Using affirming language with LGBTQIA+ patients

We’re two queer psychiatry doctors based in New York City. We care for patients in a range of settings including the emergency room, hospital, and clinic. We’re passionate about making sure LGBTQIA+ (Lesbian Gay Bisexual Transgender Queer Intersex Asexual) patients have equal access to quality care. One of the most important things we can do as clinicians is know and understand the basic language that applies to this population.

We’ve taught queer health to medical students and doctors. There are many common questions that come up related to language. We’d like to address those questions here so you can go into the next encounter with confidence.

How do I ask patients about their gender identity or sexual orientation?

1. Studies show LGBTQIA+ patients want to be asked about their sexual orientation and gender identity, aren’t likely to take offense, and are most comfortable when these questions are normalized, universal, and confidential.

2. One of the best ways to do this is through routine intake forms with questions on sexual orientation, gender identity, sex assigned at birth, name, and pronouns. Here are some helpful guidelines from the CDC.

3. When asking verbally, you can say, “To make sure we give the best care, we ask all patients about their gender identity and sexual orientation. How do you define your gender identity? What pronouns do you use? How do you define your sexual orientation?”

How do I take a social or sexual history without making assumptions?

1. Remove gender assumptions from your routine social history. Here are a few questions we like:

“Who lives at home with you? Are you in a relationship? If so, tell me more about it. Do you have a partner or spouse? Tell me more about them.”

Remember, sexual orientation doesn’t always match sexual practice, and many people, in a relationship or otherwise, have multiple sexual partners. Avoid assumptions with these routine questions:

“Do you have sex with men, women, or all genders? Tell me about your sexual partners”

Won’t patients be offended if I ask about their gender and pronouns?

In short, no. Patients who are transgender or gender non-conforming often have to correct or cope with people’s incorrect assumptions. Gender identity is something internal, so we can’t know how someone identifies unless we ask. If someone is cisgender (they identify with their sex assigned at birth), they may be confused by the question, but that’s ok. It’s a chance for more learning.

When someone says they’re genderqueer or gender non-binary what does that mean?

Gender can be viewed as a spectrum. Genderqueer and gender non-binary are both terms people use when they don’t identify fully with being a man or a woman. Other people use the term to refer to fluidity within their gender identity that changes over time. Some genderqueer people use “they/them” pronouns to refer to themselves instead of “he/him” or “she/her” pronouns.

How do I document that a patient is transgender in the chart?

Gender and pronouns are a big part of how people interact with the world and biological sex can be important in diagnosis, workup, and treatment. Document everything clearly and accurately, starting with gender identity, then sex assigned at birth, pronouns, and name. Try to stay away from “male-to-female, female-to-male,” as it emphasizes sex assigned at birth over someone’s gender identity. Instead, try, “The pt is a 55 y/o transgender man (assigned female at birth), he/him pronouns.” “The pt is a 12 y/o non-binary child (assigned male at birth), they/them pronouns, goes by Sam.” “The pt is a 30 y/o intersex woman (assigned female at birth, dx XY w/ androgen insensitivity syndrome in childhood), she/her pronouns.”

Is it bad grammar to use “they” when referring to an individual patient?

You may be used to using “they” to refer to a group of people, but you’d be surprised that you already use it to refer to one person, like when you say something like, “Where’s my patient? Are they over at X-ray?” We play with grammar all the time and we learned all sorts of new ways of speaking when we became healthcare professionals. We can keep learning ways to use language that is respectful to our patients.

Is it always medically necessary to ask about and document sexual orientation or gender identity?

Not always. Consider the scope of your practice, respect your patients’ privacy, but be consistent. Avoiding questions in some patients and not others can reinforce health disparities. LGBTQIA+ patients often face discrimination in healthcare settings, starting from the front desk. If possible, reserve documented information on sexual orientation and gender identity for only relevant clinical staff.

What if I make a mistake? Use the wrong name or pronoun? What if the language changes?

1. You’ll make mistakes. As clinicians, we can be especially hard on ourselves for making mistakes. Remind yourself that you’re learning something new and that takes time.

2. When you make a mistake, acknowledge it and then move on. Ignoring it can send the message that you don’t care, and becoming overly apologetic can result in the patient feeling like they need to take care of you.

3. The language might change and that’s ok. Try to focus less on keeping up and being right and more on being open to learning.

This piece expresses the views solely of the author. It does not represent the views of any organization, including Johns Hopkins Medicine.