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Qualitative Research

It makes such a difference

An examination of how LGBTQ youth talk about personal gender pronouns

Brown, Camille BSN, RN (Graduate Research Assistant)a; Frohard-Dourlent, Hélène PhD (Post-doctoral Fellow)b; Wood, Brittany A. (Graduate Research Assistant)c; Saewyc, Elizabeth PhD, RN, FSAHM, FCAHS, FAAN (Professor and Director)b; Eisenberg, Marla E. ScD, MPH (Associate Professor)d; Porta, Carolyn M. PhD, MPH, RN, FAAN (Professor)a

Author Information
Journal of the American Association of Nurse Practitioners: January 2020 - Volume 32 - Issue 1 - p 70-80
doi: 10.1097/JXX.0000000000000217
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Abstract

Adolescents experience rapid physical, emotional, and social development as they transition from childhood to adulthood. During this transitional period, youth may be particularly sensitive to social determinants of health, including those related to sexual orientation and gender, which can shape health trajectories in both negative and positive ways (Halfon, Larson, Lu, Tullis, & Russ, 2014; Patton et al., 2016). Although adolescents are a generally healthy population, unmet preventative health care needs in adolescence can lead to poorer health outcomes in adulthood (Hargreaves, Elliott, Viner, Richmond, & Schuster, 2015). Conversely, adolescents who develop positive health practices set strong and potentially protective foundations for their adult health (Patton et al., 2016). Health care providers have the opportunity to improve health trajectories of young people who are at high risk for poorer outcomes by supporting the development of healthy behaviors, including health care seeking and relationship building with health care providers. However, North American data suggest that health care providers may not be optimizing this opportunity. United States and Canadian national survey data suggest that adolescents are the age group least likely to visit office-based physicians (Centers for Disease Control and Prevention, 2017; Statistics Canada, 2016). Nurse practitioners (NPs) may be particularly well situated to provide adolescent care due to their philosophical approach to health care (Kuzma & Peters, 2016) and their practice in care settings outside of traditional office-based settings, like school-based health care centers.

Youth-friendly services and minority youth

To better support adolescents and increase their health care utilization, the World Health Organization developed a set of standards for adolescent-friendly health services (World Health Organization, 2012). Adolescent-friendly—or youth-friendly—health care is characterized by positive factors in five domains: accessibility, appropriateness of care, effectiveness, acceptability, and equity. Unfortunately, equity of care can be difficult for minority adolescents, including transgender and gender diverse (TGD) adolescents (refer Table 1 for definitions of key terms). Transgender and gender diverse adolescents experience institutional and interpersonal stigma associated with their minority identities. Research has demonstrated that stigma can have a significant negative impact on the utilization of health care services for minority groups (Eaton et al., 2015; Poteat, German, & Kerrigan, 2013; Wakefield et al., 2017; Whitehead, Shaver, & Stephenson, 2016). This problem is compounded when the health care provided to stigmatized groups is of lower quality than the general public (e.g., less comprehensive) (Grant et al., 2011; MacIntosh, Desai, Lewis, Jones, & Nunez-Smith, 2013) or their care is culturally inappropriate (e.g., patients being referred to using incorrect pronouns) (Kattari, Walls, Whitfield, & Langenderfer-Magruder, 2015; Shah, 2015). A recent policy article by Kuzma and Peters (2016) supported a shift in NP practice to promote youth-friendly practices.

Table 1
Table 1:
Definition of Terms as Used Within This Article

Transgender and gender diverse youth

In a Minnesota survey of high school students, 2.7% of respondents identified themselves as transgender, genderqueer, gender fluid, or unsure about their gender identity (Eisenberg, Gower, et al., 2017). The US national level data describing the health of adolescents identifying as TGD is limited. However, state- and city-level studies, as well as national studies in Canada, have found TGD youth face significant health disparities compared with their cisgender counterparts (Eisenberg, Gower, et al., 2017); Perez-Brumer, Day, Russell, & Hatzenbuehler, 2017; Reisner et al., 2015; (Veale, Watson, Peter, & Saewyc, 2017). For instance, in Minnesota, TGD high school students were more likely than cisgender students to report engaging in risky health behaviors and experiencing emotional distress (Eisenberg, Gower, et al., 2017). This included the striking statistic that 31% of TGD students participating reported having attempted suicide in their lifetime; this was over four times the rate reported by cisgender participants (Eisenberg, Gower, et al., 2017).

