Abstract
In this edition of the Canadian Association of Radiologists Journal, Yan et al have published a thought-provoking study exposing a finding likely overlooked by many radiologists. 1 While the naming of imaging fellowships may seem trivial to some readers, the use of gendered terminology is problematic and harmful.
We all work in hospitals, universities, or organisations with mission statements promoting some version of inclusion. In the last few years, pledges and commitments to equity, diversity, and inclusion (EDI) have become commonplace and are often proudly and prominently displayed. The Canadian Association of Radiologists has, in fact, released its own EDI statement in October 2021 proclaiming to “[celebrate] diversity in all its forms, including race, ethnicity, language, nationality, age, experience, physical ability, gender, sexual orientation, religion, culture and other visible and non-visible expressions of diversity” and to work to “identify and mitigate the adverse effects of any barriers to full participation in our profession and society.” These statements will fall short without our willingness to hear concerns and makes changes.
As physicians practicing modern Western medicine, we have and continue to fail our transgender and gender non-binary patients. A comprehensive US study of 27 715 transgender individuals found that a third reported discrimination and/or mistreatment in healthcare and 28% have postponed or avoided care due to fear of a negative experience. 2 Even more striking, 19% report to have been denied care because of their gender identity, 28% report having been verbally harassed in medical settings, and 50% had to teach their medical providers regarding transgender health. Beyond direct clinical encounters, transgender and gender non-binary individuals also risk being misgendered by our current medical and data systems, most of which present gender as a strict and immutable binary. One of the authors of this editorial is reminded how they had encountered diagnostic images of transgender individuals whose Picture Archiving and Communication System (PACS) profiles still contained their incorrect gender identity markers and deadnames, and how they were later informed that this error was impossible to change.
Respect for our patients and avoiding the creation of an environment redolent of past trauma are already ample reasons for change. Regardless, the use of gender-specific language, such as “women’s health/imaging,” and the persistent conflation of gender and sex is incorrect and unscientific. Even if we nominally acknowledge the gender identity of transgender and gender non-binary individuals, the continued dichotomizing of anatomy, physiology, and pathology as “male” or “female” is harmful. The New England Journal of Medicine recently published a case report where a 32-year-old transgender man presented with abdominal pain and hypertension later revealed to be pre-eclampsia, placental abruption, and possible labour. 3 The triage nurse recognized his gender identity and even ordered a Beta-Human chorionic gonadotropin (β-HCG) but ultimately did not make the connection that he could be pregnant as he was listed as a “male.” His care was delayed by hours and the case ended with the birth of a stillborn. This case is a striking illustration of the avoidable error that may occur when our clinical thinking is hindered by outdated and oversimplistic binaries.
This problem does not start or end with our transgender and gender non-binary colleagues and patients; the presence of any systemic and institutionalized discrimination is a healthcare crisis. As leaders and experts in medicine, physicians should be at the forefront of advocating for equity and inclusion. However, too often physicians stand on the sidelines. We believe most physicians are not transphobic, but ongoing indifference sends a powerful message. Allowing patient records to reflect both gender and sex, using non-gendered terminology, respecting pronouns, calling patients by their preferred name, and allowing patient records to be updated are simple changes that can have a profound impact for many in society, including our friends, family, mentors, trainees, and colleagues.
We refuse to believe that our profession is inveterate to outdated and harmful ideas and terminology. In fact, radiologists, together with our clinical colleagues, have increasingly recognized the importance of gender-affirming care in redressing the current health disparities experienced by the transgender and non-binary population. Published in September 2019, a RadioGraphics article by Stowell et al delineated an approach to imaging evaluation in those who have undergone gender-affirming surgeries, which included a non-comprehensive list of acceptable terminology used to reference the transgender population along with their definitions. 4 These changes are in their infancy and there is a current dearth of published research investigating their overall effects on health outcomes. Nonetheless, maintaining this momentum will require us to accept the rights of our transgender and gender non-binary patients to safe and dignifying care, to learn how to provide this care, and to diligently eliminate any hindrance to providing this care. Regarding competence in gender-affirming care, radiologists must no longer sit in the dark.
