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Inclusive language and environment to welcome lesbian, gay, bisexual, transgender, queer, questioning, intersex, and asexual+ patients (2024)

Using inclusive language and creating an inclusive clinical environment to serve lesbian, gay, bisexual, transgender, queer, questioning, intersex, and asexualþ patients is vital to optimizing access to care and patient outcomes. Practical recommendations are made for increasing inclusivity in the clinic, and a glossary of current terms is included. (Fertil Steril® 2024;121:954–60. ©2024 by American Society for Reproductive Medicine.)

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The lesbian, gay, bisexual, transgender, queer, questioning, intersex, and asexual þ (LGBTQIA+) community has long faced prejudice, discrimination, and stigma, including from medical professions (1).  LGBTQIA+ stigma, defined as the social process of labeling, stereo- typing, and rejecting human differences as a form of social control (1), has created an array of structural barriers to care that can prevent LGBTQIA+ people from receiving adequate health care. The legacy of pathologization (or unfairly recognizing someone or something as a medical problem) of LGBTQIA+ identities and behaviors continues to affect LGBTQIA+ people. Despite significant improvements, LGBTQIA+ people still face intersectional marginalization, discrimination in health care and in policies affecting access to health care and family building, and societal stigma surrounding LGBTQIA+ families and parenting. These lead to poor patient experiences, emotional trauma, and decreased access to appropriate care (2–4). Unfortunately, access to high-quality and culturally competent fertility care is no exception, and this problem is compounded by the fact that many LGBTQIA+ individuals will need to access fertility services for family building (5). 

Both the American Society for Reproductive Medicine and the Euro- pean Society for Human Reproduction and Embryology have put forth statements that access to fertility services should not be limited on the basis of marital status, sexual orientation, or gender identity (5, 6). However, it is not enough to just ‘‘accept’’ LGBTQIA+ patients for evaluation and treatment. It is incumbent on fertility clinics and agencies to ensure that our services are oriented toward the needs of LGBTQIA+ people. Additionally, LGBTQIA+ patients should feel safe, welcome, and understood in our spaces. Semi structured interviews of 66 LGBTQIA+-identified individuals in Ontario, Canada, identified five main areas for improvement in fertility practices: patient education materials specific to LGBTQIA+ people; patient-centered practice by providers (e.g., inclusive language, respectful questioning, and forms that are representative of all sexual orientations and gender identities); training of all clinic staff on health care for LGBTQIA+ people; visible LGBTQIA+ presence in clinics through displayed materials; and provision of services addressing care gaps known to affect LGBTQIA+ populations (e.g., legal counsel for nontraditional family structures or sexually transmitted infection testing for sperm donors) (7). This document aims to address some of these areas by educating reproductive providers about current inclusive language and terminology and creating inclusive clinical spaces. 

INCLUSIVE LANGUAGE AND TERMINOLOGY

Inclusive language acknowledges that individuals express and experience their gender and sexuality in diverse ways and can be fluid and ever changing. The use of inclusive terminology, although important in and of itself, is also a reflection of a mindset that avoids cisgender and heterosexist assumptions about patients, their lives, and their desired family fi. Such a mindset enables an improved care experience for LGBTQIA+ people as well as for all other patients, embracing the wide array of cultural and personal differences between patients. Terminology evolves over time, and nuances can be generational, cultural, regional, and personal. Commonly used terms are defined and contextualized in Table 1, but this table should not be considered comprehensive or definitive. When in doubt, it is always best to ask a patient the terminology they use to describe themselves, their body parts, and their sexual activities, and then use those terms in subsequent conversations with that patient. Importantly, patients should not be asked the terminology they prefer (e.g., ‘‘what pronouns do you prefer?’’), but rather the terminology they use (e.g., ‘‘what pronouns do you use?’’). An individual’s name or pronouns are not a preference (7). Stating one’s pronouns at introductions (e.g., ‘‘hello, my name is Dr. XYZ; I use she/her pronouns’’) can also subtly communicate respect for diverse gender identities and allow space for patients to share their own identities and pronouns.