Transgender and gender diverse youth are part of a minority group who often experience gender-related stigma and barriers to seeking or receiving health care in a multitude of ways and on several levels. The US Transgender Discrimination Survey results suggested that among transgender adults, nearly 1 in 5 (19%) had been denied care because of their TGD identity (Grant et al., 2011). A Minnesota study found that TGD high school students were less likely than cisgender students to report preventative medical or dental care in the past year (Rider, McMorris, Gower, Coleman, & Eisenberg, 2018). In the Canadian Trans Youth Health Survey (CTYHS), approximately one third of transgender youth reported high rates of forgone physical health care, and over two thirds reported foregone mental health care (Clark, Veale, Townsend, Fohard-Dourlent, & Saewyc, 2018). Notably on the CTYHS, nonbinary trans youth were significantly more likely to forego needed health care than their binary counterparts and were also 61% more likely than binary trans youth to report experiencing barriers to accessing needed hormone therapy (Clark et al., 2018). These barriers are compounded because stigmatization can mean that TGD youth may require more health care support than cisgender youth due to the burden of chronic stress related to their stigmatized identity (Hendricks & Testa, 2012; Meyer, 1995, 2003).

As with the general adolescent population, employing the principles of youth-friendly care is essential to health care services accessed by TGD youth. Transgender and gender diverse youth need health care services that are accessible, appropriate, effective, acceptable, and equitable. One aspect of care foundational to four of the five domains of youth-friendly health care services is the interpersonal relationship between health care provider and patient. Young people report interpersonal relationship components (e.g., respectful staff attitudes) as crucial aspects of appropriate, acceptable, equitable, and effective youth-friendly health care (Ambresin, Bennett, Patton, Sanci, & Sawyer, 2013).

The present study

This study explored one aspect of interpersonal relationship building necessary for youth-friendly care for TGD adolescents: use of personal pronouns. When speaking about someone in the third person, English speakers generally use gender-marked pronouns based on perceived gender identity most often rooted in physical appearance and name. For example, if someone appears feminine, typically she or her are used when referencing the individual. This can be problematic for TGD people who may not conform to societal expectations of physical appearance for their gender. Adding to the discussion, personal pronouns used to reference nonbinary gender individuals (e.g., they, them, ze, or zir) are unrelated to feminine or masculine gender expression and may be unfamiliar to health care providers.

Using pronouns that are not gender-affirming is a form of misgendering and can be harmful to the individual (Yarbrough, 2018). Best practice guidelines indicate that use of gender-affirming pronouns in practice, like the use of chosen names (Russell, Pollitt, Li, & Grossman, 2018), is important to ensure appropriate care for TGD individuals (Rafferty, 2018). As Donald and Ehrenfeld (2015) note, “recording and using preferred name and pronouns can suggest to trans individuals an inclusive and affirming clinical environment” (p. 178), whereas the opposite may contribute to distress, result in discrimination, provoke accidental disclosure of personal medical information (e.g., that a youth is receiving cross hormone care), and lead patients to not return for further care. Using correct pronouns is one of the supportive behaviors that has been linked to better mental health outcomes for TGD children and youth (Olson, Durwood, DeMeules, & McLaughlin, 2016). Researchers involved in this study are not aware of any studies, however, that have approached pronoun use from the perspective of youth within the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community. This study explored how LGBTQ youth think about binary and gender-neutral personal pronouns, often emphasizing the importance of using or learning to use correct pronouns to create safer and more welcoming spaces for TGD youth. These youth insights will help NPs and others who work with youth to better understand how to respectfully use pronouns and, therefore, provide youth-friendly services to all young people.

