They, Them, Theirs: The Importance of Pronouns and Other Considerations When Caring for Patients Who Identify as Gender Diverse

ACLP Bulletin | Winter 2020 | VOL. 38 NO. 1

Nikki Orkoskey, MA, CCLS

Cincinnati Children's Hospital Medical Center, Cincinnati, OH
Aiden* is a 14-year-old patient who was admitted to the hospital for appendicitis. Aiden has recently come out to his family as transgender and asked his family to call him Aiden and refer to him with male pronouns (he/him/his). Aiden’s legal name, the name he was given at birth, is listed in the medical record. Aiden and his family have shared his gender identity and preferred name and pronouns with the hospital staff. Aiden’s family is supportive of his gender identity but sometimes forget to call him Aiden and accidentally use female pronouns (she/her/hers). You overhear staff discussing Aiden’s gender identity in the breakroom and his nurse repeatedly calls him by his legal name using female pronouns. His nurse states,“If her parents still call her (legal name), why should I bother calling her anything else?” You know that Aiden will be hospitalized for at least a week and will have medical procedures in various departments throughout the hospital. As a child life professional, how do you best support Aiden and his family throughout his hospitalization? *Patient and story are fictional.

People who identify as gender diverse, specifically transgender, have become more visible in recent years. As such, youth who identify as gender diverse are being seen more often within healthcare settings. Medical professionals, including child life specialists, receive little, if any, training related to providing healthcare services to patients who identify as transgender (Rider, et al., 2019). The American Academy of Pediatrics recommends that provider education, both medical training and continuing education, include information about best practice for caring for youth who identify as transgender and gender diverse (Rafferty; American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health; American Academy of Pediatrics Committee on Adolescence; & American Academy of Pediatrics Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness, 2018).

"Youth who are gender diverse often face challenges both at home and in the community, but they have shown the ability to be resilient, especially when they receive social support and acceptance." 

Gender identity is a term that is used to describe a person’s sense of being female, male, a mix of these traditional genders, or having no connection to either gender. Gender diverse is a relatively new term that describes people with a gender identity that is different from the gender assigned to them at birth. People who identify as gender diverse may also identify as transgender or any of a number of other gender identities, including genderqueer, gender fluid, or non-binary (Rafferty et al., 2018). It is always best to ask a person what a specific term means to them as terms and their definitions (see Table 1) change frequently.

Identifying one’s gender begins at the age of 2 or 3 years, and is typically established by the age of 4 (Austin, 2018). Not all children who are gender diverse identify as transgender. Some people may identify as non-binary, or having no connection to the traditional system of gender. Other people prefer to not have a label placed on their gender. Children who identify as transgender or gender diverse are aware of their gender to the same degree as developmentally comparable peers who are cisgender (Rafferty et al., 2018). A child who identifies as transgender is “consistent, insistent, and persistent” about their gender identity being different than the gender they were assigned at birth (Human Rights Campaign, n.d.-b, para. 8). While statistics detailing the number of children who identify as gender diverse are not currently available, according to the Williams Institute’s most recent survey in 2017, approximately 0.7% of youth (150,000 youth) between the ages of 13 and 17 identify as transgender in the United States (Alumit, 2017).

Youth who are gender diverse often face challenges both at home and in the community, but they have shown the ability to be resilient, especially when they receive social support and acceptance. Torres and colleagues (2015) described the importance of three spheres of influence that can create a safe environment for transgender youth (see Figure 1). Parents, schools, and the community can work together to create safe environments for youth who identify as gender diverse. The healthcare environment is included within the community sphere (Torres et al., 2015). Child life professionals can make a difference within this sphere by advocating for supportive healthcare environments, promoting continuing education for staff, and providing resources to patients who identify as gender diverse.

Gender Dysphoria

As defined in the DSM-5, gender dysphoria is the name of the clinical diagnosis given to people who identify as a gender that is different than the gender that was assigned to them at birth (American Psychiatric Association, 2013). Not all people who are gender diverse will be diagnosed with gender dysphoria. Gender dysphoria is only diagnosed if there is distress related to the discrepancy between one’s gender identity and the gender they were assigned at birth (American Psychiatric Association, 2013).

