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Sex, Gender, and Orientation 101

But when it comes to human sexuality, words are important.

by Yvonne Piper, MLIS, MS, RN, FNP

published 10/02/14

You look at the demographics for your next patient.

Gender: Trans (FTM). Orientation: Gay.

Preferred pronoun: they/them. Parity: G1P1.

Any confusion? For folks who have never questioned their sex, gender, orientation, or preferred pronoun, it may be a challenge to keep up with patients who have spent years thinking about these questions themselves. But when it comes to human sexuality, words are an important tool that we as providers can use to better understand our patients. Let’s start by breaking down the differences between a few terms that may be easily conflated: sex, gender, and orientation. While we are at it, let’s talk about the pronouns your patients may use besides she and he.

Sex

This is biology: “sex” refers to the organs, hormones, and secondary sex characteristics that are considered male or female. This is usually assigned at birth, when the provider attending the birth announces whether the genitalia are those of a boy or a girl (though those terms actually describe gender, not sex). If we were being more accurate, babies would be proclaimed male or female at birth.

The majority of the time, these biological factors align with the sex label given at birth, meaning the internal and external genitalia match one another, and the gonads produce the sex hormones that one would expect given those genitalia.

Males have testes that produce testosterone and a penis. Let’s not attach the word “man” to this description. Let’s accurately describe this as male anatomy.

Females have ovaries that produce estrogen, a vagina, and a uterus. As above, let’s avoid the word "woman" when describing anatomy. This is female anatomy.

Intersex people may experience an incorrect proclamation of their sex at birth. There is biological variation in the production of hormones, the forming of sex organs, and the interaction of genetics that may make one not absolutely male or female. Relatively common chromosomal anomalies, like Turner or Klinefelter syndrome, can result in being intersex. Gonadal or genital anatomy can be different, such as in Mullerian agenesis, or ovotestes, or Swyer syndrome. One’s body may not respond to the hormones that are produced by the gonads, as in androgen insensitivity syndrome. There are many such conditions that would make someone somewhere between male and female. We can consider sex to be a spectrum with male at one end, female at the other, and intersex every step between.

Gender

If sex is the hardware of the body, then gender is the software. This is how a person identifies, or feels, in terms of man, woman, trans, or none of the above. People’s gender identity may match their biological sex or not.

When someone uses the words “man” or “boy” to identify himself, he is stating that his gender is male. He may also have the biologic aspects of a male—or he may not. When someone uses the words “woman” or “girl” to identify herself, she is stating that her gender is female. She may also have the biologic aspects of a female–or she may not.

The terms cisgender or cis come from the Latin meaning “on the same side.” When people’s sex (biology) matches their gender (identity), then they are cis. For example, having a body with male genitalia that produces testosterone and calling oneself a man.

The terms transgender or trans come from the Latin meaning “across.” When people’s sex does not match their gender, they may identify as trans. One may have been born male and now identify as a woman, which can also be known as MTF (male to female) or trans woman. One may have been born female and currently identify as a man, trans man, or FTM (female to male). And yes, the trans acronyms use sex words rather than gender words, just to keep you on your toes.

Some patients may identify as genderqueer. This term means any gender identity that does not fit into the man-woman binary. Just like sex, gender is also a spectrum. If man is one end of our gender spectrum and woman is another, genderqueer is the area in between. Some folks consider themselves gender fluid – moving along this spectrum. Others may decline masculine or feminine, and instead identify as a unique gender or genderless.

Many cultures have gender concepts that eschew the binary man-woman model. For example, some Native Americans use the term two-spirit to describe community members who do not fit into a man’s or woman’s gender roles.

Orientation

Now we are describing someone’s attraction set. One may be attracted to people of the opposite sex or gender, or perhaps the same sex or gender, or maybe one has a very wide attraction set that goes beyond binary. As yet another alternative, maybe one’s attraction set is…nobody.

An orientation of straight or heterosexual means one is attracted to members of the opposite sex and/or gender. Bisexuals are attracted to both their own and the opposite sex and/or gender. Gay, lesbian, homosexual, and same-gender-loving are all terms describing people attracted to their same sex and/or gender. Those who identify as queer have a variety of attraction sets; the main point is that they reject traditional gender identities. Pansexuals’ attraction set is formed without taking into account sex or gender. Asexuals are not sexually attracted to others.

Pronouns

Many languages use gendered pronouns. Pronouns are often assigned to folks based on whether they are presumed to be a man or a woman. It’s easy to get this wrong when you’re working with patients with non-binary sex and gender identities.

He/his is often preferred by those who identify as men, and she/her is often preferred by those who identify as women.

Grammar sticklers, stay with me on this one: you may hear they/their/them used as singular pronouns. Some people may choose this gender-neutral pronoun to reflect their sex or gender, or as a personal preference. Here’s an example: Jay, a genderqueer individual, prefers they/their them. When talking about Jay, I may say “Jay went shopping. They bought some new shoes. Their shoes are a little loud for my tastes, but look great on them.”

Other gender-neutral pronouns are more creative: ze (or zie), hir/hirself, ya/yum, thon/thons/thonself. It/its is another gender-neutral choice, although less popular than they or zie.

How do these fit together?

Each of your patients has a unique relationship to sex, gender, and orientation. Given that their location on these spectra directly affects their sexual and reproductive health, it’s a good practice to get comfortable asking them about it.

Want to learn more? We've got an article on how to be a great provider for patients of all sexes, gender identities, and orientations.

Yvonne Piper, MLIS, MS, RN, FNP has her dream job as a primary care provider at Lyon-Martin Health Services in San Francisco, CA. She has TA'ed two rounds of UCSF's Coursera class on Contraception and loves helping her patients choose the best birth control method for their crazy-busy lives. When she isn't at work she can be found lifting at her Crossfit box, hanging out with her pet rats, or volunteering as a trainer with San Francisco Sex Information (SFSI).
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