My friend is about to have her knee replaced, so she’s been engaged in a lot of bureaucratic wrangling with the health care system. On a recent pre-op prep visit, she was asked – for the millionth time – to recount her medical history. The nurse doing the intake looked at her each time she asked a question, and then dutifully recorded the answers. Until she got to the question about gender. Then she didn’t look up until she’d marked a box and said to my friend, “I have to ask your gender. I put female. Okay?” My friend, well-versed in the hazards of assuming a person’s sex or gender based on appearance, politely explained “It’s correct in my instance, but really you should ask. I mean how would you know for certain?” The nurse then gestured to her body, moving her hand up and down in front of her, as if to say, “Well, I mean, look at you.”
There are so many way that medical treatment can go wrong when people make assumptions. Atul Gawande wrote a whole book on the importance of using checklists to remind us exactly how to do things we assume we can do by rote, like washing our hands or asking important questions. Assessing a person’s gender or sex by looking at them might feel like something we can do without asking, but it isn’t. Ricci could have been a transwoman. She could have been intersex. She could have been male-identified, but in the early stages of transition. There is so much information that would have been lost were any of those things not discovered.
But just as bad is the feeling that would have been created for the patient in each of those circumstances: a feeling that would certainly have undermined any confidence that they were feeling about the treatment they might receive; a feeling that screamed out, “I don’t belong here. I’m not welcome.”
When health care providers and patients can’t talk openly about identities, bodies, and needs, then the quality of care will be reduced and people will be harmed. Whenever you are faced with a doctor, nurse, or other health care worker who verbalizes an assumption about you, I hope you will challenge it even if it is correct. Making assumptions is a habit, like poor hand washing, that can be corrected. Unfortunately, assumption-making about sex and gender is deemed so social acceptable that it’s going to take a ton of advocacy and intervention to persuade people change the professional norms that lead to the creation of a harsh, unwelcoming, and dangerous environment for so many.
Elizabeth Anne Wood, Ph.D. 
Brilliant article! As a 40+ year RN many times nurses don’t know how to ask a question they’re uncomfortable asking like those around gender, race, sexual orientation, marital status, and if the patient is having suicidal thoughts. I generally teach nurses to avoid sounding judgemental by carefully wording the question in advance, and practicing via role playing prior to interacting with patients. I would ask the question something like this: “What gender do you identify as?” Some patients may be confused with the question worded that way, which makes for a great teachable moment and insightful conversation.
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Thanks for this comment, Mike. I love your strategy of scripting out the questions in advance. There’s no better way to make things comfortable than to practice them over and over. And starting any question with “I’m required to ask,” or “I need to ask,” signals that you don’t really want to say what follows, which risks down the conversation before it’s even begun. Your way of asking the question keeps the conversation open and creates a more welcoming space for anyone. The same could be done with all kinds of potentially uncomfortable questions – until they ultimately become comfortable!
A person at my reading the other night said that her primary care office now routinely asks patients “Do you feel safe at home.” Imagine how uncomfortable – and yet how imporant – that question might have been when it was first introduced to the practice. If someone had started that by saying “I have to ask: Do you feel safe at home,” I can imagine many victims of intimate partner violence or other domestic abuse would not have felt safe answering “yes”.
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