Gender Affirmation Treatment

Some people who identify as gender diverse choose to undergo gender affirmation treatment. The decision to undergo gender affirmation treatment is a very personal decision and treatment will vary depending on the person. Social affirmation occurs when a person adapts their gender identity to be more congruent with their identified gender, not the gender they were assigned at birth. This affirmation may manifest itself most often in choice of clothing, hairstyle, name, and pronouns (Rafferty et al., 2018). According to the World Professional Association for Transgender Health’s Standards of Care (2012), medical affirmation can begin at the start of puberty when an adolescent can receive hormone blockers. This treatment delays the physical changes of puberty. This has been shown to have a significant positive impact on the adolescent’s mental health (Tellier, 2019). A few years after puberty blockers are started, an adolescent can receive gender-affirming hormones. The age at which gender-affirming hormones are first given varies; the decision about when to begin this treatment should be made collaboratively between the adolescent, their family, and the treatment team (World Professional Association for Transgender Health, 2012). Surgical affirmation can be chosen to more closely align a person’s body with their gender identity. Not all people who are gender diverse choose to undergo surgical affirmation. This treatment is usually not done until a person reaches adulthood (Rafferty et al., 2018).

Table 1
Gender Terminology
Gender Terminology Table

Healthcare Challenges

People who identify as gender diverse often face barriers and challenges related to accessing healthcare and feeling com- fortable within the healthcare setting. Youth who identify as gender diverse often have poor access to physical and mental health services. This can be due to a multitude of factors, including incorrect name and pronoun usage, anxiety related to healthcare that is specific to the gender that they were assigned at birth, insurance coverage, lack of family acceptance, lack of knowledge or understanding among healthcare providers, and/or being denied treatment due to their gender identity. Lack of access to physical and mental health services can lead to worsening gender dysphoria and poor mental health outcomes (Rafferty et al., 2018).

Parents Community School Venn Diagram
Figure 1. Spheres of influence in youth development
(Torres et al., 2015, reprinted from BMC Pediatrics under the terms of the Creative Commons Attribution 4.0 International License [http://creativecommons.org/licenses/by/4.0/])

Name/Pronoun

People are referred to many times a day using their name and/ or pronouns. A person’s name and pronouns are closely tied to that person’s identity. Some pronouns are gendered, such as the use of “she/her” when referring to a female-identified person and “he/him” when referring to a male-identified person (Human Rights Campaign, n.d.-a). Other pronouns, such as “they/them,” are considered gender neutral when referring to a single person. As such, “they” has become the pronoun that is used by many people who do not identify as either male or female (Merriam-Webster, 2019). “They” is also the pronoun that should be used when the gender of the person you are referring to is unknown. “They” has been deemed to be an appropriate singular pronoun when used in writing and speaking by Merriam-Webster (2019) and the American Psychological Assocation (Lee, 2019) when referring to a person whose gender is unknown or when referring to a known per- son who uses “they” as their pronoun. While it may initially seem unusual to refer to a single person using the pronoun “they,” this will become easier with time and practice.

The use of the correct name and pronoun are essential to affirming a person’s identity and showing respect. Often the first step that someone who is gender diverse takes to affirm their gender is to choose a name that is different from their birth name. After changing their name, many people refer to their birth name as their “dead name.” When someone accidentally or intentionally refers to a person by their birth name, this is called “deadnaming” (Clements, 2017). Misgendering, or the use of an incorrect name or pronoun, can be extremely upsetting to someone who identifies as gender diverse. If you accidentally misgender someone, the best way to handle this is to apologize and do your best to not allow this to happen again. When you are not sure about a person’s pronouns, ask them which pronouns they want you to use (Human Rights Campaign, n.d.-a).

