She/her, he/him or even ze/zir – with the proliferation of neo-pronouns in recent years, there are now over 70 different ways to refer to someone in the third person.

We know from the 2021 Census that an overwhelming majority of the population do not consider themselves to have a gender identity that differs from their natal sex and are presumably content to be referred to by the pronouns synonymous with their sex. Unfortunately, the opportunity to estimate the trans-identified population, who may have used alternative pronouns, was squandered by a badly phrased question and the accreditation of these statistics have now been declassified (Office for Statistics Regulation Census Report).

Our colleagues in EDI encourage the importance of promoting ‘allyship’, arguing that patients with a gender identity different to their natal sex feel ‘seen’ and ‘safe’ when their preferred pronouns are respected by healthcare staff who may subsequently avoid ‘misgendering’ them. Indeed, we have members here at SEEN in Health who have been asked to declare their pronouns to cultivate an ‘inclusive’ environment.

However, the social prescription of pronouns is not a neutral act, it has an impact on staff and patients alike. This was recognised in the recently published Cass Review, which the NHS has committed to implementing (Final Report – Cass Review).

Impact on patients

Gender-affirming care which inherently adopts the use of gender pronouns is often portrayed as suicide prevention for a minority of patients. This claim has been rejected by the Government’s advisor on suicide prevention, Professor Sir Louis Appleby (Suicide Risk in Gender Dysphoria, 2024).

Declaring pronouns is not an unequivocal good and the assurance that no other patient groups are disadvantaged by their use cannot be guaranteed. Unfortunately, the social prescription of pronouns can cause harm and exclude other patient groups.

Patients who have detransitioned and no longer subscribe to a belief in gender identity will not feel safe in a department where they are asked their pronouns. These vulnerable patients will be reminded of past trauma that will often be filled with regret and may already feel disillusioned in reengaging with a healthcare system they feel let down by.

For those patients who are still contemplating their identity or living in stealth, asking them their pronouns may be the tip of an iceberg of deep personal contemplation, causing them unnecessary distress in an already stressful clinical environment. We must consider the harms of social transition, of which pronouns are a fundamental part. The flippant but well intended gesture of prescribing gender pronouns may alter the trajectory of a gender questioning patient’s future culminating in a lifelong commitment of medical intervention.

We must also consider health literacy as we have reports from staff in our network who have witnessed patients feeling embarrassed when they haven’t understood what pronouns are (NHS England Health Literacy).

Other members have raised concerns regarding the practicalities of asking patients with learning difficulties, mental health issues or have suffered a traumatic head injury. These concerns extend to the acute setting where healthcare staff have a responsibility to care for many acutely ill patients with multiple co-morbidities and demands. This environment is the culmination of pressure in the healthcare setting – the question must be asked regarding the appropriateness of pronoun enquiries when patients have more pressing health needs.

Moreover, is it appropriate to record pronouns, justify the collection and storage of this information in line with Caldicott Principles? The wealth of experience our members have, attests to the reality that patients do not need encouragement in declaring what they wish to be called. We are capable of individualised care, without the necessity of blanket pronoun prescriptions for every patient in the system.

Impact on staff

It must not be forgotten that our healthcare system is bolstered and heavily reliant upon an increasing number of staff whose first language is not English. Given the complexities of neopronouns and pronoun fluidity, the enforcement of gender-based pronouns is an additional, unnecessary distraction for this group of staff amongst others, such as those with dyslexia and neurodivergence who are already saddled with the expectation to overcome their own barriers to effective communication.

Moreover, many staff members hold the protected belief that sex is biological and immutable, irrespective of how many times a body is surgically altered. Similarly, to SEEN in Health members, they believe that sex cannot be changed and these staff members are protected from discrimination under the Equality Act 2010.

Healthcare professionals adopt an evidence-based approach to treating patients, not a social justice model. The social prescription of gender pronouns promotes the belief that sex can be changed when staff know it cannot be; indoctrinating them into an ideological belief system they contest by virtue of their profession. Our job in healthcare is not to affirm the self-perception of our patients. Despite this, undoubtedly, these patients are certainly still deserving of compassionate care, but this must not be in exchange of the well-being or rights of any other group and rightfully stated by Hiliary Cass, there is a need for all clinicians to receive better training about how to work sensitively and effectively with young gender questioning patients.

SEEN in Health focuses on ensuring the protected characteristic of sex is not overlooked in our healthcare organisations, and in this instance questions how the interpretation of pronouns as gendered and not sexed has crept into our organisations?

Whilst we respect the rights of anyone to hold a belief in gender identity the prioritisation of gender-based pronouns over those that are sexed-based, is a misguided interpretation that pronouns are gendered, not sexed.

Additionally, we should not countenance a culture of compelled speech. Regardless of staff beliefs, we are already bound by our professional standards of proficiency to treat patients without discrimination. Staff understand they cannot misgender patients with impunity. They are well versed in polite, respectful interactions, irrespective of differing beliefs – this patient-staff rapport is not constituted by pronoun use (despite what some commentators may say). Healthcare staff have access to their patient’s details and know their patient’s name – let’s start using them!