Methods

This study was conducted as part of a larger mixed-methods study titled Research and Education on Supportive and Protective Environments for Queer Teens (Project RESPEQT). Interviewers met with 66 LGBTQ youth between the ages of 14 and 19 years in Minnesota, Massachusetts, and British Columbia, Canada to learn about supportive resources in their lives (Eisenberg, Mehus, et al., 2017; Porta et al., 2017).

Participants were recruited through direct invitation from research staff through schools, events, and LGBTQ youth-serving organizations. Potential participants were prescreened to ensure diversity within the study sample. Youth were asked to self-identify their gender, sexual orientation, and ethnocultural background. Research with LGBTQ youth requires additional awareness of ethical and risk management strategies (Meezan & Martin, 2003). For example, parental consent can put adolescents at risk by disclosing their sexual orientation or gender identity to family members. In two of three sites, this risk was minimized by allowing youth to assent or consent without parental involvement (one site's Institutional Review Board [IRB] required parental consent), and all sites allowed youth to decide where they were interviewed. All three sites received approval from the IRB associated with their academic setting for all protocols and materials used in their respective locations.

Participants were invited to lead interviewers on a tour of spaces in their community where they went for resources or support that followed go-along interview methodology (Bergeron, Paquette, & Poullaouec-Gonidec, 2014; Carpiano, 2009; Garcia, Eisenberg, Frerich, Lechner, & Lust, 2012). Participants walked, drove, or took public transportation, and interviews followed a semi-structured guide. Additional details of methods and other findings are available elsewhere (Eisenberg, Mehus, et al., 2017; Porta et al., 2017). Although no questions specifically asked about pronouns, pronoun-related content resulted from questions included in the interview guide, such as “if an LGBT friend came to visit you, where would you recommend they go for fun?” and follow-up probes like, “what is it about this place that gives you a feeling they would be supportive?”

Interviews were conducted between November 2014 and July 2015 by six graduate student interviewers who had experience working with this youth population. Each interview lasted between 35 and 110 minutes. Participants received a $40–$50 gift card in appreciation for their time and insights.

Analysis

After interviews were professionally transcribed, transcripts were uploaded to Atlas.ti to facilitate coding and management of the interview data. Pronoun usage was not part of the main study's research aims; therefore, transcripts were not originally coded for this content. For the present analysis, all 66 transcripts were re-read at least twice and coded by a single team member (CB) to ensure all related text was included in this secondary analysis. In addition to the manually selected text, computerized searches of the transcripts for related terms (e.g., the pronoun “ze” and the word “pronoun”) were used to check for thoroughness in the text included in analysis. The coding process included two steps: (1) descriptively coding all references to pronouns and pronouns used to reference TGD individuals within each transcript and (2) sorting and combining codes into four descriptive, nonoverlapping themes representing what youth shared about pronouns.

Results

Seventy-one quotes mentioning pronouns and pronouns used to reference TGD individuals were identified and coded from nearly half of the parent study participants (32 of 66). Characteristics of the overall sample and the analytic sample are shown in Table 2. Notably, although TGD participants were more likely to discuss pronoun-related content (67% of the TGD sample), many cisgender LGBQ youth (40% of the cisgender sample) also brought up pronoun content related to TGD individuals. Four themes were identified through the coding process: (1) positive views on pronoun-checking, (2) importance of appropriate pronouns, (3) pronouns in the learning process, and (4) navigating complex contexts. Each is detailed below with quotes illustrating critical points. Characteristics of each speaker are given in the text. Findings were then mapped onto recommendations for clinical practice (Figure 1).

Table 2
Table 2:
Demographics for full sample and those included in the subanalysis
Figure 1
Figure 1:
Recommendations for navigating pronoun use during clinical encounters with young people. Note: TGD = transgender and gender diverse.

Theme 1: Positive views on pronoun-checking

Pronoun-checking is asking another person what pronouns they would like used when being referenced. The youth interviewed spoke positively about pronoun-checking, and the importance of actively asking which pronouns to use. Participants described pronoun-checking in personal interactions and group encounters; they also talked about where they wished pronoun-checking was done, but often was not, such as in health care settings.