Gender-Specific Treatment vs. Identified Gender

Patients who are gender diverse will arrive in the healthcare environment due to illness or injury that is similar to their peers who are cisgender, but they may also be seen due to an illness or injury related to the gender they were assigned at birth, not the gender with which they identify. For example, someone who identifies as male may be seen due to a gynecological concern, or a female-identified person may seek treatment for testicular pain. Patients who are experiencing medical care that is inconsistent with their identified gender should be approached with sensitivity. Physical examinations can be stressful for patients who have gender dysphoria, regardless of the reason for the examination (Klein, Paradise, & Goodwin, 2018). Child life specialists are in the unique position to provide procedural preparation and support that is sensitive to the patient’s gender identity. Honest, straight-forward communication is essential in such situations. Many healthcare professionals become unsure about how to discuss gender identity in relation to gender-specific body parts. Such conversations should be approached in a sensitive manner, as would be done for any child or adolescent, keeping in mind that the patient knows what body parts they have, whether this is consistent or inconsistent with their gender identity. As with any child or adolescent, patients who identify as gender diverse should be asked what word(s) they use to identify their genitalia. Patients should not be asked about their private body parts unless that is necessary for the treatment or procedure that they are undergoing (Clark, Vealè, & Zaleski, 2018).

Insurance Coverage

People who identify as gender diverse often experience difficulty with insurance coverage. Insurance denials for transgender-related services can be a significant barrier to receiving proper healthcare for people who identify as gender diverse. One study found that approximately 25% of people who identified as gender diverse, specifically transgender, were denied insurance coverage based solely on their gender identity (James, Herman, Rankin, Keisling, Mottet, & Anifi, 2008, cited in Rafferty et al., 2018). The denial of treatment for gender dysphoria in pediatric patients is often based on the idea that gender dysphoria is a mental disorder and not a physical disorder. Based on this assumption, gender affirmation treatment, such as hormone therapy, is often deemed to be unnecessary by insurance providers (Rafferty et al., 2018). People who identify as gender diverse may also be denied insurance coverage for examinations and treatments related to the gender that they were assigned at birth, especially if they have changed their gender marker on their legal paperwork. For example, someone who identifies as male but was assigned female at birth and has female genitalia may be denied access to a PAP test. In addition, youth who identify as gender diverse may or may not have parental support related to their gender identity. Those who do not have parental support run the risk of not having access to health insurance and parental consent for healthcare (Torres et al., 2015).

Uninformed Healthcare Providers

The healthcare setting can often be an unwelcoming environment for people who identify as gender diverse due to many factors, including providers’ insufficient knowledge or competency regarding care for patients who identify as gender diverse. Many people who are gender diverse report that they have had to educate medical staff on caring for a person who is gender diverse. This is an additional hardship to accessing medical care that should not be the responsibility of the person who is gender diverse (Torres et al., 2015). The American Academy of Pediatrics (Rafferty et al., 2018) recommends that provider education include information about the best practices for the care of youth who identify as gender diverse and their families.

Healthcare Environment

People who identify as gender diverse often worry about whether the clinical environment will be a safe place for them (Rafferty et al., 2018). A safe environment is the responsibility of not only the healthcare provider, but all staff within the healthcare setting. Education and training about terminology and other gender diverse topics should be provided to all staff (Klein, Paradise, & Goodwin, 2018). People who are gender diverse report that the correct use of name and pronoun is one of the most important aspects that leads to feeling safe within the healthcare environment (Torres et al., 2015). Healthcare settings should ensure that their electronic medical record systems include options for the inclusion of preferred names and pronouns so that all staff have access to this information. Providing access to gender-neutral bathrooms is another way to ensure that people who identify as gender diverse feel safe (Torres et al., 2015). The healthcare environment itself can be more welcoming by including pictures of diverse families and people in public areas and including gender-neutral language on intake forms (Klein, Paradise, & Goodwin, 2018).

Healthcare Avoidance

Due to various healthcare challenges and previous negative experiences, many people who identify as gender diverse avoid healthcare settings. There is limited research regarding youth healthcare avoidance, but one study found that 25% of adults who identified as transgender had avoided going to a necessary doctor’s visit in the last year because they were afraid of being mistreated (James, Herman, Rankin, Keisling, Mottet, & Anifi, 2008, cited in Rafferty et al., 2018). Maintaining a confidential, safe clinical space is an important step to gaining the trust of gender diverse youth and their families (Rafferty et al., 2018). Child life professionals can advocate for and work toward fostering an emotionally safe clinical environment, in both inpatient and outpatient settings. This includes advocating for the use of correct name and pronoun and providing supportive and sensitive care for youth who identify as gender diverse by all members of the healthcare team and clinical staff. Setting the foundation for early successful medical experiences may minimize healthcare trauma and lessen healthcare avoidance later in life.