Table 1. Common terms with definitions and context


Term Definition Context
General    
  LGBTQIA+ An acronym for ‘‘lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and more.’’ The plus is added to recognize the growing understanding of sex and gender, including, but not limited to, those who identify as pansexual, two-spirit, androgynous, as well as others. This acronym is subject to perpetual evaluation and improvement with the goal of maximizing inclusivity.
  Queer This term is often used to express a spectrum of identities and orientations that are counter to the mainstream, such as those who do not identify as exclusively heterosexual and/or those who have nonbinary or gender-expansive identities. This term was previously used as a slur (and is still considered a slur by some), but has been reclaimed by many parts of the LGBTQIAþ movement. It is typically not used by those outside of the group.
  Questioning A term used to describe someone who is exploring their sexual orientation or gender identity.  
  Intersectionality The overlapping systems of oppression and discrimination that communities face on the basis of race, gender, sexuality, ethnicity, ability, and others. Initially coined to recognize the unique challenges of Black women, who, as a group, experienced both racism and sexism.
  Sexual and/or gender minority According to the National Institutes of Health, sexual and gender minority populations include, but are not limited to, individuals who identify as lesbian, gay, bisexual, asexual, transgender, two-spirit, queer, and/or intersex. Individuals with same-sex or -gender attractions or behaviors and those with a difference in sex development are also included. These populations also encompass those who do not self-identify with one of these terms but whose sexual orientation, gender identity or expression, or reproductive development is characterized by nonbinary constructs of sexual orientation, gender, and/or sex. The term ‘‘minority’’ may be suboptimal. Historically, ‘‘minority’’ has been used to describe individuals who are non-white and comprise <50% of a populace. More recently, this term has been expanded to include those who do not identify with heterosexual or cisgender identities. The word ‘‘minority’’ may also carry a negative connotation as representing otherness or lessness, and thus terms such as underrepresented, oppressed, marginalized, and underprivileged have been increasingly used in the medical, education, journalism, and civil rights arenas.
  Coming out The process in which a person acknowledges and shares their sexual orientation or gender identity with others, specifically when their sexual orientation or gender identity have been differently assumed or communicated in the past. Coming out is a unique process for every individual, and some people may choose to come out to only select people in their life or may choose never to come out at all. Because of societal assumptions, coming out is a constant process. Because they meet new people, individuals must decide whether, when, and how to come out. Specific to the reproductive clinic, people may also need to ‘‘come out’’ as a nontraditional family structure (e.g., three parents).
  Living openly The choice to live as one’s authentic self in spite of harassment and oppression.;  
  Outing The practice of revealing someone’s LGBTQIAþ identity to others without their permission. Outings can have serious consequences for individuals and may affect their employment, economic stability, personal safety, or relationships.
  Pride Pride is the promotion of equality, dignity, and self-affirmation of LGBTQIAþ identifying people. Pride began with the Stonewall Riots of 1969 and stands in contrast to shame and social stigma imposed on LGBTQIAþpersons by members of majority groups.
  Ally A person who makes the commitment and effort to work in solidarity with oppressed groups in the struggle for justice. Allies understand that it is in everyone’s interest to end all forms of oppression, even those from which they may personally benefit.  
Sexual Attraction    
  Sexual orientation Describes an individual’s attraction to other people and can include emotional, romantic, and sexual attraction. Sexual orientation is completely independent of gender identity.
  Bisexual (‘‘Bi’’) A person attracted to two or more genders or gender identities. Because understanding of gender diversity has grown, the term has expanded beyond the gender binary.
