Reevaluating Gendered Language in Surgery.

Misconceptions about gender are common in the United States, and binary gendering is pervasive in our culture. Although public acceptance of diverse gender identities has increased, binary language remains deeply ingrained in our health care system.1 Generations of surgeons, including those who teach professional communication, learned to address patients using a surname and gendered honorific (eg, Mr, Ms, Mrs). This language is routinely used in patient encounters, oral presentations, and the electronic medical record (EMR). Gendered titles, however, are easily misinformed by inaccurate demographic information or assumptions based on a patient’s name or appearance. In 2021, at least 1% of the US adult population identified as transgender, and for these patients, exclusionary language contributes to negative health care interactions and poorer health outcomes.2,3 Moreover, 1 in 4 transgender and gender diverse (TGD) individuals who felt their identity was not respected attempted suicide in the past year.4 Fortunately, protections for TGD individuals are expanding through federal legislation such as the proposed Equality Act, which explicitly prohibits discrimination based on sexual and gender identity. If enacted, these protections could have broad implications for cultural sensitivity in surgery.5 TGD patients, especially those with intersecting sexual and racial identities, experience health disparities that would benefit from medical and surgical intervention.6,7 Under Section 1557 of the Affordable Care Act, individuals may not be denied, limited, or refused health care coverage on the basis of gender identity.8 Subsequently, the American Society of Plastic Surgeons reported that gender-affirming surgeries increased 5-fold from 3256 in 2016 to 16,353 in 2020.9 Importantly, increased utilization of health care by TGD people extends beyond gender-affirming care. All surgeons have a responsibility to advance health equity by examining societal constructs. Recently, qualitative methods have been used to identify outdated or inaccurate terminology in the surgical care of TGD patients.10,11 In this respect, the surgical field has already demonstrated some progress in reevaluating gendered language.12 For example, it is now standard practice to use gender-neutral terms such as “spouse” or “partner” in place of “husband” or “wife” when describing an individual’s marital status.13 While seemingly trivial, simple linguistic changes can establish a safer space for TGD individuals and improve health outcomes. However, pragmatic guidelines for the implementation of affirming interventions in surgery and the associated challenges have not been addressed. As surgeon engagement with TGD patients increases, it is time for the surgical community to reexamine gendered language and actively promote an affirming environment throughout a patient’s surgical journey. Patients encounter gendered language in multiple contexts when seeking surgical care: in public spaces (eg, reception), during provider visits, on the day of surgery, and in documentation (eg, EMRs, intake forms). Each situation requires unique considerations. An analysis of online gender-affirming surgery reviews identified salient themes that characterize the experience of TGD patients seeking surgical care. Overall, interactions with staff and surgeon bedside manner were given greater attention than operative results, highlighting the importance of communication and language in high-quality surgical care.14 Furthermore, surgeons may express negative thoughts or inaccurate perceptions of a patient’s identity in encounter notes, which are now accessible by patients.15 Often these transgressions are not explicit, but rather stem from a lack of information about the patient. A study of 1618 patient encounters in a surgical clinic found that the most common reason a patient would not recommend their surgeon was a failure to “show interest.”16 Suboptimal communication or rapport can negatively impact the disclosure of pertinent health information and hinder shared decision making. At the start of an encounter, providers should ask: “How would you like to be addressed?” or “What name do you like to go by?” This applies to all patients, including the heteronormative majority, as many patients like to be addressed by a name that is not included in the medical record. Since gender is inherent to one’s identity and not a deliberate decision, the phrases “preferred name” and “preferred pronouns” must be avoided. Patient name and pronouns should be documented in the title information of the EMR and used in notes to inform future providers, as well as those who interact with patients in public spaces. It is also important to reaffirm this information periodically, as gender identity can evolve. When possible, a statement of title should be made during oral presentations, encouraging surgical trainees and interprofessional colleagues to use patient-centered language as well. In addition, health care institutions may