A recent survey found trans people do not always understand how sexual health advice applies to them when clinicians talk about gender rather than anatomy, report Melanie Newman and Julie Bindel.
Since 2019 the British Association for Sexual Health and HIV (BASHH) has recommended sexual health clinics ask service users for the gender of their sexual partners, rather than if they are male or female.
But a report of a survey by Waverley Care and Scottish Trans of trans people’s access to sexual health services in Scotland found references to gender were causing confusion.
“Participants told us that they lacked access to tailored information to enable them to understand how sexual health advice applied to their circumstances,” the report said. “This was especially the case if risk factors or prevention options were communicated with reference to gender, rather than anatomy.”
The report added that participants cited access to HIV preventative drug PrEP, as an example of this confusion. “Many non-binary participants were unable to understand whether they would be eligible for PrEP, despite reporting potentially high-risk sexual behaviour,” it said.
BASHH also advises clinicians to use patients’ preferred terms to describe their anatomy and discuss their bodies using models or diagrams rather than “anatomically correct terminology”.
Dr John McSorley, President of BASHH, said it is important language in sexual health consultations is inclusive of all genders while also obtaining all the relevant clinical information.
He explained: “It is generally good practice for all medical history taking to start with more open questions and we feel that asking about the partner’s gender accomplishes that (rather than asking a closed question that only gives the option of male or female). Of course, the clinician will follow that up with more detailed questions.”
“Healthcare workers, should treat everyone politely and sensitively, but viruses do not recognise pronouns.”
But critics say ignoring biological sex in healthcare settings and health data risks obscuring medical realities for patients and policy makers.
Maya Forstater, of the campaign group Sex Matters, said when it came to healthcare not recording birth sex was “reckless”. “Healthcare workers, should treat everyone politely and sensitively, but viruses do not recognise pronouns,” she said.
A decision to drop a question about biological sex from official surveys about HIV and STIs has also proved contentious.
Public Health England told sexual health and HIV clinics to stop collecting data on the sex of service users after advice from the LGBT Foundation that it may be unlawful to do so.
Clinics now ask patients for their gender identity and give them the option of preferring not to say if this is different from their “gender assigned at birth”.
The changes were aimed at capturing data on the transgender population. But one data expert said the decision to omit the sex question risked obscuring what was really happening with HIV and other sexually transmitted infections (STIs). Professor Alice Sullivan, head of research at the Social Research Institute at University College, London, said conflating sex with gender could make it difficult to identify and understand differences between males and females.
“Sex is an essential piece of information, both for the effective treatment of individual patients, and for health research. There is no reason why we cannot record a patient’s sex and gender identity as separate variables rather than confusing the two.”
The idea that it may be illegal to ask for a respondent’s sex in a confidential survey has “no foundation,” added the professor, who has herself been the director of large cohort surveys.
The suggestion of illegality was refuted by the recent Judicial Review judgment on the sex question in the England and Wales census.
The US’ HIV surveillance system has a 2-step question which asks for participants’ sex and then for their gender identity. The US system will not allow data to be passed from the clinic to the central survey administrator if the section on sex is not answered.
Public Health England administers the HIV and AIDS Reporting System (HARS), which collects data on all people accessing HIV Services, and the Genitourinary Medicine Clinic Activity Dataset (GUMCAD) collects data on STI tests, diagnoses and services from all sexual health clinics in England.
The HARS questionnaire used to start with a question on sex, with a binary choice of responses (“male” or “female”) and no opt-out. In 2015 Public Health England removed the question from the form, stating: “Work with the LGBT Foundation and the transgender community has informed that it is not good practice or possibly even legal to ask for gender at birth therefore we propose to remove this field from the dataset.”
The questionnaire now asks: “How do you identify your gender?” The options for response are “woman (including trans woman)”, “man (including trans man)”, “non-binary” or “in another way,” and an opt-out is offered in the form of a “prefer not to say” box.
The survey then asks: “Is this the same gender you were assigned at birth?” The options for response are “yes/no” and “prefer not to say”.
In 2018 the GUMCAID questionnaire was changed to include the same questions. Guidance to the questionnaire advises that both gender identity and assigned gender at birth may change.
The latest GUMCAID dataset released contains STI diagnoses and rates broken down by “gender” (male/female). Public Health England’s notes to the statistics advise: “Male gender includes transgender (trans) men and female gender includes transgender (trans) women”. The published data does not allow analysis of differences in rates of diagnosis between males and females, because the categories collected are now both mixed-sex.
We invited Public Health England to comment but it declined. One clinician supporter of the data system, who asked not to be named, said the questions allowed respondents of each biological sex to be identified by working backwards from the “gender assigned at birth” question.
Very few people opted out of answering this question, the clinician added. “We have to give people choices about revealing their gender or gender assigned at birth, just as we give choice about answering questions on sexuality. Over 99.9% of people answer these questions so whilst opt out is possible it is not common practice.”
Our source accepted that the sex of non-binary participants could not currently be determined but said the “gender assigned at birth” question would be changed in future to capture whether individuals were “assigned male or female at birth”. Meanwhile, numbers of people currently identifying as non-binary or a “different gender than at birth” were too small for their inclusion to significantly affect male and female datasets.
“The question has been well accepted by community groups including those focused on women’s issues,” our source added. “The dataset will continue to be revised to ensure it is relevant and meets the needs of most affected communities.”
“This has the potential to substantially skew research results for both gay and lesbian and trans people.”
Professor Sullivan said the absence of a question on sex may also compromise the categories for same-sex attracted and opposite-sex attracted people.
For example, GUMCAID asks if respondents have opposite-sex partners (which the questionnaire defines as men and women who have sex), or same-sex partners (defined as men who have sex with men). Similarly, a question on the HARs form asks if respondents were exposed to HIV through sex between men.
It is unclear how non-binary and trans people and those with trans partners would answer these questions, given that both the terms “men” and “women” are explicitly defined as referring to either sex.
“This has the potential to substantially skew research results for both gay and lesbian and trans people,” Professor Sullivan said.
Our source said they were confident data could be accurately segregated by sexuality as well as by gender and “gender assigned at birth”.
Numbers of trans respondents are small, but critics fear the impact of their inclusion in an opposite-sex group may be significant when the data is analysed and presented at a granular level.
PHE published results from the national HIV self-sampling service in 2019. Its report counted trans men who have sex with women (ie females with exclusively same-sex partners) in the results for heterosexual men and presented transwomen in a dataset with women.
The report shows that 10, or 5.8% of trans respondents had condomless sex with more than 12 partners in the previous year – a higher percentage than that for gay and bisexual men. The figure for women (including trans women) was 62 (1.3%). If all 10 trans respondents in the category were transwomen, their inclusion will have increased the total figure for women by a fifth (from 52 to 62) and the percentage from 1.1% to 1.3%.
Melanie Newman is a freelance journalist covering health, legal and other areas.
Julie Bindel is a journalist, author and feminist campaigner. Her new book Feminism for Women: The real route to liberation is out now and published by Hachette.
Photo: Radharc Images/Alamy Stock Photo