April 27, 2017

I Now Pronounce You Man and Muxe

By Domenic Fraboni


By: Domenic F. Fraboni


The following is a fictional vignette:

I have a penis. Well, I was born with one, I guess. The sex organs I was born with would make you think I am a man. However, I identify as a woman who is attracted to what most would call “traditional” manly men. Furthermore, the activities that I like to participate in when I have leisure time are traditionally masculine activities. I love playing basketball, going fishing and hunting, working on home improvement projects, and four wheeling. Sometimes people find my situation confusing. I just think that my self-identity is unique, as is every single person’s self identity on our planet. 

The above scenario is something that is not talked about nearly as often as it needs to be in today’s medicine. The woman that I described in the previous paragraph identifies some of the differences in how people describe gender. She has described for you her biological sex, gender identity, gender expression, and sexual orientation. These are just four of the many facets that help us to define self. Last month, on March 8th, I was fortunate enough to be a part of an incredible session that helped the attendees dig into gender. Anna Schettle and Dr. Cesar Gonzalez (their bios can be found below) led a cultural competency session called “Transgender affirming care in medical settings: Where cultural competence meets evidence-based practices.” They helped those in attendance explore a few questions: Where did gender come from? How can our language and culture influence our perception of culture? What is the prevalence of those that identify with the LGBTQ+ community? How can we as medical providers better prepare ourselves to give the highest quality of care to a very gender diverse population?

Diagram trying to decode the different aspects of gender and self-identity. PC: Dr. Gonzalez's slideshow

Before the session began, I had the opportunity to prod the minds in the crowd. Echocardiography student from Mayo Clinic School of Health Sciences, Lauren Emerson, said hands down that this topic required continued discussion. She found herself in clinical experiences where providers had not known how to react towards, treat, or handle a patient who does not align with a binary gender. I then turned to Erin Mason, a Physician Assistant Fellow in Emergency Medicine, who stated she observed similarly unfortunate scenarios. Erin followed up by saying that her colleagues did not want things to be awkward in these instances. They even express that they want to better understand how to treat gender diverse individuals. Perhaps they do not have sufficient “experience” with this population. Erin hopes to work with Dr. Gonzalez to develop an educational program for providers to broaden their education on gender diverse medicine. Okay, lets get back to the talk.

The session began with a video based in the Southern Mexican city of Juchitan. Understanding of gender in Juchitan has evolved a bit differently than in most cities in the United States. In Juchitan, they have a third gender, muxe. Many muxes are assigned male at birth, but consider themselves a woman (aka their gender identity). However, as the documentary went on, others said that they define themselves as a muxe and do not fit the “stereotypical” muxe mold. The muxe term is one that just allows them to know who they are, how they identify, and what this identification means to them. In other words, muxe in Juchitan seems to have given this region a gender diverse outlet that most other areas do not have. I hope no one found the title of this piece to be heterosexist or heteronormative. I just wanted to use this example of cultural gender diversity to show that there are many different ways in which gender is understood and socially practiced globally. This short Central American documentary acts as a small example of how culture and language have functioned as a catalyst for the evolution of gender. How can our society impact the development of how we collectively understand gender in our country? I daresay we could come up with a laundry list.

One of the main topics of discussion was health care best practice for the LGBTQ+ community. It is well documented that those who identify with this group have markedly higher prevalence of some health conditions. Of those that identify as transgender, 47% currently experience depression (general population 8.7%) and about 41% of them attempt suicide across their lifetime (2.4% in the general population). There also tend to be higher rates of sexually transmitted infections in the gender diverse population. These statistics may not mean a whole lot out of context. However, it tells me that something may be going astray in the health care management of those who are not straight cisgender individuals.  In fact, the rates of access between the general and transgender populations are very similar. What can we do to help improve healthcare for the queer population?

Minority stress can be another factor resulting in the health disparities found in the LGBTQ+ population. PC: Dr. Gonzalez's presentation

Why is it that these individuals have had such a bad go at it in the realm of medicine and healthcare? This could be because for years (and still today) they have been seeking care from within a system that only understands medicine through the scope of male and female. What is the first question most people are asked when they fill out medical forms? My guess is it looks something like this – Sex: Male Female. It is unspoken microaggressions like this that can immediately put a sour taste in a gender diverse individual’s mouth. In addition to the many homosexual, bisexual, and transgender microaggressions seen in medicine, it was only in 1992 that homosexuality was removed as a mental disorder by the World Health Organization. Now I’m not very old, but that is within my lifetime. Furthermore, transgender identity is currently listed as a classification under mental disorders in the ICD-10 codes… We wonder why there are higher rates of depression, self-harm, and attempted suicide among these patient populations. To me it is easy to see why while operating within this system that disaffirms their existence.

