual orientation is defined by researchers in reference to their sex assigned at birth. One solution for some researchers has been to use the terms androphilic or gynephilic to avoid confusion. .
A distinction should be made between self-identified sexual orientation (or sexual orientation identity) and sexual behavior. Researchers studying LGBTQ health may use terms such as men who have sex with men (MSM). These terms refer to behaviors and not identities. Some men who have sex with men do not identify as gay or bisexual. Primary care providers should have open discussions with their patients about the kinds of sex they are having and which body parts are involved in order to screen for cancers and sexually transmitted diseases. Psychiatrists may want to explore with their patients how they came to identify with the terms they use to describe themselves.
The terminology introduced above is basic, and there are many more nuanced ways that people describe their sexual orientations and gender identities. The most respectful way to approach understanding a person’s gender identity or sexual orientation is to ask them. This may seem daunting, especially if it is a new practice or an individual’s gender identity or sexual orientation is not accurately reflected in the electronic medical record, but most people appreciate being asked rather than assumptions being made. When meeting a transgender person for the first time, it is typical to ask about name and pronouns. Asking what name someone uses is more simple, and can be phrased, “What name would you like me to use when referring to you?” Asking about pronouns can also be straightforward, and can be phrased, “What pronouns would you like me to use when referring to you?” Most transgender people use the pronouns he/him or she/her, but nonbinary individuals may use the plural pronouns they/them, or a different pronoun altogether. While it can be hard at first to learn to use new pronouns, it becomes easier with time. An example of a sentence using the pronoun they to refer to one person is: “They called about their labs and I suggested they check back tomorrow because we hadn’t received them yet.”
CME Question:
Which of the following is true?
1 in 10,000 people identifies as transgender
All men who have sex with men identify as gay or bisexual.
Transgender men are those who are assigned male at birth and identify as female.
Transgender men are those who are assigned female at birth and identify as male.
Answer: 4