  Pansexual Someone who experiences attraction to people of all genders, although not necessarily simultaneously. Some people use pansexual and bisexual interchangeably, whereas others only identify with one or the other.
  Straight/heterosexual An individual attracted to the opposite gender. Both cis and trans people can be heterosexual.  
  Gay An adjective to describe an individual attracted to the same gender.  
  Lesbian A woman attracted to another woman.  
  Asexual Someone who very rarely or never experiences sexual attraction.  
Gender Identity    
  Sex/Sex assigned at birth Sex is designated at the time of birth, usually on the basis of external genitalia. It may also be on the basis of chromosomes, particularly in cases of ambiguous genitalia. Sex is generally thought to be binary (male/female) vs. intersex. Terms to describe individuals by their sex assigned at birth include ‘‘assigned female at birth’’ or ‘‘AFAB’’ and ‘‘assigned male at birth’’ or ‘‘AMAB.’’
  Intersex An individual who is born with variations in internal or external genitalia, hormones, and/or chromosomes compared with binary medical definitions of male and female. It may also be called ‘‘differences of sexual development’’ or ‘‘disorders of sexual development.’’ ‘‘Hermaphrodite’’ is an antiquated term and generally considered offensive. Many people see treating intersex as a pathology as inappropriate, and there is a movement away from assigning sex or performing surgeries on these individuals as young children.
  Gender binary The classification of gender into two distinct and opposite categories, man or woman It is widely used concept in society but is oppressive to people who do not feel they completely fall into one of the two categories.
  Gender/gender Identity An individual's conceptualization of themselves as gendered beings does not necessarily correlate with gender expression or the sex assigned at birth. Gender identity is distinct from sexual orientation as well as disorders and differences in sexual development.  
  Gender expression How an individual expresses their gender externally? This may include clothing, makeup, accessories, speech, and/or mannerisms.  
  Gender expansive An umbrella term to describe people with a wider range of gender identity or expression than the traditional gender binary system that corresponds with sex assigned at birth. It has been also called gender diverse or gender nonconforming.  
  Gender dysphoria Psychological distress results from incongruence between one’s gender identity and the sex assigned at birth.  
  Pronouns The pronouns used by an individual to refer to themselves. Should not be called ‘‘preferred pronouns.’’ Pronouns may include she/her, he/him, they/them, ze/hir, or ze/zim, with the latter three options considered gender inclusive and/or nonbinary. People may use different pronouns in different settings, e.g., work vs. home.
  Misgender The act of misgendering someone is the act of deliberately or accidentally referring to someone by the wrong gender assignment. Misgendering can take on many forms, for example, using the wrong pronouns, using the wrong name and nickname, putting the wrong gender marker on paperwork, referring to anatomical parts in a way that is uncomfortable for the individual, assuming stereotypic gender traits, and others.
  Cisgender (‘‘cis’’) A person whose gender identity corresponds to the sex they were assigned at birth.  
In addition to understanding and appropriately using terminology, inclusive language means avoiding heteronormative and cis-normative language. Examples to avoid are language that assumes, centers, and normalizes cisgender and heterosexual people and establishes those as preferred and superior. Such language should be avoided when speaking to patients, about patients, and on clinic forms. For example, the use of terms like ‘‘husband’’ or ‘‘mom’’ on generic forms sets those relationships as assumed, defaults, and implies superiority. We recommend using more inclusive words such as ‘‘partners’’ and ‘‘parent.’’ The use of inclusive language when referring to all patients and on clinic forms signals to LGBTQIA+ patients that there are no assumptions about gender, sexuality, relationship, or family configurations (8). Furthermore, the use of neutral, non-presumptive terminology can have a positive impact on all patients. It is essential to recognize the difference between sex assigned at birth, gender identity, and sexual orientation (Table 1) and not to assume that one influences or predicts another. Mistakes are inevitable, in which case a quick, sincere apology should be given, and then the conversation continued (8). 