“What now?” you may ask. The goal of “treatment” is to help relieve the “dysphoria” surrounding patients as they explore their own gender. Here at Mayo, as a leader in world-wide inclusive medicine, we must educate ourselves on teaching self acceptance and affirmation, social transition, cross hormone therapies, and/or potential surgical procedures that these patients may need. In an American society that has more individuals that identify as transgender than have diabetes mellitus I, we should behoove ourselves to meticulously understand how to treat this population. We can add these tools to our clinician tool belts in order to educate these patients and their parents or loved ones on all the options available. After all, those trans youth with supportive parents are one third as likely to experience depressive symptoms and almost 14 times less likely to attempt suicide in a calendar year. Piggy backing on that little fact, 80% of those who undergo hormonal therapy and genital reconstructive surgery have an improved quality of life.

To me the data rings clear. I hope that all out there in the Mayo community can join this team to help create a thoughtful, inclusive, and evidence based medical approach for ALL patients that walk through our doors. We can take a page out of the Mayo Brother’s book for that one.


“Within its walls all classes of people, the poor as well as the rich, without regard to color or creed, shall be cared for without discrimination” –Dr. William J. Mayo (October 09, 1912).


Acknowledgements: Huge thank you to Ms. Schettle and Dr. Gonzalez for giving such an enlightening educational session on transgender medicine. Also, thank you to Pete and Mayo Clinic School of Health Sciences for coordinating and advertising this event.


Presenter Bios:

Anna Schettle, LICSW, MSW, is a Licensed Independent Clinical Social Worker at Mayo Clinic’s Transgender and Intersex Specialty Care Clinic (TISCC). She completed her undergraduate degree in Social Work, Gender and Women’s Studies, and Lesbian, Gay, Bisexual, and Transgender Studies from The University of Wisconsin in 2011 and earned a Masters of Social Work Degree from the University of Central Florida in 2013. While Ms. Schettle’s background includes clinical social work experience within a variety of multidisciplinary inpatient and outpatient hospital departments, her current role focuses on providing individual and family therapy to transgender and intersex patients, coordinating patients with open and inclusive community-based services, advocating for patient rights, and serving as a resource for allied health professionals. Ms. Schettle’s education, passion, experience, and identity within the LGBTI+ community positively impacts her understanding of and work with transgender and intersex partners.


Dr. Cesar A. Gonzalez, PhD, LP, ABPP, is board certified psychologist and is and assistant professor of psychology and family medicine at Mayo Clinic. His clinical practice and community involvement in transgender health has spanned over 14 years and includes over 400 psychological assessments among transgender and gender diverse individuals.

In 2010, Dr. Gonzalez completed his research and clinical postdoctoral fellowship in human sexuality at the University of Minnesota, where he specialized in transgender health. His research activities are focused on topics pertaining to minority stress and transgender mental health. He is an editorial board member of the International Journal of Transgenderism and served as faculty at the University of Minnesota Medical School’s Program in Human Sexuality. In 2014, Dr. Gonzalez was nationally recognized by the American Board of Professional Psychology for his dedication to multiculturalism and diversity in professional psychology.


Valuable Websites for Additional Information:

Gay & Lesbian Medical Association: www.glma.com

MN LGBT Therapists:: www.lgbttherapists.org

National Center for Transgender Equality: www.transequality.org

Out Front Minnesota:: www.outfront.org

PrEP Locator: https://preplocator.org

World Professional Association for Transgender Health: www.wpath.org

Author Bio: Domenic Fraboni is a second year Doctorate of Physical Therapy student at the Mayo Clinic School of Health Sciences. One of his goals is to do whatever he can to advocate for culturally competent and evidence based care for all patients. Please feel free to email Domenic if you want to chat about different aspects about cultural competency or even colaborate on a post about care surrounding a different population, please feel free to reach out to him.

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