Using the correct pronouns for trans patients in primary care is important. Blake Cavve and Xander Bickendorf review the evidence and explain why.
Trans is an umbrella term that describes gender identities which differ from one’s sex as registered at birth. This difference can cause significant distress and psychosocial impairment, known as gender dysphoria. In order to alleviate this distress, trans people might seek to have their gender affirmed socially through the use of a name and/or pronouns which better reflect their affirmed gender.
In English, the pronouns we use often indicate that person’s gender, most commonly he/him/his or she/her/hers. Some people may prefer neutral or other pronouns, commonly they/them/theirs.
Some trans people will request gender-affirming medical intervention to help their body align with their experienced gender. General practitioners are often the first point of contact for trans people seeking medical intervention or psychological support.
Additionally, while some people may seek a GP referral to specialist endocrinology or sexual health care, GPs commonly prescribe and monitor gender-affirming hormone treatments. Overall, GPs are the most common service for young trans Australians to access regarding their gender identity.
Trans people may also have elevated need for other forms of medical care. Mental health care is a particularly important ongoing factor to consider for trans patients.
Trans people have elevated rates of depression and anxiety, and 80% of young trans Australians have a history of deliberate self-harm, with one in two having attempted suicide in the past – a rate 20 times higher than adolescents and young adults in the general population. Similar rates have been found for trans adults.
Discrimination and victimisation contribute to these higher rates of mental health difficulties.
However, health care for trans people is not always about gender-affirming needs; trans people also sprain their ankles and have vaccinations!
While providing sensitive and individualised treatment for general health care needs may require knowledge of someone’s trans status and consideration of gender dysphoria in planning care (e.g. preparing for and coping with transvaginal ultrasounds or cervical screens in trans masculine patients), doctors should avoid asking intrusive questions (e.g. about genitals or surgical procedures) unless relevant to the patient’s current care concerns.
Barriers to care
Many trans people report significant barriers to accessing health care, including primary care, through being misgendered (e.g. using the incorrect name and pronouns), feeling humiliated or unsafe, and, in some cases, being refused care.
Australian trans adults largely receive sexual health care from a GP clinic (72.3%), however, fewer than 50% feel their GP provides care sensitive to their needs, and fewer than 30% feel that their GP intake form allows them to properly describe their gender identity (including name and pronouns).
Similarly, 61% of Australian trans youth have experienced feeling isolated from health services (of which GPs were the key provider) and these individuals have higher rates of self-harm and suicidal thoughts than those who did not experience this isolation.
Negative experiences with primary care, such as incorrectly gendering patients and using the wrong name or pronouns, can lead to hesitation towards accessing future medical care, leading to preventable illnesses and contributing to poor mental health.
Personal testimony: “Regular and routine visits to a trusted GP don’t happen for me, instead I’m scrambling for a once-off option when I’m truly unwell or joining considerable waitlists in search of care that is more inclusive. I feel this affects my ability to maintain good health and access timely preventative care.”
Pronouns matter
The use of chosen names and pronouns is associated with improved mental health and a sense of wellbeing for trans people. Trans patients who feel more comfortable with, and respected by, GPs also have better mental health. A number of medical and psychological organisations therefore recommend use of patients’ chosen names to be integrated into clinical care.
The RACGP Standards for General Practices (5th edition) advice also recommends collecting information about birth-registered sex, gender and pronouns. By using the correct name and pronouns for trans patients, you are helping to support their mental health and helping to establish a relationship of respect and trust.
Personal testimony: “There’s an enormous relief in knowing from the outset that your identity will be respected and that is reflected in how openly I interact with a care provider. It’s very hard to establish trust without having that acceptance.”
What GPs can do
As many trans people require regular and long-term medical services, the GP-patient relationship is important to a vast array of health outcomes. Providing inclusive care is key for health care providers to develop positive relationships in which trans patients:
- feel they can be honest and do not have to withhold their trans status in order to receive care
- trust their information will be treated confidentially (e.g. that their trans status will not be shared inappropriately)
- feel they are safe, respected, and not judged.
In order to provide this sensitive care, it is important that health care providers collect accurate information on trans status, preferred names and pronouns. Because we can’t always tell someone’s gender just by looking at them, the best way to know which pronouns to use for someone is to ask them.
It is important to ask everyone, and not just people who “look trans”. Standard protocols, including a correctly worded question on gender identity, results in patients being more open about their gender identity, and provides the practice with more accurate information.
Personal testimony: “If I can’t self-identify when filling in my medical information, or there is no indication that people like me are welcome, I will assume the worst, edit myself and won’t engage honestly with the provider … I feel disempowered.”
For sample intake form questions, see the RACGP Standards for General Practices (5th edition) fact sheet. Online e-training for primary care teams are available via the Australian Professional Association for Trans Health or Gender Identity Research and Education Society. ACON’s TransHub also has resources for clinicians and affirming waiting room posters.
Recently published best practice guidelines for LGBTQA+ young people include recommendations on creating an affirming and inclusive environment for LGBTQA+ youth, as well as a specific section on considerations for trans young people.
Key messages
- Collect self-identified gender, birth registered sex, legal name, chosen name, and pronouns at intake, and ensure that these are reflected on the medical record.
- Consistently call people by their chosen name and pronouns
- When you make a mistake, apologise briefly, correct yourself, and keep trying
- Train your practice staff (and students) to do the same, regardless of their job within the practice
- Take a respectful history obtaining informed consent to physical examination minimising trauma from physical examination and investigations
- Use correct name and pronouns when you are talking about the person in their absence, as well as when they are present
- Use date of birth and address as the additional points of identification – don’t say the person’s legal name
- Continue to learn more about gender-friendly and trauma-informed primary care.
ED: Blake Cavve is from the University of WA and Xander Bickendorf is from Telethon Kids Institute.