Taking a Sexual History: Words Matter (Part 2)
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Transcript
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introduction[00:00] Introduction
Dr. Meena Ramchandani
Hello everyone. My name is Meena Ramchandani. I’m an infectious disease physician at the University of Washington in Seattle. This podcast is dedicated to an STD [sexually transmitted disease] review for health care professionals who are interested in remaining up-to-date on the diagnosis, management, and prevention of STDs.
For this episode, we welcome back Barbara Wilgus and Bambi Galore. Barbara Wilgus is a program administrator for the STD/HIV Prevention Training Center at Johns Hopkins, and is a certified women's health nurse practitioner who specializes in reproductive health, STIs, and HIV. Bambi Galore is the assistant training coordinator for the Prevention Training Center at Johns Hopkins and works closely with the LGBTQ and kink communities.
identity-vs-gender-usage[00:51] Identity vs Gender Usage
Dr. Meena Ramchandani
What is the difference between gender identity and gender expression?
Bambi Galore
So, gender identity and gender expression are definitely related to each other, but they are two very different things. I'm a very visual type person, so the best way I could use to describe it: Gender identity is how you see yourself in your head. When you are like, "Let me envision myself. Let me close my eyes and envision who I am," that is your identity. When you close your eyes, if you see a woman, guess what? There's a woman living inside that body. If you see a man, there's a man living inside that body. If there's a human, there's a human living inside that body. Whereas gender expression is what you see in the mirror. Gender expression is what you wear, it's how you present. It's the things that you put on your body or do to your body to express your gender, so it's literally the expression of gender.
And one reason it's important to keep in mind that they're related and they often do flow into each other, but they are separate is because some people's gender expression may not necessarily align as one would assume with their gender identity, and that can be for a number of reasons. It could be because they live in a situation where being true, expressing their gender identity, may be a dangerous place for them to be. It may because they're at an age where they aren't allowed to buy their own clothes or they have to wear a uniform for work or for school, and they say that if you have certain genitals, you wear certain clothes, and that, again, has nothing to do with how you see yourself when you close your eyes. So, gender identity is what you see on the inside; gender expression is what is shown on the outside.
Dr. Meena Ramchandani
That's really helpful.
how-to-ask[02:41] How to Ask
Dr. Meena Ramchandani
What are some good ways for providers to ask about gender identity and expression?
Bambi Galore
Well, there's not much to ask about gender expression because it's just the clothes on their back, and to that point being mindful that some people may dress up a certain way because they're going to the doctors. It's a saying as old as time, "Don't judge a book by its cover." That's what gender expression is; it's just the cover that's been put on the book.
When it comes to gender identity, asking someone, “How do you identify? What pronouns would you like me to use?” are usually an indicator, potentially, of how someone may perceive themselves, and also, listening to your client. If your client says, "I am a woman," even if they're wearing a three-piece suit and they have a penis, so one would assume that they are a male or a man. Trust that the person lives with themselves, sleeps with themselves. They are always in their own head. They know who they are. So trusting your clients, if your client discloses their identity to you, that they know who they are. I myself, as a non-binary person, may go in wearing a full face of makeup and a dress, but if I tell you that I'm non-binary, trust that I know that I'm non-binary, regardless of how I may be expressing gender on that day.
gender-fluidity[04:06] Gender Fluidity
Dr. Meena Ramchandani
Yeah. I really like that idea of also expressing gender on that day. Some of my patients are gender fluid and so I ask them questions at every visit. And I think it's helpful to set up the visit so that I can help them the best way that I can.
Bambi Galore
Absolutely. For some people, it does flow, and it can change hour to hour, and for other people, it's a process and it's going from one end of the spectrum to the other. But again, they know that because they're the ones who are putting their heads down at the end of the day, and they're the ones who are getting up with themselves in the morning, and they're the ones having those conversations with themselves all the time. So, trust your clients when they tell you what their gender identity is and honor it.
asking-about-pronouns[04:51] Asking About Pronouns
Dr. Meena Ramchandani
Are there common mistakes that people sometimes make around asking pronouns? And, if so, what are some better ways to approach this topic? You did allude to that, so I appreciate that. I don't like to usually focus on mistakes, but I think sometimes it's helpful to learn from those mistakes. And so, if you've had this experience of learning about this in one of your trainings, I think other providers can learn from that.