In personal interactions

Many participants described pronoun-checking when they talked about interactions with others. For instance, a 16-year-old, cisgender, pansexual young woman from British Columbia told a story of when she noticed a group of students who appeared gender-nonconforming and were new to her school. She said, “So, like I ran up to them. I was, like, ‘hey guys, I'm head of the GSA, like what are your pronouns?’ And they're like, ‘oh, my God, hi!’” This introduction allowed the participant to welcome new students and allowed the new students to provide their pronouns instead of having others assume pronouns based on their physical appearance.

In group interactions

Other participants described pronoun-checking as something common in group settings, such as LGBTQ drop-in centers and support groups, as part of introduction exercises. A 14-year-old, gender-neutral participant from British Columbia described, “So at first we go around the circle and we do names, pronouns, and anything else you want to talk about, like, how your day was going, how your week is going, you know, something that happened to you.” Similarly, an 18-year-old, cisgender, bisexual young man from Massachusetts described his first experience with a specific LGBTQ youth-serving organization in his community. He recalled:

The first time I went there, I walked in; they introduced themselves; we sit down, tell you who you want to be called or “he” or “she.” You say your name, who you want to be called, and it was really comfortable. You right away felt like you could be respectful and thoughtful.

A key component to this introduction is that the group leaders introduced themselves before asking the participant about name and pronouns, modeling the behavior for new group members.

In clinical settings

Participants also indicated the importance of pronoun-checking in a clinical context. In a description of her ideal initial interaction with a health care provider, one 16-year-old, cisgender, pansexual young woman from Minnesota stated:

When they come in and they introduce [them]self, if you're going to urgent care or something, they'll ask for a name, they'll ask, “Oh who brought you in?” I wish they would ask, “Do you have a gender?”… Because that's what I—like, every once in a while, if I'm talking to someone and hitting off them, I'll be like, “Just in case, what is your gender? What are your pronouns?”

This participant suggests that even for urgent care clinical encounters, it is important to ask the patient their pronouns early in the interaction. The practice of pronoun-checking may seem self-evident in clinical encounters for gender-related care, but this participant's quote suggests that even in situations where gender may not otherwise come up, asking about pronouns is integral to establishing rapport.

Theme 2: Importance of appropriate pronouns

Participants identified a number of internal reasons why appropriately using pronouns is important. Correct pronoun usage by others led to TGD youth feeling validated in their gender expression, feeling supported, and subsequently, feeling less emotionally stressed.

Validating their gender expression/presentation

Hearing others use correct pronouns can indicate to a young person the degree to which their physical appearance matches their gender identity or their gender expression. Because this use of pronouns relies on appearance-based assumptions, this is primarily an option for binary youth whose appearance are more likely to match societal expectations of what men and women look like compared with nonbinary youth. A 17-year-old, transgender young woman from Minnesota describes what made a community space feel safe for her:

There's good food and fairly kind people. I've never had problems of being called the wrong gender…Yeah, if they're addressing me, they always say “she” and “her.” I don't personally know the people working there, so I don't know if they decide that or just that's what they see, but regardless they still do it.

This participant is noting that when people refer to her with feminine pronouns, she feels it indicates either a positive environment or the degree to which she is being perceived as feminine.

Feeling supported

Participants indicated that correct pronoun use can promote a sense of being heard and supported by others. One 18-year-old, nonbinary participant from Massachusetts illustrated this in their statement:

I like that my grade will actually listen to me and try with pronouns and stuff. It's pretty great, actually. When I first came out and asked for the pronouns, a lot of people struggled or would forget, but as more people caught on, then it was like a chain effect, and more people caught on, and other people would correct people, and it was really cool.

This participant is noting that by using the appropriate pronouns, their classmates are listening and respecting their gender, which in turn promotes a sense of well-being for the participant.

