Fighting erasure: Navigating the new environment of gender-affirming care

Joseph Cherabie, MD, MSc

2/20/2025

In this post, Joseph Cherabie, MD, MSc, shares their views as a sexual health provider on the Trump Administration’s executive order on gender and sex and explores possible approaches for medical providers navigating this new environment. Dr. Cherabie’s views do not reflect official IDSA or HIVMA clinical guidance.

An early act of the new Trump Administration was to publish an executive order — “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government” — that focused on the “biological reality of sex” and states that “sex shall refer to an individual’s immutable biological classification as either male or female … and does not include the concept of “gender identity.” (1)

The order defines what it means to be a female and male, with the former being “a person belonging, at conception, to the sex that produces the large reproductive cell” and the latter belonging to the sex that “produces a small reproductive cell.” The order also says that “Gender ideology replaces the biological category of sex with an ever-shifting concept of self-assessed gender identity” and “reflects a fully internal and subjective sense of self, disconnected from biological reality … and cannot be recognized as a replacement for sex.”

The federal government then sent out a clarification, “Defining Sex” (2), in which they clarified that “there are only two sexes, female and male, because there are only two types of gametes” with sex being determined by whether “the person is of the sex characterized by a reproductive system with the biological function of producing eggs (ova) or sperm.”

This executive order sent shockwaves through the medical community, especially those who focus on sexual health. Following the order’s release, federal health agencies were directed to remove — including from datasets — any mention of transgender individuals, individuals assigned male or female sex at birth, LGBT+ individuals, gender and pregnant persons — erasing a portion of the population. The directive leaves many of us in the dark on how to treat an already largely neglected population. (3)

Sex and gender

I agree that sex is different from gender, with sex being assigned at birth based on the appearance of external genitalia. Not everyone agrees with me with, however. Some say that chromosomes determine sex and that sex is determined by biological traits, but that’s not always true. Many people have never had a chromosomal analysis, and people can be born with XY chromosomes — those typically associated with male sex — but appear female due to lack of androgen receptors. This is an example in a long list of ways in which individuals may have differences in sexual development, not to mention the fact that intersex individuals exist — and are as common as redheads! (4)

If we follow the definition of sex proposed in the executive order, all of us are female, because at conception, we develop as females until androgens kick in to make some of us develop as males. This definition of sex is not accurate and creates confusion. This is likely why they issued the “Defining Sex” (2) document, which muddles the picture even more. Here they stated that “some females or males may not or may no longer produce eggs or sperm due to factors such as age, congenital disorders, or other developmental conditions, injury, or medical conditions that cause infertility.” They also state that there cannot be a “third sex” because there is no “third gamete.” So, by definition, males and females are determined by their genetics, except when they’re not, by their gametes, except when they can’t produce them, and it is “immutable” and “unchangeable,” except for all the reasons listed above.

But let’s move on to gender. The definition here is not that bad, except for one glaring issue: The order states that gender “reflects a fully internal and subjective sense of self,” meaning gender is to be determined by each individual. Their language here is purposeful, that this is subjective, whereas sex is objective, and therefore immutable. In other words, it doesn’t matter how you identify, your sex is what it is — a “biological fact.”

This assumption is dangerous, because gender is important! It is how people express themselves, how they feel about themselves, and how they would like to be acknowledged. Accepting this means people are being acknowledged as they desire. Gender affirmation is for everyone, not just trans folks. The majority of gender-affirming care we provide is for individuals whose sex and gender align (cisgender). Examples include testosterone replacement therapy, estrogen replacement therapy and breast augmentation.

These are meant to allow people to present themselves as they would like to. And when we see that individuals who are transgender are less likely to access care due to having been misgendered or abused (3), the effects of erasing gender-affirming care and acknowledgment for this population become very real. Our biggest problem here is we are equating sex and gender, which biology has nothing to do with how a person presents as masculine or feminine, which has all largely changed over time.

What now: Navigating the new environment

The perspective of the new Administration is that sex is all there is and defines who you truly are. But every major medical association acknowledges that there is more to individuals than their sex assigned at birth, with gender being a mix of identity, expression and social norms. (5) How do we as medical providers navigate this new environment? Maybe we remove gender from the equation, only in clinical settings, and move towards a more gender-neutral approach. This could help patients of a variety of different identities and expressions and allow us to be respectful, inclusive and possibly avoid trauma.

Many patients have told me that they don’t want providers to fixate on their gender identity and just want to be acknowledged by their name and pronouns and receive individualized care based on their anatomy. On the flip side, providers, who often misgender patients, intentionally or unintentionally, often say they just need to know where and what to swab or examine.

Here is where an anatomical survey is essential. This survey is often done on intake forms in doctor’s offices, before any person-to-person interaction. These surveys ask what anatomy you were born with and what anatomy you currently have. If you have a prostate, you may need to be screened for prostate cancer. If you have a vagina, a pelvic exam may need to be done. If you have a cervix, cervical cancer screening is necessary.

In a clinical setting, it turns out, much of the reason we need to know patients’ genders, beyond how we refer to patients, is for research and metrics. Now here is the danger: Erasing individuals from research and metrics, especially LGBT+ individuals, increases inequity, trauma and disparities, which are already present. My goal is to provide patient care, first and foremost; this may be a way to continue person-centered care in the current environment while we work to restore care driven by science and compassion.

A way forward for clinical practice

What does this look like in clinical practice? Focusing on using gender-neutral language and pronouns as much as possible in clinical documentation and language. Instead of saying “he/she had a new sexual partner,” saying “they had a new sexual partner.” They/them pronouns are a great means of being inclusive, are not offensive and are terms you likely use all the time. They make templates easier as you don’t need to switch pronouns and can be applied broadly both to cisgender and gender diverse folks, without the possibility of insulting or misgendering anyone.

Many gender-diverse folks actually ask for people to default to they/them pronouns if people are unsure of a person’s gender expression, and if they make their pronouns known, then pronouns can be changed. You can also encourage a patient to share their name under “nickname” in electronic medical records and use secure notes to share their pronouns once they are known.

What about clinical guidelines that refer to men and women? It’s much easier to say “individuals with a penis/vagina.” It removes gender, is anatomically correct and tells us exactly what we need to do with each patient, based off their anatomical survey. I use this in all my documentation, lectures and textbooks I write in. Most guidelines say men or women and leave it unclear if the terms mean cisgender men, trans men, cis women or trans women — not to mention neglecting nonbinary folks. Instead, you can say “individuals with a penis” or “individuals with a vagina,” which encompass all genders who may have that anatomy and can be made more specific for each person and their anatomy.

These are confusing times for many of us as clinicians. Many of us fear for our jobs and our ability to take care of our patients, with some health systems fully removing any survey of individuals’ sexual orientation or gender identity. But the current situation may also allow us to speed up our move to more gender-neutral language in guidelines and clinical practice, a move we have been trying to make for years, for all the reasons I listed above.

Let me be clear here, I am not trying to invalidate the experience of gender-diverse individuals. I myself am gender diverse and want to be acknowledged how I present. And while anatomy doesn’t define a person, in a clinical and medical education setting, it helps focus the physical exam and clinical thought process. I am asking us to divorce sex from gender, and in a clinical setting, we may have to focus more on sex, but that doesn’t negate gender. We can continue to advocate for our patients’ rights and acknowledge their existence beyond our clinics. But the approaches described above may allow us to practice clinically and respectfully take care of patients in an environment hostile to science that also denies the strength and beauty of diversity.

References

Science Speaks