Bambi Galore
I think the biggest mistakes that people have around it is the presumption, the assuming of someone's pronouns instead of just asking, "What pronouns would you like me to use?" I also say take out that word preferred because I may prefer vanilla ice cream, but if you offer me chocolate ice cream, I'll eat it. I don't prefer to use they/them, that's who I am. There's no preference in that. Some people may be ambivalent to pronouns, but people who are ambivalent to pronouns have a long relationship that has developed them to that point. There's an importance in what pronouns you use, so removing the preferredness of it, because it's not a preference, it's who they are, and just asking out front. And if one does make the mistake, it doesn't have to be a big thing. Just be like, "Sorry," restate the statement using the correct one, and also using the pronouns regardless if the person is present or not.
That's the biggest mistake that I see, is people will be like, "Oh, your sheet says your pronouns are this. I'm going to use these pronouns with you, but based on your sex, I'm going to use a different set of pronouns when I talk about you to another clinician." And that right there is where the biggest faults start to happen in the ground, as far as places where things can become problematic, and also, the more you practice using the right pronouns, the easier it is.
Barbara Wilgus
Yeah, that was what I was going to say. We train a lot of providers, and many times people say, "I don't really know how to do that. I feel uncomfortable with figuring out how to ask for pronouns." And so, just doing the 100 sit-ups each day, of normalizing, "Hi, I'm your provider. My name's Barbara; my pronouns are she/her." Then it's just in your brain because you've been doing sit-ups until you get physically fit. I guess in this case, genderly fit, I don't know, to ask or to have an awareness. And, in general, I think the more standard and normalized it becomes to just start at the beginning. "My name's Barbara; I'm your provider today. Pronouns are she/her." And the person says back, "I'm Bambi, I'm your patient today. My pronouns are they/them," and go from there.
Bambi Galore
I was going to say the example that Barb gives is such a great one because when you give your pronouns, we as human creatures have this copycat built into us. So, if you give your pronouns, there is a better chance that the person who you gave your pronouns to will give their pronouns back. Sometimes, it doesn't work, but there's a better chance that they're going to than if you don't say your own. Most people are going to be a little hesitant to offer that up if you haven't offered up yours first.
Dr. Meena Ramchandani
That's really helpful.
sex-birth--genital-anatomy-questions[08:13] Sex at Birth & Genital Anatomy Questions
Dr. Meena Ramchandani
Trainees have asked me this question and I pose it to you guys. What's a good way to ask patients about genital parts? And is it okay to ask a patient what was their sex assigned at birth?
Bambi Galore
I think that it is perfectly okay to ask because that may align with what type of tests you need to do. Starting it off with giving a disclaimer, "I want to make sure we get the right tests for you so that we can make sure that we are taking care of your health as best way possible. Would you mind telling me what sex you were assigned at birth?" Or, "What genitals do you currently have?" Because, to that point, if someone has had any type of gender-affirming surgeries to their genitals, it may or may not matter as much. But if you ask, "What genitals do you have now? Are these the same ones you were born with? Awesome." But you've already set that disclaimer, "I'm asking these questions so that we can get you tested in the right places with the right tests."
Barbara Wilgus
Right. Like, it's certainly okay to ask about an “organ inventory.” I think is what the weird thing it says in Epic, which makes me feel like a zombie or Frankenstein, I don't know. But, I mean, in all seriousness, it's definitely okay to ask when you are asking because of medical reasons. When you're asking because you just want to know, it's clear and it's awful, so don't do that, providers. If you're curious, keep your curiosity at home and read a book or something. But with patients, when you actually need to know the information, again, clarifying why you need to know and getting consent, and then ask away.
Dr. Meena Ramchandani
That's really helpful, with the question relation to STI testing, knowing the body parts, to do the appropriate testing.
polyamory-terms[10:14] Polyamory Terms
Dr. Meena Ramchandani
My next question is what are some poly language definitions that would be helpful for providers to know more about?
Bambi Galore
I think understanding, one, that no poly relationship is going to look like any other poly relationship is a good place to start. Often, it's a weird thing in our head where we know that no monogamous relationship is the same as any other monogamous relationship, and yet there's an assumption that in polyamory, that that is going to be the case. And yet, in polyamory, it's going to be a widespread, even within one "relationship polycule."
So, polycule is a term that is used to describe a connection of relationships, and again, they may look completely different. Some may be married, some may be a one-night stand, some may be someone that they're seeing on the side, someone may be a nesting partner. But that amalgamation is called a polycule. Another term that's sometimes used is constellation because if you think of how a star map is drawn (a constellation), that's how relationships can look.