Feeling less stress

Participants also identified use of correct pronouns as important for overall mental health. A 16-year-old, pansexual, cisgender young woman from British Columbia explained how communication about pronouns made LGBTQ youth feel less stressed:

If you're all chatting, the first thing they do is ask you your preferred pronouns, just so, like, know everyone's gender is respected. That kind of thing. Just, like, it’s really small and, like, if someone doesn't know what preferred pronouns are it doesn't take long to explain. But it makes such a big difference because you feel, like, you don't have to repeatedly come out. “Cause that's the thing about, like, the reason you have to come out now isn’t, like, it’s not that you come out once, you have to, like, repeatedly come out on a day-to-day basis” cause people assume that you're going to be straight and bigendered.

This participant draws a distinction between other spaces, where people must constantly come out to counter people's assumptions, and this space where this stress is not present. She identifies pronoun-checking as a crucial practice to building this kind of space.

Theme 3: Pronouns in the learning process

Participants acknowledged that for many people, going against gender assumptions imbedded in practiced speech patterns or using unfamiliar pronouns can take time to become habitual. Participants readily understood the difficulty and made allowance for others who may not be as practiced with appropriate pronoun use.

Making allowances for the learning process

It is imperative to understand that while participants identified appropriate pronoun use as an important indicator of support, the intention to use correct pronouns was equally important, as evidenced in this quote from an 18-year-old, nonbinary participant from Massachusetts, “Well, [my mom], she's supportive. Pronouns are hard for her...It is a process because it's all new. She's always been supportive.” In another example, a 17-year-old, transgender young man from Minnesota described how the local game shop in his community showed their support for his gender identity:

It's one of the first places where it was okay to be myself. It was pretty cool. This was the first big group I came out to, and everyone was like, “Alright, we're probably going to get your pronouns wrong, but we are going to try our darned hardest”…and everyone's okay with blunt correcting.

The participant felt validated by his peers' intentions to use correct pronouns and further supported by the group's acceptance of reminders when they inadvertently misgendered him.

Policing your own pronoun use

The youths also discussed their own difficulty with pronoun usage. A 17-year-old, bisexual, cisgender young woman from Massachusetts discussed her workplace, an LGBTQ youth organization, and their policy for personal pronouns:

Even the people who don't look traditionally female, if they ask for female pronouns, we use female pronouns to the best of our ability, and we also ask that people understand if people slip up on pronouns once or twice as long as it’s not an intentional thing.

Participants talked about understanding that mistakes happen and looking for immediate self-correction as an indicator of support when misgendering occurs. A 17-year-old, transgender young man from British Columbia was describing the outcome of coming out to his classmates:

And they all really try, so it’s really nice that way. Even the younger class, if they would say “she” they'd be, like, “oh, shit. Sorry. I meant ‘he,’” it’s like “oh, it’s fine, just correct yourself.” So… they're all really accepting so it’s always nice.

Supporting others in the learning process

Support can also be indicated by correcting others when the wrong pronouns are used and supplying brief education as needed. For instance, one 18-year-old, cisgender lesbian from Massachusetts discussed correcting her aunt in conversation:

[My aunt]'s like, “Oh, your friend [name] came over. How's she doing?” and I'm like, “Oh, no, it's they/them/their. It's a gender nonbinary thing.” She's like, “That makes no sense, but I'm going to try and learn.” I talked to her about it and she understands a little more. It's going to take time, but she'll understand.

This indicated addressing incorrect pronoun use remained important even though the person being identified with the pronoun was not present. As a person who knows which pronouns the nonbinary friend prefers, the participant corrected and briefly educated her aunt who is considered a supportive person because of her willingness to adjust her pronoun usage when referencing the participant's friend.

Theme 4: Navigating complex contexts

Although, in general, participants talked about using pronouns that are usually understood to match someone's identity (e.g., he for someone who identifies as a man), internal and external contexts for an individual could influence what pronouns were appropriate in specific situations. Participants identified complex scenarios in which context influenced decision making around pronouns in ways that do not adhere to the general guideline. Although both internal and external contexts interplay in all circumstances, for ease of understanding only one or the other are discussed in the subthemes below.

