Learning Objectives
By the end of this section, you will be able to:
- Define biological sex and what it encompasses
- Recognize how gender identity is applied to one’s self-identity
- Identify various gender role expressions
- Explain various sexual orientations
The importance of nurses being knowledgeable about patient gender identity, gender role expression, and sexual orientation cannot be overstated. However, just being knowledgeable about the subject is not enough. Nurses must actively work to remain open-minded and nonjudgmental to provide quality care to all patients, regardless of gender identity, gender role expression, or sexual orientation. Nearly a quarter of LGBTQIA+ (lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, and gender diverse) Americans report being blamed for their health problems by a healthcare provider, as compared to less than 10 percent of non-LGBTQIA+ individuals (Rummler & Mathani, 2022). Additionally, one in every six LGBTQIA+ individuals reports avoiding health care in anticipation of discrimination (Casey et al., 2019). When care is provided in a manner that is closed-minded and/or judgmental, it is discrimination, and it leads to poor health outcomes (Tabaac et al., 2020). These poor outcomes are seen in disproportionately higher numbers in the LGBTQIA+ population, resulting in health disparity, which are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations (Centers for Disease Control and Prevention, 2023). The key word in that definition is “preventable,” which is why there has been a significant focus in recent years on reducing risk factors in these populations to improve health outcomes (U.S. Department of Health and Human Services, n.d.).
This unit is designed to enrich your nursing understanding of biological sex, gender identity, gender expression, and sexual orientation. By deepening your knowledge in these areas, you will be better prepared to deliver holistic, patient-centered care (PCC) to individuals across the spectrum of sexuality. The goal is to empower you with the insights and sensitivity needed to address the unique needs and concerns of every patient, ensuring that quality care is provided to all. This section of the chapter is designed to enrich your nursing understanding of biological sex, gender identity, gender expression, and sexual orientation.
Biological Sex
The sex that is assigned to an individual at birth is referred to as one’s biological sex. In some cases, you will have patients that prefer to refer to their biological sex as “assigned male at birth” or “assigned female at birth.” This sex assignment is made based on biological factors including chromosomes and physical characteristics (e.g., genitals). At birth, if ambiguous genitalia are noted, meaning the genitalia don’t look as expected for a male or female, the child may be classified as “Intersex.” A broad classification term, intersex encompasses situations in which a person is born with chromosomes or reproductive or sexual anatomy that does not fully align with being male or female. Some intersex characteristics are recognizable at birth, while others do not present until later in life. The key takeaway about biological sex is to understand that the sex assigned to an individual at birth may not necessarily correspond to the gender they identify with or perceive themselves to be. It is important to be mindful of this when caring for patients and avoid assuming that a person is a certain gender solely based on their assigned biological sex at birth.
Chromosomal Sexual Development
Biological sex is determined by specific combinations of chromosomes, which are threadlike structures containing DNA located in the nucleus of cells. Chromosomes that determine the sex of the individual are referred to as sex chromosomes and are designated as X and Y chromosomes. Biological females have two X chromosomes (XX) and biological males have one of each (XY). The biological sex is determined during fertilization when a sperm cell fertilizes an egg cell. The egg cell always carries an X chromosome and the sperm carries either an X or a Y, so the biological sex is dependent on which type of chromosome is carried by the sperm. If the sperm carries an X chromosome, the result will be a biological female, and if the sperm carries a Y chromosome, it will be a biological male. It is important to note that although XX and XY are the most common chromosomal configurations for sex, there are some instances where variations may occur. For example, males with XXY sex chromosomes are diagnosed with Klinefelter syndrome (Figure 33.2). This condition can result in symptoms such as abnormal growth patterns, reduced facial hair growth, enlarged breasts, low sex drive, and infertility. Another example is females with three X chromosomes (XXX), which causes Triple X syndrome. This condition may cause symptoms including infertility, abnormal growth patterns, or early menopause.