Terms like primary and nesting partner are ones to be aware of because those usually signify that this is a person that a person is probably tied to in some form, other than just a romantic or intimate relationship. Usually, it may be someone that they share a house with, that they share a child with. There's some type of financial or lifestyle combining of the two. Nesting, bird's nest, kind of makes sense. Primary goes back to a practice that is still practiced because, again, every poly relationship looks different, which was more hierarchal in how relationships were dealt with. A lot of relationships nowadays don't necessarily follow that same hierarchy of "This person is primary, this person is secondary" as far as getting their needs met. But that language around primary partner may still be used to describe the person with whom they are married, they share a house with, they share a car with, they share a child with. There's some other thing that's tying them together than just the relationship as a whole.
Other poly terms that I think are really important: NRE (new relationship energy) is something to be aware of and to talk about. It's something that happens in monogamous relationships. But you sometimes find in poly relationships that people are chasing that new relationship high. It can sometimes cause people to do behaviors that are less than potentially best for their health. To that, the term ethical non-monogamy, or I prefer consensual non-monogamy because to say ethical non-monogamy is eluding that there's something unethical about non-monogamy as a whole. But it is a term saying that we are people who are having open communications around our non-monogamy, and that's where I personally prefer the term consensual non-monogamy. Everyone involved is consenting to the non-monogamy that is happening.
Compersion is also another term that is often newer for people who aren't in the poly circles. Compersion is a feeling that we all feel, but we don't realize it. It is the joy that you feel for your partner in whatever their relationships are occurring elsewhere in their life. So, if my partner was to go out on a date, I would have a feeling of giddiness over wanting to hear how the date went, wanting to know did they have a good time, did they enjoy themselves, that excitement over their excitement.
The best way I find to describe it to people who are monogamous, and they're like, "That makes no sense to me. I would feel jealous if my partner went out." I say think if your best friend won a trip to go to France. They have always wanted to go to France, your best friend won a ticket to France. You can't go with them to France, but you're still excited that your best friend gets to do that. You're still excited that your best friend gets to live their best life and gets to have this experience that they wanted, and you can't wait to hear about and see the photos when they get back. You can have just as much joy that they went on that trip, even though you didn't. That's having compersion for your best friend. That's a feeling that I think often people don't understand because it is the opposite of jealousy. You're not jealous that your partner is going out on that date. You're excited that they're going out on that date because you get to hear about it afterwards, and you get to be excited that they had that joyous time.
Yeah. Compersion, NRE, polycule. Those are the ones that I feel that come up in conversation most often. Do you feel compersion when your partner goes out? "Well, no, I don't. I actually feel ..." Okay, well maybe there's a place that you need to have more conversation with your partner around how you are practicing your non-monogamy because if you're not feeling those things, it just means more talking, more processing. If there's something about polyamory that people don't realize until they are in it is, it's a lot of talking. It's a lot of talking, and a lot of processing, and a lot of Google Calendars.
Dr. Meena Ramchandani
Wow, that was a wonderful overview. I learned so much. I did not know a lot of those definitions or those words, so it was really helpful for me. Thank you.
Bambi Galore
Absolutely. Yeah, those are the words I would say are the most important or that you're most likely to hear in an open beginner conversation around polyamory. And then again, from there, you may have someone be like, "Oh, well, I'm in a throuple." What does that mean to you? "Oh, I'm involved in a solo monogamous relationship." What does that mean to you? And, that's where that comes in, to find out a little bit more, because again, those dynamics of how those relationships look are going to be distinct to those relationships themselves.
Dr. Meena Ramchandani
I really like that question, “What does that mean to you?” It helps the patient to define what it means for them, which might be different than another patient.
Barbara Wilgus
I'll add, too, disclosure: I am not polyamorous or I'm not in a polyamorous relationship. I'm not in any relationship right now. But I have vast amount of friends that are in poly relationships. And, when you hear the words that are used to describe relationships, there do tend to be common languages, common words, and when I am seeing a patient, when I ask them about, "Who are you having sex with?" And somebody answers, "Well, I'm a unicorn," I know instantly that's a common word for basically how to describe one's self in relation to others. And, that lets me know how to enter the rest of my history taking, too. If you start hearing words like "my primary partner" or "I'm fluid-bonded with this person," that language set is very common with poly communities. When you listen to your friends too, to then understand it actually helps you listen to other human beings, too.