Ethical Considerations

Most, if not all, healthcare professions have a code of con- duct or similar position statement outlining professional responsibility related to the care of patients and families. The Association of Child Life Professionals’ (2019) Code of Ethics outlines this obligation for child life professionals. Care for patients who identify as gender diverse is addressed under Principle 3, which states “Child Life professionals shall have an obligation to serve children and families, regardless of race, gender, religion, sexual orientation, economic status, values, national origin, or disability” (Association of Child Life Professionals, 2019). Additionally, the Joint Commission first asserted in 2011 that accredited organizations must prohibit discrimination based on many factors, including gender identity or expression. Healthcare institutions also have specific policies related to diversity and inclusion, as well as patients’ bills of rights that employees must follow as terms of employment. Within these policies, many healthcare settings include a statement related to the appropriate care of patients regardless of gender identity/ expression. Child life professionals should follow their institutions’ policies, as well as the child life code of ethics.

Child Life Support for Youth Who Identify as Gender Diverse

Child life specialists utilize assessment to individualize care for all patients. Information obtained during the child life assessment is essential to providing optimal care to patients who are gender diverse. Child life professionals should do the following to maintain a safe and supportive healthcare environment for patients who are gender diverse and their families:

 
  •  Provide preparation and support that is sensitive to the patient’s gender identity and, as with all patients, privacy should always be protected.

  • Advocate for consistent use of the patient’s chosen name and pronouns. 

  • Assure that toys, games, and crafts that are provided to patients are not gendered. Toys should not be seen as “boy toys” and “girl toys” but simply as toys. When hospital staff request toys or activities for a specific gender, child life professionals can educate staff that toys and activities should be provided that are based on the patient’s preferences instead of their gender.

  • Playrooms and activity centers should be decorated with regard to diversity and include pictures of different types of families inclusive of diverse gender identities.

  • Pamphlets and brochures outlining available hospital and community resources for patients who identify as gender diverse should be made available to all patients and families.

  • Advocate for continuing education for staff related to the care of patients who are gender diverse.

    The child life profession values diversity in healthcare services, which lends itself to advocacy for a safe and supportive healthcare environment for all patients, including those who are gender diverse

 

REFERENCES


Alumit, N. (2017). New estimates show that 150,000 youth ages 13 to 17 identify as transgender in the US. Retrieved from https://williamsinstitute.law.ucla.edu/ research/transgender-issues/new-estimates-show-that-150000-youth-ages-13-to- 17-identify-as-transgender-in-the-us/

American Psychiatric Association. (2013). Gender dysphoria. In Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. doi. org/10.1176 Washington, /appi.books.9780890425596.dsm14

Association of Child Life Professionals (2019). Child life code of ethics. Retrieved from https://www.childlife.org/docs/default-source/certification/child-life-code-of- ethics.pdf?sfvrsn=46f7b04d_6

Austin, A. (2018). Transgender and gender diverse children: Considerations for affirmative social work practice. Child and Adolescent Social Work Journal, 35, 73-84.

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Clements, K. C. (2017). What is deadnaming? Retrieved from https://www.healthline. com/health/transgender/deadnaming

Human Rights Campaign. (n.d.-a). All children, all families: Pronouns 101. Retrieved from https://www.hrc.org/resources/all-children-all-families-pronouns-101 

Human Rights Campaign. (n.d.-b). Transgender children & youth: Understanding the basics. Retrieved from htttps://www.hrc.org/resources/transgender-children-and-youth-understanding-the-basics

Joint Commission. (2011). Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: A field guide. Retrieved from https://www.iontcommission.org/assets/1/18/LGBTFieldGuide_WEB_LINKED_VER.pdf 

Klein, D. A., Paradise, S. L., & Goodwin, E. T. (2018). Caring for transgender and gender-diverse persons: What clinicians should know. American Family Physician, 98(11), 646-653E.

Lee, C. (2019). Welcome, singular “they.” Retrieved from https://apastyle.apa.org/ blog/singular-they

Merriam-Webster. (2019). Singular ‘they.’ Retrieved from https://www.merriam- webster.com/words-at-play/singular-nonbinary-they

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