provide patients with an optional name tag and ensure hospital wristbands reflect accurate name and gender. When a patient’s gender and pronouns are unknown, we advocate for the use of the prefix “Patient” (abbreviated Pt.) followed by a surname (eg, Patient Smith), in place of gendered honorifics. Alternatively, the patient’s full name can be used. Surgeons should default to “they/them/their” pronouns or simply refer to them as “the patient” until their pronouns are known. Not only does this language avoid inadvertent misgendering, but it maintains an appropriate level of formality within the patient-physician relationship. As health care professionals, we expect to be addressed using nongendered titles (ie, “Doctor” or “Nurse”)—we should provide the same inclusivity to our patients. When gender information is collected passively through intake documents or online registration platforms, attention should be given to ensuring that a full spectrum of identities is presented. Inadequate documentation of patient gender not only promotes misgendering, but also fosters a lack of gender-specific medical research.17 Ideally, gender should be collected using an open-response field, rather than a finite list of choices. When this is not feasible, an inclusive set of gender identities should be provided while acknowledging the limitations of a finite list. For example, “Are you transgender?” with choices of “yes” and “no” followed by “What gender do you most identify with?” with choices of “agender,” “man,” “woman,” “genderfluid,” “non-binary,” “questioning,” and “prefer not to disclose.” Responses should be listed in alphabetical order, avoiding a binary gender normative ordering. Without the ability to examine surgical outcomes based on gender demographics, it is impossible to identify the biopsychosocial mechanisms underlying health disparities for TGD patients. In a recent qualitative study, gender-affirming surgery patients reported correct pronoun usage and patient-centered terminology as being major factors in determining their comfort, trust, and satisfaction with their surgeon.11 Accordingly, when marking a patient, it is important to use patient-directed words to describe anatomy. For example, If the patient uses the word “pec” to describe their chest, then the surgeon should use the same term. Some inclusive practices may be perceived as foreign, or even unwelcome, by patients who are accustomed to certain cultural norms, such as gendered honorifics. Ultimately, linguistic changes should be implemented by providers in a manner that is culturally sensitive to all patients. Asking, “How would you like to be addressed?” may be more appropriate for some patients than, “What pronouns do you use?” Some patients may use a gendered honorific, while others may use a nickname. By normalizing an inclusive and comprehensive introduction, surgeons can limit inadvertent microaggressions and build rapport, improving the patient-physician relationship for all patients. Despite supporting inclusive practices, surgeons may unknowingly or accidentally use the incorrect name, honorific, or pronoun with a patient, particularly during an initial encounter. In such instances, a simple apology is justified. Surgeons can maintain an affirming environment by acknowledging the mistake and communicating understanding. For example, “I’m sorry. Thank you for letting me know you go by ___. I’ll use that name from now on and let your team know.” Understandably, the proposed interventions require institutional support and additional cognitive demands to implement (Fig. 1). EMRs and hospital information technology were built around binary genders. In some cases, ordering preventive health tests (eg, a pap smear for a transgender man) may trigger an order validation alert if the patient is not documented as the concordant sex. At the institutional level, surgeons should advocate for inclusive policies, such as displaying pronouns on provider badges and email signatures and visible nondiscrimination statements in clinics. Moreover, surgical societies, such as the American College of Surgeons, should put forward unified and comprehensive recommendations regarding gender in surgical care and research. As the US health care system moves toward value-based care, the importance of interventions that improve patient satisfaction, postoperative outcomes, and health care utilization continues to increase.FIGUE 1: Recommendations for inclusive and affirming surgical care.Ultimately, our health care system cannot treat the effects of historical trauma and oppression for TGD patients with therapeutics and procedures alone. Systemic heteronormativity is rampant in health care, and improving inclusivity requires deliberate change in how health care centers operate. Rethinking the language we use and the assumptions we make is necessary to promote inclusion and equity. Improving professional communication is the first of many steps needed to move toward higher quality patient care and address health disparities for marginalized communities.