Gender Affirmation Imaging Revisited

Florence X. Doo
Resident Physician Diagnostic Radiology
Icahn School of Medicine at Mount Sinai West

Alexander S. Somwaru
Assistant Professor of Diagnostic Radiology
Icahn School of Medicine at Mount Sinai West

How often does gender or sex come up in your daily practice? In a publication or article you read? In your daily interactions with your family or colleagues?

Based on your answers to the above questions, suffice it to say that although gender is arguably a core piece of each individual’s identity, it variably affects one’s daily lived experience. For example, do you experience your gender differently in different contexts—such as when you were eight years old vs as a 45-year-old, or in different settings like a black-tie event? Just from these instances, it is clear that many factors influence our experience of gender, including language, societal norms, cultural background, etc. A recent article in the Journal of the American College of Radiology (JACR) excellently described basic gender terminology and definitions, emphasizing the need for greater gender inclusivity in radiology.

Whereas radiologists are not expected to be gender studies experts, there are several key aspects of gender that radiologists should be aware of in daily practice.

  1. Be able to clearly and accurately describe imaging findings of physical anatomy, including gender affirmation therapy and surgeries, which we described in our original article in AJR, “Gender Affirmation Surgery: A Primer on Imaging Correlates for the Radiologist”. Gender affirmation therapy is multidisciplinary by nature; as radiologists, we are part of the team providing necessary care for individuals experiencing gender incongruence.
  2. Consider adjusting protocols for relevant anatomy: training staff to allow self-insertion of transvaginal probes; utilizing an endovaginal, rather than transrectal, approach for prostate cancer screening in transwomen who have undergone gender affirmation surgery; and correctly evaluating atrophied structures secondary to hormone therapy.
  3. Study developing educational cases and share research in transgender health and imaging. Our colleagues (Maglione, Margolies, Jaffer, et al.) published one of the first descriptions of imaging findings of breast cancer in transgender women in AJR, and others have proposed adapting breast cancer screening guidelines for transgender women. More investigations with outcomes-based research are needed to improve understanding of transgender healthcare, including developing screening guidelines and protocols.
  4. Collaborate with counselors, pediatricians, endocrinologists, general practitioners, surgeons (breast, plastic, maxillofacial, gynecologic, general, etc.), and allied health professionals who specialize in gender affirmation therapy, as there are treatment options (i.e., hormonal therapy) and ongoing advancements that may impact imaging interpretation.
  5. Be aware of your local facility and institution’s Human Rights Commission “Healthcare Equality Index” score, and how you may either maintain or improve that score. Our own institution, Mount Sinai Health System, is fortunate to have a 100/100 score and a strong multidisciplinary team at the Center for Transgender Medicine and Surgery. What is the experience of LGBTQ+ patients in your facility? Are all staff trained? Two separate studies in 2015 and 2017 found that almost a quarter of transgender people said they avoided doctors or health care for fear of being discriminated against. The 2017 study, which detailed LGBTQ+ American experiences, showed that 33% had one or more negative experiences with a health care provider.
  6. Assess workplace and educational climates for colleagues and trainees, who may face invisible or systemic barriers, even if not addressed explicitly in the scoring system. A 2015 study of medical students showed that approximately 43% of sexual and gender minorities concealed their identities, due to fear of discrimination. Do you consider your workplace gender diverse? Have you personally advocated for gender inclusivity, or defended someone from discriminatory attitudes, remarks, or behaviors? How are issues reported and addressed individually and systemically?
  7. Encourage your professional society and journal publications to be aware of sex and gender terminology. Many journals, including AJR, require sex to be labelled on image captions. This posed an interesting dilemma, particularly in our recent article, as “sex assigned at birth” (SAAB) and “anatomical sex” are not necessarily equivalent, and anatomical sex may change. And, of course, these labels do not necessarily match the patient’s gender identity or chosen pronouns. These guidelines should be contextualized when publishing articles on transgender imaging.
  8. Examine your local, state, and national policies regarding gender rights and safety protections. As described in a recent call to action published in JACR, the Association of University Radiologists moved its annual meeting location, in part, due to California’s Assembly Bill 1887, which prohibited California state employees (including those at medical centers) from state-funded travel to states that have discriminatory laws in place. Other radiology organizations should be encouraged to follow this example. Only half of the United States has state or local laws protecting LGBTQ+ workers. Is your state one of them?
  9. Survey identification (ID) laws, as well as how difficult it may be to correct identification to reflect gender identity. The National Center for Transgender Equality’s 2015 study also revealed that 32% of transgender individuals who have shown an ID with a name or gender that did not match their gender presentation were verbally harassed, denied benefits or services, asked to leave, or assaulted. What are the requirements for ID in your institution, and how are staff trained to respond?

Imaging is simply one, albeit vital, facet in the overall care that we provide to our patients. The landscape of gender and sex, both inside and outside of radiology, continues to evolve, as we improve our individual understanding and address systemic flaws. All of us—ourselves, our healthcare providers, our patients, and our society—benefit by respectfully recognizing our individual identities. Let us be allies for one another.

The opinions expressed in InPractice magazine are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher.