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From the WOMGEND SIG, the LGBTQ+ SIG, and the BABCP EDI Committee
The BABCP’s core values include a commitment to equality, diversity, inclusion, and collaboration. To further these commitments, and to coincide with International Pronouns Day, we are highlighting the importance of gender inclusive language and the harmful effects of non-inclusive practices on people’s psychological and physical wellbeing, particularly those who do not conform to the gender binary.
To understand the issues faced by these groups, we first need to distinguish between sex and gender. Sex refers to biological characteristics such as chromosomes, hormones, and aspects of anatomy. These characteristics are often used to divide people into two groups; male and female. It’s important for us to recognise, however, the presence of intersex people, where biological sex characteristics do not neatly align with these categories (with some estimates, such as from Fausto-Stirling’s 1993 article, suggesting a prevalence of up to 1.7% in the general population, although definitions and therefore prevalence rates are contested). Gender, on the other hand, gender refers to both a set of prescribed social and cultural norms, expectations, and values typically associated with sexual differences between persons, and to how people conform to, adapt, or disrupt such prescribed expectations (Unger, 1979). The degree to which people typically conform to social gender expectations varies and can vary within the same individual day to day. The term ‘transgender’ refers to people whose gender identity is different to the gender they were assigned at birth, and gender non-conforming or non-binary refers to a person whose gender identity doesn’t ascribe to current social norms and expectations around gender.
Transgender and gender non-conforming people often experience stigma on the grounds of their identity, which can lead to discriminatory treatment. One instance of such treatment that frequently occurs in healthcare settings is misgendering: when a person is addressed or described using language (e.g. with names, pronouns, or titles) that does not match their gender identity, or is treated in a way which is suggestive of a gender other than the one with which they identify (Poteat et al, 2013). This happens for a variety of reasons, not least because our systemic policies and practices heighten the risk of misgendering. Many electronic health records, for example, automatically populate letters with a person’s legal rather than preferred name, or an incorrect title, or may have a layout which display a person’s legal name more prominently than their preferred name. The way that these systems work can therefore increase the risk of clinicians misgendering service users. Misgendering invalidates a person’s identity and is likely to be one among many micro-aggressions a person faces, which have a cumulative and profound effect on a person’s mental wellbeing (McLemore, 2018). The language we use, and specifically how we refer to people, signals to them whether or not we respect and acknowledge their gender identity, and as such misgendering can significantly erode any trust that transgender and non-binary people have us as professionals and in healthcare services more generally. As such, misgendering (among other ways in which transgender and non-binary people are shown that their experiences and needs are not understood) influences subsequent interactions with healthcare services and can dissuade people from accessing much needed physical and mental health care due to fear of further stigma (Dolan et al, 2020).
The case of Jessie Nelson, a Canadian restaurant server who took their case to tribunal after being fired for challenging a colleague for persistent misgendering is just one example of how this can affect a person’s psychological wellbeing. The tribunal ruling found that deliberate misgendering is a violation of human rights. Nelson described their experience as “A piece of trauma in a long line of trauma for a trans person living a trans experience”. They added: “I was scared and sad for myself, but more than that I was really worried about future people… I am here today in bringing this forward because it is important for me, as a trans person, to have my existence respected”.
As clinicians we need to understand how language, policies and practice used by health care providers can serve to further stigmatise and marginalise trans individuals and can infer pathology. This was underscored in a recent editorial in the British Journal of Psychiatry (Perlson et al., 2021) which emphasised the importance of training clinicians to validate diverse gender identities and to promote the self determination of transgender and gender diverse patients within an affirmative framework that reduces stigmatisation. Using the correct language is integral to this aim and we therefore encourage you to learn more about the importance and practice of gender inclusive language. This issue has risen to prominence recently as transgender and gender non- conforming people continue to struggle for greater recognition in our culture.
Things we can all do to support gender inclusive language:
We leave you with this quote:
“If everyone makes it a habit to include their pronouns in email signatures and social media bios, then it becomes easier for me, a non-binary person, to let people know my pronouns without any fuss. I won’t need to feel like an exception asking for special treatment, but rather I’ll feel accepted and understood.” - Prospect member Binni Brynolf, who uses pronouns they/them.
The website www.pronounsday.org provides lots of useful guidance on ways in which you can support gender inclusive language and embed these practices into your ongoing clinical work with patients.
Stonewall has some wonderful resources including an online LGBTQ+ glossary which can help with familiarising yourself with relevant terms. It can be accessed at https://www.stonewall.org.uk/list-lgbtq-terms.
The BABCP Equity, Equality, Diversity and Inclusivity Statement can be accessed at https://babcp.com/EDI.
Dolan, I.J., Strauss, P., Winter, S. and Lin, A., 2020. Misgendering and experiences of stigma in health care settings for transgender people. Medical Journal of Australia, 212(4), pp.150-1.
Fausto‐Sterling, A., 1993. The five sexes. The sciences, 33(2), pp.20-24.
McLemore, K.A., 2018. A minority stress perspective on transgender individuals’ experiences with misgendering. Stigma and Health, 3(1), p.53.
Perlson, J. E., Walters, O. C. and Keuroghlian, A. S. (2021). Envisioning a future for transgender and gender-diverse people beyond the DSM, The British Journal of Psychiatry. Cambridge University Press, 219(3), pp. 471–472.
Poteat, T., German, D. and Kerrigan, D., 2013. Managing uncertainty: a grounded theory of stigma in transgender health care encounters. Social science & medicine, 84, pp.22-29.
Unger, R. K. (1979). Toward a redefinition of sex and gender. American Psychologist, 34(11), 1085–1094.