CREATING AN INCLUSIVE ENVIRONMENT

Every aspect of the LGBTQIA+ patients’ experience from the first contact needs to be taken into consideration.

  • What is the clinic’s name? References to patient populations such as ‘‘women’s health’’ or ‘‘for couples’’ may have the unintended consequence of causing discomfort for people who do not feel they fit into those categories.
  • What is on the website? A recent analysis of reproductive endocrinology and infertility websites revealed that only 53% of websites examined had LGBTQIA+ content on them (9). Moreover, websites were even less likely to have references specifically to bisexual people and gender minorities (9).
  • Who answers the phone? Patient service representatives should be trained on names and pronouns, be aware that the clinic offers services to a diverse group of patients with diverse needs, and not collect information that would be irrelevant to scheduling (e.g., ‘‘are you married?’’).
  • What do the intake forms look like? Intake forms should be crafted without assumptions about sex, gender, sex as- signed at birth, sexuality, sexual behavior, and relationships. Separate questions about sex assigned at birth, natal sex organs, and open-ended self-identified gender identity may be distinct from the binary language often found in electronic medical or insurance records (10). 

The initial encounters between patients and the clinic can reflect an open and inclusive mindset and atmosphere among clinic staff and so set the tone for the remainder of the clinical interaction. They offer an opportunity to create and communicate in a welcoming environment, which helps ensure that the information collected from the patient is relevant to their lives and needs.

Once a patient arrives at a clinic, what they see and who they interact with should confirm these positive first impressions. Waiting room materials and posters should include im- ages of sexual and gender minorities, and pornography offerings for semen collection rooms should have options beyond those that appeal to heterosexual cisgender men. Physical indicators, such as a pride flag or patient bill of rights, communicate that patients are in a safe and welcoming environment (7). Gender-neutral bathrooms should be available for patient and staff use when possible. All clinic staff, including clerical staff, medical assistants, sonographers, lab- oratory staff, nurses, and physicians, should be trained in cultural humility, sensitivity, and appropriate terminology. Name tags or lanyards with pride flags and staff pronouns help communicate allyship and, incidentally, create a more inclusive environment for LGBTQIA+ staff. Training should be ongoing, integrating LGBTQIA+-relevant content and needs into all training and educational materials. Options for using the electronic medical record to minimize the chance of office staff deadnaming or misgendering a patient include allowing patients to indicate a name that is different from their legal name and indicate pronouns. Like with all patients, a trauma-informed approach should be used for all sensitive conversations and examinations. Lesbian, gay, bisexual, transgender, queer, questioning, intersex, and asexual+ people are much more likely to have experienced trauma, and clinicians should be particularly attuned to the potential of triggering trauma or gender dysphoria during sensitive examinations. 

Lastly, when clinic providers collect the medical history or discuss the treatment plan, they should use the inclusive language discussed above and in Table 1 and not ask probing questions that are not directly relevant to the patient’s care. It is important to have patient education materials that are specific to issues unique to LGBTQIA+ patients instead of using the same materials that were created for cisgender, heterosexual couples. When referring to external consultants, including mental health providers, ensure that the consultants are knowledgeable in LGBTQIA+ care. Review all electronic medical record templates and other automated messages to ensure that they are inclusive and do not have cis-heterosexist assumptions or potentially offensive wording. Partnerships  with and active outreach to LGBTQIA+ community members can help inform clinic protocols and policies to ensure they are as inclusive as possible, as well as provide community re- sources for patients (11).

CONCLUSION

To ensure that LGBTQIA+ people receive appropriate, knowledgeable, and affirming care, we need to acknowledge the stigma they face within and outside health care. Inclusive language and spaces are just the start. We need to improve on education surrounding LGBTQIA+ health early in medical education and throughout one’s professional career. There is a need for more targeted research, including the collection of sexual orientation and gender identity data in all studies, to truly make an impact (12).

Acknowledgments
This report was developed under the direction of the Practice Committee of the American Society for Reproductive Medicine (ASRM) as a service to its members and other practicing clinicians. Although this document reflects appropriate management of a problem encountered in the practice of reproductive medicine, it is not intended to be the only approved standard of practice or to dictate an exclusive course of treatment. Other plans of management may be appropriate, taking into account the needs of the individual patient, available re- sources, and institutional or clinical practice limitations. The Practice Committee and the Board of Directors of the ASRM have approved this report.