Congenital Adrenal Hyperplasia (CAH)
A genetic disorder, congenital adrenal hyperplasia (CAH) affects the adrenal glands, which sit on top of the kidneys. The adrenal glands are responsible for producing several different hormones, including cortisol, aldosterone, and sex hormones (testosterone and androgens). Genetic mutations in CAH result in a lack of certain enzymes needed by the adrenal glands to make hormones. When the body produces less cortisol and/or aldosterone, the body tries to compensate by stimulating the adrenal glands to make more. This stimulation results in an overproduction of sex hormones, which manifests as enlarged external female genitalia in infants and early appearances of pubic hair and acne and rapid growth patterns during adolescence. It is typically treated with hormone replacement therapy to treat the deficient levels of cortisol and aldosterone and antiandrogen medications such as spironolactone to decrease the amount of sex hormones in the body. In severe cases, females may opt to surgically alter the appearance of the enlarged external genitalia for cosmetic or functional reasons.
Gender Identity
Gender is often used interchangeably with biological sex; however, they are two completely different concepts. Sex refers to the biological and physiological characteristics of a male or female such as reproductive organs, hormones, and chromosomes. On the other hand, gender is a social construct that includes norms and behaviors associated with being a man or a woman. One’s gender identity is defined as “a person’s deeply felt, internal and individual experience of gender, which may or may not correspond to the person’s physiology of designated sex at birth” (World Health Organization, n.d.). In other words, gender identity is the gender that an individual perceives themselves to be, regardless of their biological sex. Gender identity is just as important, if not more so, than biological sex because it encompasses an individual’s internal sense of self, which can directly impact both mental and physical health. It is vital that nurses recognize and understand that a patient’s gender identity may not align with their physical characteristics; however, the patient should be recognized as the gender with which they identify. For example, if a biological male who identifies as female prefers “she/her/hers” as their pronouns, the nurse should consistently use them in conversation, even if the patient has external physical characteristics that are male. Gender identity is a highly personal and sensitive part of an individual’s life and should be treated with open-mindedness and respect, especially within the healthcare setting.
Link to Learning
Learn more about health considerations specific to LBGTQ+ youth in this publication by the Centers for Disease Control and Prevention (CDC).
Cisgender
Individuals whose gender identity aligns with the biological sex they were assigned at birth as referred to as cisgender. For example, an individual who was assigned male at birth and who identifies as a male is cisgender. Historically, cisgender individuals were called “normal,” however, this would indicate that other variations of gender identity are “abnormal,” which is not accurate. There are many variations of gender identity, all of which are normal, so this term has been adopted to help change the societal narrative about there being only one “normal” type. Using this term is a way to demonstrate the use of inclusive language and foster understanding and respect for all individuals.
Gender Nonconforming
The term gender nonconforming is used to describe individuals who display behaviors or appearances that do not align with societal expectations of their sex assigned at birth. An example would be an individual assigned male at birth who enjoys wearing female clothing and makeup. Another example could be an individual assigned female at birth who prefers to keep their hair short and wears masculine clothing. It is important to remember that being gender nonconforming does not necessarily indicate the person’s gender identity. In many cases, the individual may be cisgender but just enjoy expressing themselves in ways that do not align with societal expectations of their sex assigned at birth. This again highlights the need for nurses and other healthcare professionals to maintain an open mind that is free from judgment and allow patients to express themselves authentically, regardless of societal norms.
Life-Stage Context
Navigating Puberty and Gender Identity
As teenagers enter puberty, they embark on a journey of self-discovery that includes exploring their identity, sexuality, and gender expression. For some teens, this period may involve questioning traditional gender norms and embracing a gender identity that differs from societal expectations. The following are some key considerations for teens experiencing gender nonconformity during puberty:
- Physical changes: Puberty brings about significant physical changes, such as the development of secondary sexual characteristics such as breast growth, voice deepening, and facial hair. For nonconforming teens, these changes may not align with their gender identity, leading to feelings of discomfort or dysphoria.
- Emotional challenges: Adolescence is a time of heightened emotional sensitivity, and navigating gender identity can add an extra layer of complexity. Teens may experience confusion, anxiety, or depression as they grapple with societal pressures and expectations regarding gender roles and expression.
- Supportive environments: Creating a supportive and inclusive environment is crucial for teens exploring their gender identity. Schools, healthcare providers, and families can play a pivotal role in offering acceptance, understanding, and resources to help teens navigate this journey with confidence and resilience.
- Access to resources: Access to resources such as gender-affirming therapy, support groups, and LGBTQIA+ organizations can provide valuable support and guidance for teens experiencing gender nonconformity. These resources offer a safe space for teens to connect with others who share similar experiences and access affirming care.
