In an ongoing series of commentaries, Lynette Reid describes the work done at Dalhousie University to diversify the case-based learning curriculum in the medical program.

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Our working group diversified patients’ gender identities and sexual orientations in Dalhousie Medicine’s pre-clerkship case-based learning (CBL) curriculum, while also addressing the role of medicine in defining, reinforcing, and challenging normative assumptions about sex, gender, and sexual orientation. Our approach was shaped by the late Eli Manning, a social work faculty member who was a visiting scholar in the Faculty of Medicine. In one check-in, she argued (in the wake of the Pulse nightclub shootings) that when we use sex binary language, we are in effect making trans and non-binary people “disappear” — a form of violence. Our work was also crucially shaped by the expertise of JR Johnston Chair in Black Canadian Studies, which was held in the Faculty of Medicine by OmiSoore Dryden during our project, on queerness in the African diaspora.

Recommendations for inclusive language in medicine typically are to remove redundant references to sex and gender (“male penis”), to say “all sexes/genders” instead of “both”, and to be specific about physical traits rather than relying on the shorthand of binary sex language. Physicians respond well to the request to be “more factual”, and we made revisions along these lines in almost all cases. In some cases, however, we don’t know specifically which anatomical or physiological or social aspects of sex/gender are responsible for differences (hormones? chromosomes? organs? pervasive developmental processes? social structures?). Also, our working group did not have the authority to rename, e.g., the “maternal serum screening” test or the “maternal fetal medicine” subspecialty. During the project, another group published an approach to sex and gender in the medical curriculum that they described as “harm reduction,” recognizing that effort required to completely cleanse the language and conceptual frameworks of the sex binary can readily overwhelm other goals. A lot more work could be done to tease out where sex-based differences in diagnosis and treatment do or do not stand as proxies for specific factors (e.g. body composition, weight) that could instead be used more scientifically, in the way that medical science is re-examining how to identify the actual physiological factor for which race has been mistakenly used as a proxy. For example (and this is hypothetical), if we knew that differences in the risks of alcohol consumption actually reflected differences in body composition, and binarized sex were just a proxy for this, we could provide evidence to physicians that reflects more accurately the actual causal feature that underwrites the differences that we now ascribe to sex, and they could customize care for the individual patient within the overlapping distributions of body composition across sexes.

Image Description: An AI generated colorful graphic highlighting the terms Sexual Orientation and Gender Identity in bold text.

A curriculum that is inclusive and affirming doesn’t just modify terminology. Post-secondary biology teachers recommend leading with diversity and grounding teaching in the history of science, for example in how hypotheses emerge and what experimental procedures are used to investigate them. Our students were already learning the complexity of the biological processes on which medicine and society have imposed a sex binary. The authors of these core cases agreed with modifying language of “male” and “female” e.g. to talk about genitals “typified as male” rather than “male genitals”.

Some resources have simply done a “search and replace”—padding “male” and “female” with “assigned … at birth.” There are important limitations to “language swapping.” For example, with nonbinary patients, following up on their gender identity with “but what are you really?” is deeply offensive. You need to take a trauma informed approach to gathering more detailed biological information when and as necessary. In addition, “assigned male at birth” (AMAB) and “assigned female at birth” (AFAB) are ambiguous: they mean one thing for trans and non-binary persons (assuming their sex assigned at birth fits the normative binary) and another thing for intersex persons (that is, their sex is assigned at birth, despite their not having the normative sex characteristics associated with that assignment). Our recommendation not to routinely include reference to sex assigned at birth led to challenging discussions, a lot of creative problem solving, more than a few power plays (on all sides). As it stands, our implementation looks inconsistent. In any case, these questions are evolving across medicine and society and require regular revisiting.

In my next commentary, I will continue my description of our efforts to address the diversification of sexual orientation and gender identity in Dalhousie’s CBL cases.

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Lynette Reid is an associate professor in the Department of Bioethics at Dalhousie University.