Bambi Galore
And that’s actually a good one, too, Barb, and I always forget it because the circles I float in are kink and poly circles, and so a lot of these terms I'm like, "What terms would you need to know? This is just everyday language." But the term fluid-bonded. I don't realize how much that's not used in heterosexual, monogamous relationships. But fluid-bonded, for those who don't know, means that you are having sexual intercourse where there is fluid transference, so no barriers of any sort, so there is a bonding of bodily fluids, fluid-bonded.
most-common-questions[17:56] Most Common Questions
Dr. Meena Ramchandani
You guys give a Words Matter lecture, which is really helpful for providers and public health professionals. What's the most common question you get in this Words Matter lecture, and what's your answer?
Bambi Galore
Funny enough, and I will be more than happy until I am no longer needed at the PTC, to give a presentation on pronouns. But the biggest things that people ask is how to use pronouns, why does it matter, what difference can it make. And, to those of us who spend any time thinking about it, it's like, "Well, of course it matters." Or it shouldn't matter because we should be beyond that point, and yet, because there was a period of time in which pronouns themselves became a politicized issue, I think there's still a lot of trepidation around what it means around pronouns. So often, most people, once they realize that pronouns are just something that you're using instead of someone's name, that's all you're expressing to people, they're able to have an aha moment like, "Oh, it doesn't matter, but it does."
When we train in-person, we give out pronoun pins, and someone came up and was like, "I don't know what pin to take." And I was like, "Okay. If you left your book on that table, would they say she left her book, he left their book, or they left their book?" The person went, "She left their book." I was like, "Okay, your pronouns are she/her." And you could just see the flash, like the light bulb go off where it was like, "Oh, that's literally all it is, is instead of saying my name, what would you say instead? Oh, okay."
And yet, to the point, if someone has dealt with their gender identity, if they have dealt with who they are on the inside, that little use of the proper pronoun, of using the pronoun that matters to them, can make a huge difference in the trust that they have, in their ability to be open and honest with you. Because if you tell someone, "Hey, my pronouns are this," and they continue to not use them, all you're hearing as a client is, "You do not care what I tell you. You're not listening to what I'm telling you, and you think you know better than me about myself." And, you're not going to build trust where you're actually going to be able to give them the care that they need if you're doing that.
Barbara Wilgus
I persist in the belief that people want to do right by other people, and so, people want to be correct, like they want to understand how to say pronouns or what their pronouns are.
We did a training last month, that was an in-person training, that was saying taking a sexual history, words matter, and a deep discussion of pronouns and pronoun use. At the end, Bambi and I were packing up to leave, and the administrative assistant that was outside, I guess, I don't know who they were, but somebody who had a desk right outside, stopped us, and said "Thank you. I was listening from outside. I have nephews who are non-binary and I've been trying to really be cognizant, mindful of saying they/them."
Bambi Galore
It was one of those things where we much prefer an ally to a non-ally, and we love people who are willing to learn and grow. I had to have my own personal, internal little giggle when it was like, "I have nephews who are non-binary." I was like, "Just to help you on your language journey, there is actually a term that is for non-binary children of your siblings, and that's called nibling." She's like, "Nibling?" I was like, "Yes. You have niblings instead of nephews or nieces." She was just like, "Oh, this is great! This is a new term. I can't wait to tell them that I've learned this and I can use it." Showing the effort, making the effort, not centering one's self when one does make the mistake because we all are human. I use they/them pronouns, and I mess up people's pronouns, but I don't center around my mess-up. I center around getting the correct pronoun for that person.
resources[22:16] Resources
Dr. Meena Ramchandani
If providers wanted to learn more, what are some good resources you recommend around gender identity, gender expression, and pronouns?
Bambi Galore
One resource that I highly recommend is the Trans Student Educational Resources (TSER). I recommend them because you're hearing it from people who are living it, and I think when you get information that is from the actual population versus what people have decided should be said about a certain population, you're going to get a more authentic answer to your questions and a better understanding, because you're understanding it from the person who's actually living that experience.
Dr. Meena Ramchandani
That's really helpful. Thank you so much. This has been such an informative session and I learned a lot from speaking with both of you. Thank you for being with us here today.
Barbara Wilgus
Thank you for having this wonderful podcast.
Bambi Galore
Absolutely. Thank you so much for having us.
credits[23:15] Credits
This podcast is brought to you by the National STD Curriculum, the University of Washington STD Prevention Training Center, and is funded by the Centers for Disease Control and Prevention.
Transcripts and references for this podcast series can be found on our website, the National STD Curriculum, at www.std.uw.edu. Thank you, and have a wonderful day.