What We Talk About When We Talk About Genitals
In July 2018, Healthline published an inclusive guide to safe sex in which they used the phrase “front hole” in place of the word “vagina.” The internet subsequently went into a frenzy, and the following month the publication issued a note assuring the public that it wasn’t attempting to replace the word “vagina.” It was using more inclusive language, as some trans and gender non-conforming folks use “front hole,” as well as other terms, to describe their genitals.
Euphemistic language can cut the other way, too, and become exclusive. Gynecology, for instance, is often referred to inaccurately as “women’s healthcare,” when not all gynecology patients are women. All healthcare equates anatomy with gender, though in reproductive health the stakes regarding language are arguably higher. Reproductive health doctors must interact explicitly with their patients regarding anatomy, so the presumed alignment of gender and genitalia is intensified. Fields such as urology faces this issue, too, but gynecology heavily connotes femininity. A gynecologist specializes in vaginas, with Greek “gyn” meaning “woman,” whereas a urologist specializes in the non-gendered urinary tract, with “uro” meaning “urine.”
“The language that doctors use in the exam room is as important as pronouns to making trans and non-binary patients feel safe.”
Medical offices struggle enough with pronouns, let alone preferred anatomical terminology. While some trans people use language like “vagina” and “uterus” with their doctor, having no alternative terms can create an exclusionary environment for those who don’t. Most trans people face enough obstacles merely getting to the waiting room, and those challenges are magnified for people who are poor, non-white, non-English speakers, and marginalized in other ways. The language that doctors use in the exam room is as important as pronouns to making trans and non-binary patients feel safe. How, then, can gynecologists work to ensure people of all genders feel safe getting reproductive care?
Jess Lee, a non-binary person and member of the Episcopal Service Corps in Tucson, Arizona prefers non-euphemistic, medical language in their exams. “When we talk about women’s healthcare, that often means how we look at breast tissue and vaginas and uteruses,” Lee says in an interview with Lady Science. Stating the names of the body parts directly “feels more comfortable for me,” they say.
Liam McBain, a transmasculine student at NYU, also describes the necessity of speaking straightforwardly. “If you’re at the doctor you can’t just beat around the bush about the fact that your vagina’s fucked up.”
Dr. William Andrew, a cis OB/GYN in Ohio, agrees. Dr. Andrew has been practicing for more than 24 years and has treated trans men. He finds that direct medical language works well. “He has a vagina and we’ll talk about his vagina,” Dr. Andrew says. “I’d never call it anything else.”
Still, many medical professionals do not have experience and training in discussing genitals with trans patients. Emma Young, a trans woman, is in a unique position to change that. Since August 2019, she’s worked as a standardized patient at the Philadelphia College of Osteopathic Medicine (PCOM), where she participates in simulations for medical students who must diagnose and treat the symptoms she describes. “It’s interesting to see how little students are prepared,” Young says. “For so many of them, I’m the first trans person they’ve met and certainly treated.”
Young describes how students skirt around explicit questions, especially when it comes to genitals. “I have breasts. They don’t know if I have bottom surgery. They’ll try to dance around it most of the time. Everybody’s on edge. They’ll ask me, ‘Do you stand up or sit down to urinate?’”
When medical students read Young as trans, they ask her questions that make presumptions about her body and what care she needs. “They look and clock me immediately. That often happens because of my voice. They won’t ask me female questions.” For example, she’ll be asked about a prostate exam rather than a Pap smear. The danger here is that a doctor is presuming, based on Young’s appearance, what healthcare she needs. Regardless of whether that presumption is accurate, it subscribes to a deleterious equation that the way a person appears, sounds, or presents indicates genitalia.
If doctors-in-training are uncomfortable talking to trans patients about genitals, trans people risk access to competent care. Young says, “Only a couple of times has anyone said out and out, ‘You were born with male genitalia?’” Even that language was off-putting. “It would have been better for him to say, ‘You were born with a penis?’ I was not born with male genitalia.”