- Respect and affirmation: Respecting a teen's self-identified gender and using their chosen name and pronouns are essential for affirming their identity and fostering a sense of validation and acceptance. Providing opportunities for open communication and validation of their feelings can help teens feel understood and supported during this critical time.
- Legal protections: Understanding the legal protections and rights afforded to gender nonconforming individuals is vital for ensuring their safety and well-being. Educating teens and their families about their rights in areas such as health care, education, and employment can empower them to advocate for themselves and navigate any challenges they may encounter.
Navigating puberty and exploring gender identity can be a complex and deeply personal journey for teens. By fostering a supportive and affirming environment and providing access to resources and information, we can empower teens to embrace their identity with confidence and live authentically.
Transgender
Individuals whose gender identity does not align with the sex assigned to them at birth as known as transgender. For example, an individual who was assigned female at birth but identifies as a man is a Transgender man, whereas an individual who was assigned male at birth but identifies as a female is a Transgender woman. It is important to note that Transgender is a broad term that encompasses many different situations, not just the ones described here. Some other categories of Transgender individuals include those who are gender nonbinary and gender fluid, both of which are discussed in more detail in the following sections. Another term that is sometimes mistakenly used in place of Transgender is transsexual. While many people refer to themselves using this term, it is important to note this term is usually considered outdated and could be offensive to some people because not all transsexual individuals identify as Transgender and vice versa. Use this term only when the individual has used it to identify themselves first.
Transgender people may undertake several processes to express their gender identity or to live in congruence with their gender. These steps or changes are often referred to as "transitioning," but they vary greatly among individuals, and may occur over a relatively long period of time and in no set order. Internal transitioning can be described both as changing the way one thinks about themselves and about how they act when alone. Some transgender people undertake a social transition, in which they may express their identity through choosing a new name and pronouns, changing their style of dress, hair, and other expressions. Legal transitioning may include a legal name change, as well as updating or replacing one's driver's license, passports, and other documents. Some, but not all, transgender people seek and undertake gender-affirming medical care, such as using prescribed hormones, puberty-blockers, voice changes (either through training or surgery), changes to the chest/breast area, changes to genitalia, and other procedures or treatments. Nurses are very likely to care for patients who are considering or undergoing one or more of these transitions, or who have already done so.
Link to Learning
Some Transgender individuals may choose to undergo gender affirmation surgery. This procedure involves surgical interventions to alter portions of the body to better align with the individual’s gender identity. Learn more about gender affirmation surgery including procedure details, risks, benefits, recovery, and outlook.
Gender Dysphoria
The term gender dysphoria is used to describe the distress experienced by some -- but not all -- individuals when their sex assigned at birth and assumed gender is not the one with which they identify. This is a real health condition that is recognized and defined by the Diagnostic and Statistical Manual of Mental Health Disorders (DSM 5-TR), which is used to assist with diagnosis of mental health disorders by psychologists and psychiatrists (American Psychiatric Association, 2022). Though many transgender, gender noncomforming or questioning people experience challenges and concern about their gender identity, not all experience the distress associated with gender dysphoria. To be classified as dysphoria, significant distress must last for six months, usually with associated impairment in social or other areas of functioning or relationships. Some of the findings in pediatric patients with gender dysphoria per the DSM-5-TR definition include the following:
- a strong desire to be of the other gender or insistence they are the other gender
- a strong preference for playmates of the opposite gender
- a strong dislike of one’s sexual anatomy
- people assigned male at birth, a strong rejection of typically masculine toys (e.g., guns, dinosaurs, action figures), games, and activities and avoiding rough play; people assigned female at birth, rejecting typically feminine toys (e.g., dolls), games, and activities
In adolescents and adults, some of the expected findings of gender dysphoria include the following:
- A mismatch between one's expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics). For example, an individual assigned female at birth expresses themselves as a male and does not feel that the development of female breast tissue aligns with their gender identity.
- Wishing to be treated as the other gender (or a gender that is different from one's assigned sex)
- Wanting to get rid of one's primary and/or secondary sex characteristics because of a mismatch between one's expressed gender and sex characteristics
Treatment for children with gender dysphoria typically begins with counseling and family therapy to explore the child’s feelings about their gender. In adolescents and adults, treatment with hormones may be considered in addition to counseling and therapy.
