Gender, gender identity, and use of pronouns are hot button issues.1 While the actual number of non-gender-conforming individuals in the United States is small, it is steadily increasing.2 Names and gender are important and basic aspects of our identities. Hence, it is important to talk to and about people using their preferred names and personal pronouns. It affirms a person's identity and shows respect.

Pronouns are used as substitutes for nouns3 and in gendered languages are linked to the noun's gender-female, male, or neutral. However, gendered language goes beyond using pronouns. Rather, on the basis of the language, pronouns, nouns, and/or verbs can be gendered.4 Jakiela and Ozier5 estimate that almost 40% of the world population speaks some form of gendered language. Nine of the 10 most spoken languages in the world are gendered.4 Growing up with, and using, gendered languages is associated with implicit gender bias5,6 and has been linked to gender inequalities.7,8

To become more inclusive, languages must change; however, the individual approach is based on the specific language.4 In English, one way to achieve more inclusivity is to use the pronoun "they" in its singular form.9 In a 2018 survey,10 22% of US adults personally knew someone using "they" as preferred pronoun. Using the singular "they" is not new, despite the more recent awareness and increase in use. Famous English literature works using the singular "they" include The Canterbury Tales, Hamlet, and Pride and Prejudice, published in 1386, 1599, and 1813, respectively.11

Another approach is the creation of new pronouns, also known as neopronouns.4 While individual pronouns such as "ze" or "hir" may be new, creating neopronouns is also not new. Rather, there were attempts to introduce gender-neutral pronouns into the English language as early as the mid-19th century.12,13 There are no limits to creating neopronouns. Thus, using neopronouns would make it possible for individuals to create or find a preferred pronoun. However, critics worry that individuals using these pronouns and the larger LGBTQ community as a whole would face ridicule and lose credibility. Controversy around neopronouns could also distract from larger, more urgent issues the LGBTQ community faces.14 Furthermore, it is rare that even a single function word such as a new pronoun enters the English language.15 Hence, adding an unlimited number of neopronouns to the English language faces long odds, but obviously it is possible.

However, healthcare in general still functions in a predominantly binary system that focuses on biological sex. Thus, healthcare providers-to include nurses-are faced with the use of gendered medical terminology based on an individual's biological sex. This approach can conflict with a person's gender identity, especially in the areas of urological, gynecological, and obstetric healthcare where the focus is on the physiology and pathophysiology of organ systems associated with the person's biological sex.

There has been a push to desex language in healthcare. The goal of desexing language is to remove stigmas and barriers to individuals obtaining and receiving evidence-based care. In general, desexing language leads to positive outcomes.16 However, it can also have unintended negative consequences. As Gribble et al17 discuss, especially those who are young or do not speak English well may not know their anatomy or understand the technical term being used. One should not assume that even well-educated individuals have a solid grasp on male and female anatomy and physiology.

Other concerns addressed by the authors include the potential for incorrect language and misdiagnosis. For example, there are calls to use the desexed term "chestfeeding" in lieu of the term "breastfeeding." Anatomically, this is incorrect, because mammary glands are located outside of the rib cage and are thus not part of the chest. And what about if a chestfeeding person complains about chest pain. Is it mastitis or a myocardial infarction? Furthermore, masking biological sex in healthcare records may lead to missing the diagnosis of pregnancy if the provider is not aware that the patient in front of them has female reproductive organs. The researchers also outline that in research the use of gender-neutral language may contradict established definitions, dilute research findings as numerators are changed (ie, from women to person), or make it difficult to identify pertinent research.

Finally, the authors point out that the push to desex language is based on Queer Theory, a theory developed in the United States and dominated by US priorities and beliefs. The beliefs and thought processes that are underlying these theories may not be applicable in other countries. Requiring that clinicians and researchers in other countries use desexed or gender-neutral language (ie, to access funding mechanisms or publish) can be perceived as imperialistic, oppressive, or colonialist.

Ultimately, there is a place and a time to use desexed and gender-neutral language, while at other times, using sex-specific language is indicated. It is important for stakeholders such as clinicians, researchers, or public health officials to understand what language ought to be used when and to use language intentionally. There is no one size fits all. But it is also everybody's duty to create an inclusive environment. To do so, it is most important to identify one's biases and address them. It also requires asking for preferred names, pronouns, and gender identity, not just during face-to-face interactions but also on demographic intake forms, health insurance forms, healthcare records, and research questionnaires.6,18 Because after all, it is about more than just being respectful of others. It is the right thing to do.

-Alexandra Michel, PhD, CNM, FACNM

Nancy Atmospera-Walch School of Nursing

University of Hawaii at Manoa

Honolulu, Hawaii

References