External context

Not all spaces and people are safe for youth to be open about their gender identity. Participants discussed how such external factors may influence pronoun use. This might include using pronouns and gendered language associated with a TGD individual's gender identity in safe spaces, or not using them outside of the safe space, as discussed by this 18-year-old, gender-fluid participant from Massachusetts:

They might not go by that name and [those] pronouns outside of [the safe space] … [but if] they wanted to go by a different name at this place because they feel safe enough, then that is something that we want to respect.

The participant acknowledges that the appropriate pronouns and gendered language—here, a name—is dependent on how safe the environment is. The external factors influencing appropriate pronoun use are often more related to who is in the environment than the physical space itself. For instance, some participants described avoiding gendered terminology when the person is not comfortable sharing their gender with all parties present as a good way to maintain support for the person but avoid revealing their gender identity accidentally. A 17-year-old, transgender young man from British Columbia discussed how his friends appropriately navigated pronouns as an indicator of support, although avoiding outing him to family members who may not be safe to be out to.

Everyone that knows, knows to use male pronouns when my parents aren’t around and then female ones—or actually they tend to stick more to neutral ones, which is really comforting—around parents.

For this participant's sense of security it was important to have others use pronouns that would not disclose his gender identity to his parents, who were unaware of his gender. He acknowledged that gender-neutral pronouns made him feel more comfortable than those associated with his sex assigned-at-birth, when pronouns generally associated with his gender were not safe to use.

Internal context

Applying knowledge about an individual's internal context is essential to using correct pronouns in all situations. Using the pronouns identified by the individual during pronoun-checking is one way ensure that internal context is being respected. Participants discussed using pronouns that an individual identifies with, even when they may seem incongruent with gender identity, as a way of supporting TGD individuals. For instance, when discussing how LGBTQ youth are supported at her school, one 16-year-old, bisexual, cisgender young woman from British Columbia explained:

There's a boy in my writing class and he's, like, pre-transgender, trans woman so becoming a female. And, like, no one really treats him any differently. He's such a sweet guy, … he still prefers the pronoun “he” right now.

In this situation, the participant identifies that the TGD student's pronouns could be seen as incongruent with his gender identity. However, not every person attaches the same gendered meaning to pronouns, and their meanings do not always match common understandings (e.g., a nonbinary youth may use “he” and still understand himself as nonbinary). Given that contexts change over time, especially early in the process of transition, and that assumptions are not always correct, regular pronoun-checking is appropriate to ensure the correct pronouns are being used as those contexts change.

Discussion

This study shed light on the ways in which LGBTQ youth use and discuss pronouns in relation to TGD people and why different aspects of appropriate pronoun use are important to LGBTQ youth. Without specific prompting from interviewers, nearly half of the participants in all three sites brought up the topic of personal gender pronouns or used personal gender pronouns related to TGD people in the discussions about their community. This signals that pronouns are an important topic for these youth. Regardless of gender identity, youth in the study discussed appropriate pronoun use as an important marker for what makes a space feel safe for them in their communities, which adds support to current best practice guidelines.

Each of the themes identified in this study show a different aspect of appropriate approaches to using personal pronouns for TGD people. Participants described how to assess correct pronouns, how to use pronouns in different contexts, and why respecting pronouns is important. They also emphasized that flexibility is an integral component of the learning process for appropriate pronoun usage. Each of these themes can be applied to health care practice as suggested in the examples provided in Figure 1, developed following the analysis.

The recommendations based on Theme 1 (Positive Views on Pronoun-checking) emphasize the importance of avoiding assumptions about which pronouns are appropriate to use by asking patients to provide their pronouns on intake forms and having clinic staff introduce their own pronouns during introductions. Applying this practice to all patient visits, regardless of gender identity or physical appearance of the patient, can ensure that youth are affirmed and respected in their genders. In addition, having clinic staff provide their own pronouns in introduction can signal youth-friendliness and help provide openings for youth to begin conversations about gender identity.

