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

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.

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.

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