My birth sex is part of my medical history; it should be as private as the rest of my medical history

Every year, I receive an envelope from the Ontario Ministry of Health with my name on it and CONFIDENTAL, or perhaps even IMPORTANT, written across it in bold capital letters. It is my reminder that I am behind on my cervical cancer screening, along with a note on the importance of obtaining regular Pap tests to lower my risk of developing a condition that, until recently, was one of the most lethal forms of cancer for women under 50.

And every year, despite my being medically trained and knowledgeable about the benefits of cervical cancer screening, I deposit the letter in my recycling; I am not going to see my doctor to discuss my need for a Pap smear. I have no cervix and have never had one.

Twenty-four years ago, I swore in front of a magistrate in California that I was changing my name and my gender to reflect my intent to live the remainder of my days as a woman; I was recorded into the register as Laura Targownik, female.

When I returned to Canada several years later, my California driver’s license and a sworn affidavit allowed me to change my passport; a birth certificate was issued stating I was born female, my history of being male expunged. As far as the government is concerned, I have never been male, hence my need to be recalled for cervical cancer screening. And because I used to avoid disclosing my trans history when receiving health care, I have also been asked to do more than a few pregnancy tests, (as is the case with most women, my protestations that there is no way I could possibly be pregnant have generally fallen on deaf ears.)

In all of Canada, requesting a legal change of gender does not require anything more than making a sworn declaration attesting to your preferred gender identity; there is no requirement for any medical or surgical interventions to have occurred or that the person requesting the change is actually living in the stated gender role. Therefore, being legally male or female does not necessarily imply a person has a morphology or physiology generally associated with being born male or female.

As such, there can be serious risks to patient health and safety when birth sex is presumed based on appearance or on the gender indicator in the medical record over and above getting reminders for cervical cancer screening or being tested for impossible pregnancies; in one widely reported case, a pregnancy complication resulting in fetal death was originally overlooked in a trans man who has an intact and functional female reproductive system. While adverse events related to misrecognition of discordance between one’s apparent gender and birth sex are rare, they tend to get outsized attention in the media environment, creating the perception that this is a highly prevalent situation that needs a policy-based solution.

It is in this societal context that the U.K. released the findings of the Sullivan Report, which was commissioned to evaluate how sex and gender should be officially reported and measured by the government, including in health-care record keeping. Most notably, the report strongly recommended that birth sex, being immutable, should be the preferred categorization for gender for identification on vital records, as opposed to gender identity, which is fungible, and where standards for obtaining a legal change in gender can change over time. In response, the National Health Service decided that it will no longer issue new identification documents for persons who have pursued a gender transition, thus retaining a person’s birth sex as a primary identifier.  While this guidance is only directly applicable within the U.K., it is expected to influence policy across the West, including in Canada, where politicians have been withdrawing support from previously implemented laws and policies that have facilitated access to transition and to transition-related health care.

I accept there may be compelling reasons for health-care providers to have knowledge of my birth sex; my chromosomal makeup and history of having been exposed to testosterone impact my current and future health (for example, I still have a prostate gland and may be at risk of developing prostate cancer), though it still needs to be understood in the context of my current mostly female physiology and external anatomy, as well as my lived experience as a woman in society. Being recorded as male in my official record does not lower my risk of developing breast cancer related to my being on female hormones for most of my life, nor will it reflect my increased risk of being a victim of intimate partner violence. Using male reference ranges on my blood work will make it appear that I am anemic when I am not, or may mask deterioration in my renal function.

Most importantly, insisting on the primacy of birth sex in a health-care environment may discourage people like me from seeking health care in a timely fashion.

Most importantly, insisting on the primacy of birth sex in a health-care environment may discourage people like me from seeking health care in a timely fashion. When I was less up-front about my trans history, I would generally not mention it to health-care providers whom I was unfamiliar with unless I believed it to be clinically necessary; I did not want this aspect of my history to be a distraction from the reason I was seeking health care, nor did I want to put myself through the discomfort of acknowledge of outing myself to a physician or curse who may be ignorant about trans people, or worse, transphobic.

My concerns at the time were well founded: up to 50 per cent of trans people have reported being discriminated against, harassed or mistreated in a health-care environment. This is unlikely to improve if the message we are sending to trans and gender diverse patient is that their lived experience is of secondary importance or that changes induced by hormones and surgery are less relevant to one’s current health

Insisting on primary birth sex identification for trans people does little to improve the health of trans and gender diverse persons; it merely exchanges one theoretical set of adverse health care outcomes for others that are definite and far more impactful. A history of being trans or having transitioned may be clinically relevant in specific contexts and should be treated like any other piece of personal health information –  stored discretely and subject to the same rules as any other personal health information.

As a potentially relevant part of my history, governments should retain the ability to maintain a private record of birth sex, which can be included as part of the medical record. However, there is no more reason for birth sex to be displayed on my publicly facing health card or any other piece of identification than my family history of heart disease or smoking on my card; both are clinically relevant, but not anyone’s business aside from clinicians directly involved in my health care.

Physicians are quite capable of performing accurate assessments and making difficult diagnoses when clinical findings are conflicting or lacking. They can also manage to provide high-quality care for people whose recorded gender may not align with their birth sex, all while allowing trans people to live in dignity and avoid unnecessary disclosure of their private medical history.