This document was reviewed by ASRM members and their input was considered in the preparation of the final document. The following members of the ASRM Practice Committee participated in the development of this document: Clarisa Gracia, M.D., M.S.C.E.; Paula Amato, M.D.; Jacob Anderson, M.B.A.; Kristin Bendikson, M.D.; Tommaso Falcone, M.D.; Rebecca Flyckt, M.D.; Jessica Goldstein, R.N.; Karl Hansen, M.D., Ph.D.; Micah Hill, D.O.; Sangita Jindal, Ph.D.; Suleena Kalra, M.D., M.S.CE.; Tarun Jain, M.D.; Alan Penzias, M.D.; Michael Thomas, M.D.; Richard Reindollar, M.D.; Jared Robins, M.D.; Chevis N Shannon, Ph.D., M.B.A., M.P.H.; Anne Steiner, M.D., M.P.H.; Cigdem Tanrikut, M.D.; and Belinda Yauger, M.D. The Practice Committee acknowledges the special contribution of Micah J. Hill (Good Shepherd), Molly Moravek (Task Force Chair), Daphna Stroumsa, Juno Obedin-Maliver, Brent Monseur, Kim Bergman, Samantha Estevez, and Tracy Harrison in the preparation of this document. All committee members disclosed commercial and financial relationships with manufacturers or distributors of goods or services used to treat patients. Members of the Committee who were found to have conflicts of interest on the basis of the relationships disclosed did not participate in the discussion or development of this document.

REFERENCES

  1. White Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med 2015;147:222–31.
  2. Casey LS, Reisner SL, Findling MG, Blendon RJ, Benson JM, Sayde JM, et al. Discrimination in the United States: experiences of lesbian, gay, bisexual, transgender, and queer Americans. Health Serv Res 2019;54(Suppl 2): 1454–66.
  3. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 U.S. Transgender Survey. Washington, D.C.: National Center for Transgender Equality; 2016.
  4. Grant J, Mottet L, Tanis J, Harrison J, Herman J, Keisling M. Injustice at every turn: A Report of the National Transgender Discrimination Survey. Washing- ton: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011.
  5. Ethics Committee of the American Society for Reproductive Medicine. Access to fertility treatment irrespective of marital status, sexual orientation, or gender identity: an Ethics Committee opinion. Fertil Steril 2021;116:326–30.
  6. De Wert G, Dondorp W, Shenfield F, Barri P, Devroey P, Diedrich K, et al. ESHRE Task Force on Ethics and Law 23: medically assisted reproduction in singles, lesbian and gay couples, and transsexual people. Hum Reprod Oxf Engl 2014;29:1859–65.
  7. Ross LE, Tarasoff LA, Anderson S, Epstein R, Marvel S, Steele LS, et al. Sexual and gender minority peoples’ recommendations for assisted human repro- duction services. J Obstet Gynaecol Can 2014;36:146–53.
  8. LGBTIQþ Inclusive Language Guide. Available at: https://www.vic.gov.au/inclusive-language-guide. Accessed June 15, 2022.
  9. Wu HY, Yin O, Monseur B, Selter J, Collins LJ, Lau BD, et al. Lesbian, gay, bisexual, transgender content on reproductive endocrinology and infertility clinic websites. Fertil Steril 2017;108:183–91.
  10. Stroumsa D, Wu JP. Welcoming transgender and nonbinary patients: expanding the language of ‘‘women’s health.’’. Am J Obstet Gynecol 2018; 219:585.e1–5.
  11. Kirubarajan A, Patel P, Leung S, Park B, Sierra S. Cultural competence in fertility care for lesbian, gay, bisexual, transgender, and queer people: a systematic review of patient and provider perspectives. Fertil Steril 2021;115: 1294–301.
  12. Patterson JG, Jabson JM, Bowen DJ. Measuring sexual and gender minority populations in health surveillance. LGBT Health 2017;4:82–105

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