Between 0.5 percent and 1.3 percent of the U.S. population identifies as transgender. Transgender individuals need excellent orthopaedic care just as much as other patients. However, interaction with the medical establishment has historically been difficult for these patients. A better understanding of gender identity can help us to treat transgender and nonbinary patients with care and respect, forming a therapeutic alliance and allowing us to provide them with the best possible orthopaedic care.

A useful distinction is the one between sex and gender. In very simple terms, sex can be thought of as referring to biology, whereas gender can be thought of as referring to identity and presentation. People whose gender identity matches their biological sex are referred to as cisgender, whereas people whose gender identity is opposite to their biological sex are referred to as transgender. Some people may not fall neatly on a binary sex/gender spectrum and may prefer to be called nonbinary, gender nonconforming, or genderqueer.

When treating transgender or nonbinary patients, it is essential to use correct pronouns. Addressing an individual with their preferred pronouns demonstrates respect and understanding, whereas misgendering a patient is disrespectful and may start an encounter on the wrong foot. The best way to ascertain which pronouns to use is to ask. One might express one’s own preferences, such as, “Hi, I’m Dr. Franklin, I use she/her pronouns. How may I address you?” Or you could include a question about gender and/or pronouns on a new patient intake form. Pronouns may include she/her, he/him, and they/them for nonbinary people. Some patients may prefer pronouns that may sound unusual to the orthopaedic surgeon, such as ze, zhe, or xe. Although some of these may seem unfamiliar at first, with practice they will come naturally, and their use will help transgender and nonbinary patients feel seen and respected, leading to a positive clinical experience for both doctor and patient.

Transgender patients may also have changed their name from their birth name. It is important to determine by what name they would like to be called and ensure that the correct name is used. In particular, deliberately using the old name is quite disrespectful and sometimes called “deadnaming.” Of course, there may be times when physicians or staff use the wrong name or pronouns by mistake; this is understandable. At that point, it’s best to acknowledge the error, apologize, and move on with a system in place to keep mistakes from happening repeatedly.

Correct names and pronouns can sometimes present problems for electronic medical record systems that were not designed to allow for nonbinary pronouns or a name change that has not yet been legally certified (a particular problem during the pandemic). Some systems have been updated to allow for tabs to indicate preferred pronouns and names. In the absence of that, asking every patient (every time) so as not to stigmatize particular patients may be a useful alternative.

Other terminology that may be relevant includes descriptors such as trans man/male or trans woman/female (nouns to identify a person who is transgender) or transmasculine and transfeminine, which can also refer to someone who is transgender in the direction of male or female without necessarily conforming fully to that gender.

Transgender patients may pursue a variety of gender-affirming treatments, from hormonal supplementation to surgery. Surgery may be performed on the face, chest, and/or genitalia. Transgender women and nonbinary people may wear chest binders to flatten the breasts. Of particular relevance to orthopaedics and bone health is hormone therapy. Transgender women may take estrogen as well as androgen-lowering agents such as spironolactone. Transgender men may take testosterone. Transgender adolescents may suppress puberty via gonadotropin-releasing hormone analogues followed by cross-sex hormone therapy. Much remains unknown about the effects of hormone supplementation on long-term musculoskeletal health. However, it has been observed that transgender women tend to have low bone density prior to the start of gender-affirming hormone therapy, which does correct with estrogen administration. The contrary does not seem to be the case in transgender men. Of particular relevance in the perioperative period, estrogen therapy may produce an increased risk of thromboembolism. Further research is needed to better examine the effects of hormone therapy in orthopaedics.

Transgender athletes have been a recent focus of media attention. The United States does not, as a whole, have a consistent policy on transgender athletes’ participation on sports teams. Policies frequently differ from state to state and school district to school district and may also depend on whether an athlete attends public or private school. Policies may also change with changing school boards or state legislatures. For the most part, decisions about what teams an athlete can play on are not up to the orthopaedic surgeon, whose role is to keep the athlete in the best physical condition possible and support them however possible.

Anecdotally, I feel as though I am seeing younger patients who are identifying as transgender or nonbinary. I conducted an informal survey of parents of young children to find out what has been helpful or made their children feel welcome (and the reverse). Most parents stressed the importance of using correct names and pronouns, as well as staying away from gendered language in general. Several also mentioned how reassuring it is to see signage or visual representations signaling acceptance, such as LGBTQ (lesbian, gay, bisexual, transgender, or queer [or questioning]) or transgender flags or pins or “all are welcome” signs or posters.

Finally, it is essential to not make assumptions, to keep an open mind, and to be comfortable with any questions patients might ask—or to be comfortable acknowledging when we don’t know the answer.

For surgeons and staff for whom this is relatively new information, it can seem overwhelming or like one is being expected to learn a new way to speak. However, as orthopaedic surgeons, we work in a constantly changing and advancing field and are adept at acquiring new skills. With care and practice, we can become facile with these terms, leading to greater comfort for our patients and better outcomes for all.

Corinna Franklin, MD, FAAOS, is the director of sports medicine at Shriners Hospital for Children in Philadelphia.

Important definitions

• Transgender: someone whose gender is not (exclusively) the one they were assigned at birth
• Cisgender: someone whose gender is exclusively the one they were assigned at birth
• Nonbinary: an umbrella term for genders other than man and woman; can also be a specific gender
• Cis man/woman: a man or woman who is cisgender
• Trans man/woman: a man or woman who is transgender
• Deadname: a trans person’s given or former name that they no longer use, also often referred to as a “given name” or “legal name.” It can also be a verb referring to the act of using the wrong name for a trans person.
• Genderqueer: a nonbinary gender or word to describe someone’s gender
• Misgender: the act of gendering someone incorrectly. This often involves using gendered words that are inappropriate or the wrong pronouns.
• Transition: the social, legal, and/or medical process of aligning one’s life with one’s gender
• Sex assigned at birth: the sex a person was assigned at birth (assigned male at birth or assigned female at birth)

Source: Trans Journalists Association: Style Guide. Available at: https://transjournalists.org/style-guide. Accessed December 17, 2020.