This medical student, like many people, assumed that a penis is “male genitalia.” But Dean Spade, an Associate Professor at Seattle University School of Law and trans person, takes a different view. In his 2011 essay “About Purportedly Gendered Body Parts,” Spade writes, “We can talk about uteruses, ovaries, penises, vulvas, etc. with specificity without assigning these parts a gender.” Spade argues that calling body parts male or female bolsters biological determinism, which suggests that all human behavior is determined by genes and other biological attributes.
In Spade’s view, the idea that male equals penis and female equals vagina reinforces a fallacious, harmful binary. By dismantling this binary, anatomical language becomes both more accurate and inclusive. “Rather than saying things like ‘male body parts,’ female bodies’ or ‘male bodies’ we can say the thing we are probably trying to say more directly,” Spade writes. In the case of Young and the medical student, saying “male” was inaccurate.
“Spade argues that calling body parts male or female bolsters biological determinism, which suggests that all human behavior is determined by genes and other biological attributes.”
Kristen O’Guin, who is agender and a friend of Young’s, works as a sexuality educator at PCOM. They elaborated on Young’s point that a penis isn’t male genitalia. “This is not male genitalia because they’re not a man,” O’Guin says. They suggest instead doctors give patients control by asking, “Is there a particular way you want me to refer to your body parts?” This consideration takes into account that some trans people might have dysphoria related to their genitals, and the language they choose can ameliorate it.
Dr. Tim Cavanaugh, a cis doctor and formerly the Medical Director for the Transgender Health Program at Fenway Health, advocates this open communication between a doctor and patient. In a presentation on inclusive ways to discuss sexual health, Cavanaugh emphasizes the importance of language, giving the patient the power to label their own body: “Establish from the beginning what words you and the patient will use. Check in to make certain that both you and the patient have the same understanding of these terms.” Terms listed include phallus, dick, genital canal, vagina, and, indeed, front hole.
In a 2019 report, Drs. Tehmina Ahmad of University of Toronto, Anthea Lafreniere of University of Ottawa, and David Grynspan of University of Ottawa, advocate incorporation of ungendered language into electronic medical records, which patients can access. The report lists medical procedures often associated with gender-affirming surgery and discourages using qualifiers such as “male” and “female” (e.g., “male testicular tissue,” “female breast tissue). This practice affirms the importance of proper terminology in all aspects of medicine, not just when directly interacting with a patient.
Queer and trans healthcare professionals are also working to transform medical language. Dr. Daphna Stroumsa, a non-binary clinical lecturer in the Department of Obstetrics and Gynecology at the University of Michigan, specializes in LGBTQIA+ health and gender-affirming care. Among other things, she has researched and written about “the impact of gendered language on our ability to provide inclusive care and to address health disparities experienced by transgender and non-binary people.” She has also produced a series of video training modules on best practices, including a video on the care of transgender and gender non-conforming patients.
Here arises a complex question of whether the doctor or the patient is responsible for asking questions about gender identity in a medical appointment.
Dr. Andrew, the OB-GYN from Ohio, says that it’s “more incumbent upon patients to decide what they want to talk about,” indicating that the patient can bring up gender identity if it’s relevant to the appointment. Indeed, the patient is the one who knows why they came to the doctor in the first place. But, doctors can also ask inappropriate questions relating to gender or anatomy when they’re not relevant, or they might ascribe all maladies to gender (a.k.a. broken arm syndrome). O’Guin, however, offers another perspective. She mentions an integral point about doctors first asking non-judgmental questions in this conversation: “If the doctor takes the initiative, the patient knows they’re safe with that doctor.”
For trans patients or would-be patients, challenges regarding safety, access to healthcare, and basic respect all encumber visits to doctors’ offices. As gynecologists continue seeing patients, they must consider how language dramatically alters one’s experience in the exam room.
*Author’s note: Sylveon Consulting advised the writer on developing this piece.
Image credit: Image from page 266 of "An atlas of human anatomy for students and physicians," 1919 (Internet Archive | Public Domain)