Gender Role Expression
Strict societal beliefs that define “acceptable” behaviors for each gender are known as gender roles. In most cases, these roles are binary, meaning that they only encompass acceptable behaviors for male and female. An example of a common gender role is that boys should only play with trucks and dinosaurs while girls should play with dolls and have tea parties. Another example would be the traditional beliefs regarding the division of household labor. Traditionally, the female would stay home with the children and handle the cleaning and cooking while males would go to work. In recent years there has been a shift away from these roles for many reasons including nontraditional family dynamics and more women entering the workforce for personal or financial reasons (U.S. Bureau of Labor Statistics, 2023). Despite these shifts, there are still many people who strongly believe in these traditional gender roles, which can make it difficult to change the way society views gender.
The way a person communicates their gender to others is called gender role expression. This expression is external, such as by clothing, appearance, and mannerisms. It is important to note that gender role expression may or may not reflect an individual’s gender identity. For example, a Transgender female may continue to wear male clothing to work due to fear they will be judged in the workplace if they dressed like a female. When people think about gender expression, they are again usually thinking in binary terms, which in this case would be masculine and feminine. However, there are many other combinations in which a person might express themselves as both genders simultaneously or as different genders at different times, which is described as gender fluid. Another example outside of strict masculinity and femininity is called androgynous expression. Individuals who are androgynous express themselves in a manner that does not conform to societal expectations of how males or females should look and/or act (Figure 33.3). They may embrace looks or clothing from both genders, making it difficult to determine whether they identify as male or female. The main takeaway is that all individuals possess their own unique form of gender expression, and it does not automatically determine their gender identity, nor should you just assume their identity based on a simple visual examination.
Gender Binary
The term gender binary refers to the classification of gender into two distinct categories: male and female. Although considered outdated, a number of individuals still believe in this concept. This view about gender asserts that people can only be male or female and that they should conform to societal expectations (gender roles) that are appropriate for their assigned biological sex. This view fails to account for the diversity and complexity associated with gender identity, thus fostering a closed-minded approach to understanding the unique experiences of individuals with “nontraditional” gender identities. This view is inappropriate, but even more so in healthcare settings, as these beliefs can contribute to subconscious biases and subsequently poor health outcomes.
Although some healthcare professionals continue to hold onto this belief and treat patients only according to their sex assigned at birth, others are expanding their knowledge regarding gender care and advocating for better health care for these individuals. A new healthcare-delivery model called gender expansive health care is inclusive and affirms gender identity. Many healthcare institutions are beginning to adopt this model by providing continuing education to healthcare professionals about gender care, implementing gender neutral facilities and signage, and using appropriate pronouns and wording when caring for patients (Center for Transgender and Gender Expansive Health, 2023).
Gender Nonbinary
The term gender nonbinary refers to individuals who have a gender identity that does not fit within the traditional binary framework of male or female. People who are nonbinary may identify with a gender that is somewhere along the spectrum between male and female or separate from these categories. Individuals who are nonbinary may express their gender in various ways, which might include a combination of traditionally masculine and feminine traits, or they might present in a way that does not conform to conventional gender norms. Some nonbinary people use specific terms to describe their gender identity, such as genderqueer, genderfluid, agender, bigender, or other terms that best fit their personal experience. Each term may have distinct meanings or nuances that are significant to the individual using them, so it is important for nurses and other healthcare providers to ask patients which terms they prefer and use them appropriately per the patient’s preferences. Nonbinary individuals may use different pronouns that reflect their gender identity, such as they/them, ze/zir, or others. It is important to respect and use the pronouns with which an individual identifies (North Dakota Health and Human Services, n.d.).
Link to Learning
Watch this video to gain a firsthand account of the perspective of five different nonbinary individuals and what being nonbinary means to them.
Sexual Orientation
The term sexual orientation describes who an individual is attracted to sexually, emotionally, and/or romantically. It is important to remember that this term is completely different from gender identity. Gender identity describes who an individual is, whereas sexual orientation describes who that individual is attracted to. There are many variations of sexual orientation, including heterosexual, lesbian, gay, bisexual, asexual, and questioning, among others. These types are discussed in more detail in the following sections.