Respecting and using correct pronouns throughout clinic encounters as assessed through pronoun-checking may help youth feel comfortable in the ways discussed in Theme 2 (Importance of Appropriate Pronouns). It is important that, the first subtheme of Theme 2—which shows correct pronoun use may validate gender expression—should not necessarily be understood as an individual wishing to appear cisgender. Although many in the TGD community feel being read as cisgender—often referred to as passing—is important for their comfort and safety, others do not wish to be read as cisgender and feel doing so equates to erasure of their TGD identities (Stryker, 2006). So, while validating gender expression and presentation is part of why some youth in this study find correct pronoun use important, making assumptions about which pronouns are correct based on a patient's physical appearance, even in an attempt to validate their gender identity, may be alienating or hurtful to some.

Recommendations based on Theme 3 (Pronouns in the Learning Process) remind clinicians that youth do not expect perfection when using pronouns, but they do expect active attention to mistakes made by oneself and others. This active attention may come in the form of immediate self-correction; gentle, immediate reminders to others; or changes to institutional processes to ensure that it is easier for staff to use the right pronouns (e.g., including pronouns on intake forms). Mistakes should be acknowledged but not dwelt upon.

Recommendations of Theme 4 (Navigating Complex Contexts) are particularly important for the safety of TGD youth. Youth who do not wish to have others know about their gender identity might be placed into unsafe situations if their gender identity is unintentionally revealed to people who may respond violently or in other trauma-inducing ways. According to the US Transgender Survey results, 10% of respondents who were open with their families about being transgender experienced violence from a family member because of their gender identity and 8% were kicked out of the house by their families of origin because of their gender identity (James et al., 2016). As such, use of a pronoun that would identify the young person as TGD in circumstances that might cause similarly traumatic experiences (i.e. in front of unsupportive parents) should be avoided. Nurse practitioners and other health care professionals must take care to assess factors that may be influencing which appropriate pronouns to use and consult with patients to ensure the right course of action. This might look like using gender-neutral pronouns or avoiding pronouns when speaking to parents who may not know about their child's gender identity or when contacting the young person for follow-up or reminders.

Many practicing nurses report feeling unprepared to work with TGD patients owing to a lack of TGD content in their education (Rider, McMorris, Gower, Coleman, Brown, & Eisenberg, 2019). Although some NP programs are beginning to incorporate lesbian, gay, bisexual, and transgender content into curriculum (Yingling, Cotler, & Hughes, 2017), nursing programs may still lack representation of TGD-specific content (Walsh & Hendrickson, 2015). Tools, like Figure 1, should be introduced into all levels of curriculum and in continuing education presentations to bridge gaps in required curriculum and help nurses feel more prepared to work with patients of all gender identities. As leaders, NPs should provide guidance to other nurses and care team members to ensure all are aware of and utilizing available best practice tools to improve care for patients.

Limitations and strengths

Because the interview guide did not specifically ask about pronoun use for TGD people, it is possible that the findings overemphasize the perspectives of those individuals for whom pronouns are more important. An additional limitation is that member checking (i.e., approaching select participants with synthesized results to confirm accuracy of findings) was not possible after this analysis was completed because participants had not consented to follow-up contact after the primary study ended. A strength of the study is that it draws from the experiences of adolescents from the United States and Canada. The findings across all three sites (Minnesota, Massachusetts, and British Columbia) were consistent, demonstrating cohesion around the topic among diverse LGBTQ youth.

Failing to appropriately use pronouns may damage patient–provider relationships. Poor patient–provider relationships can affect treatment adherence (Castellano et al., 2014), health behavior change (Leiferman, Sinatra, & Huberty, 2014), and engagement in health care (Remien et al., 2015). Interpersonal relationships are central to youth-friendly practices (Ambresin et al., 2013) and should be emphasized in care provided to adolescents. By respecting and using a patient's correct pronouns throughout patient clinical experiences, NPs are promoting positive patient–provider relationships. Health care services and settings will be more consistent with youth-friendly practices when adults who work with adolescents take care to respectfully use pronouns.

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          Keywords:

          Adolescent-friendly health services; LGBTQ health; pronoun; qualitative; transgender

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