Heterosexual
Individuals who are heterosexual, also called “straight,” are sexually attracted to a person of a different gender or sex. There are several common misconceptions about heterosexuality. First, many people think Transgender individuals cannot be heterosexual. This is not true, because a person’s gender identity and sexual orientation are two separate things. If a Transgender man is attracted to women, he is heterosexual, even though his sex assigned at birth was female. Another misconception is that being heterosexual is the only “normal” orientation. Although heterosexuality is the most common sexual orientation, it does not make it any more “normal” than other sexual orientations. Some people have religious or personal beliefs that do not accept other sexual orientations; however, that does not change the fact they exist and are just as “normal” as being heterosexual.
Gay and Lesbian
Historically, individuals who identified as gay or lesbian were often labeled as "homosexual." However, this term is considered outdated and potentially offensive. It should only be used if the individual chooses to describe themselves in this way. The term gay is used to describe men who are romantically or sexually attracted to other men. This term is also used more broadly to describe individuals of any gender that are attracted to individuals of the same gender. Women who are romantically or sexually attracted to other women are referred to as lesbian.
Bisexual
Also commonly referred to as “bi” or “bi+,” bisexual describes individuals who acknowledge they have the potential to be attracted (romantically, emotionally and/or sexually) to people of more than one gender. It is important to note that the person’s attraction to each gender may not occur at the same time or in the same way and that these levels of attraction can vary significantly depending on the individual. Another important reminder is that individuals who refer to themselves as bisexual do not need to have had sexual and/or romantic experiences with more than one gender, or have had any experiences at all. If an individual identifies as being bisexual, they are.
Asexual
Sometimes referred to as “ace,” asexual describes individuals who do not experience sexual attraction or have a lack of interest in sexual activity. Some asexual individuals still experience romantic attraction and form romantic relationships, whereas others do not. Those who do not experience romantic attraction identify as aromantic. Being asexual is different from choosing to abstain from sexual activity for personal or religious reasons; asexual individuals do not have the inner desire to participate.
Questioning
The term questioning refers to a time of exploration and self-discovery about one’s sexual orientation, gender identity, and/or gender expression. Those who are questioning may be unsure about their attraction to others or how they fit within societal expectations of gender roles and identities. Questioning individuals can be of any age and in many cases, this may occur later in life. This is an extremely important process and one that should not be taken lightly. A common misconception about questioning individuals is that they are choosing to be lesbian, gay, or bisexual, which is not true. They are taking the time to explore their internal feelings and attraction to others so that they can become confident in their identity.
Patient Conversations
Patient Questioning Gender Identity
Scenario: The patient is a 23-year-old biological male being seen in the community clinic for a wellness exam. The nurse walks into the patient’s room to obtain a health history.
Nurse: Hi, my name is Marie and I’ll be your nurse today. Please confirm your name and date of birth.
Patient: Sure. It’s James Dobbard and my birthday is 3/29/2001.
Nurse. Great, thank you. Before we get started, I want to gather some demographic information. Do you identify as male or female?
Patient: Well, that’s kind of hard to explain actually. I’ve been confused about that lately.
Nurse: It’s okay to be confused. Do you mind explaining more about your confusion?
Patient: I don’t know . . . I guess I’ve never felt completely comfortable being a man. When I was younger, I always liked “girl” toys and enjoyed things such as painting my nails, but my parents forbid me from doing them.
Nurse: I’m sorry to hear about that—that must have been difficult.
Patient: It was. I tried to just get over it, but as I got older, I still found myself gravitating toward more feminine activities. I enjoy dressing up and putting on makeup. I know that probably sounds weird to you.
Nurse: Not at all. It’s brave of you to tell me how you’re feeling. Do you feel as though you might identify more with being a female?
Patient: Yes, I really do, but I’m too scared to say that out loud to anyone in my life because I know I will be judged.
Nurse: I’d love to connect you to some local resources and support groups for other individuals who are questioning their gender identity. They may have more insight about your feelings and how to approach the subject with your family and friends. Would you be open to that?
Patient: Yeah, that actually sounds great. I would really appreciate it. Thank you, and thank you for not judging me. I can’t tell you how relieved I feel now.