Reprimanded for using non-inclusive language

[zenmedic]

Hi all,

I just had my last standardized patient encounter for medical school before I start as a PGY1 in July. One of my "patients" identified as LGBTQ+ and used they/them pronouns. Sure, no problem. However, after the encounter was over and I was getting debriefed on how I did, I was reprimanded for asking if their partner was a man or a woman. They said that this type of language was harmful as it was gender binary and my patient clearly did not fit into this category. They suggested to ask my patients, "what does your partner identify as," as this type of language is more ambiguous/inclusive. I don't have a problem with it, I try to be as inclusive as possible, but I felt a little off-put that they told me my gender binary language was harmful. I remember when I was on inpatient psych during third year, one of the attendings rarely used pronouns other than the ones assigned at birth. He felt many of the patients frequently switched pronouns as a way to be passive aggressive and difficult, or because gender dysphoria was part of their diagnosis and he did not want to validate the illness. Obviously these are two different patient populations, but it was interesting to see the opposing argument. Ultimately, I just want to do right by the patient. As a soon to be psychiatrist I am wondering how you docs go about this/your view point on the matter.

Thanks!

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[G Sheb]

That psychiatrist was not providing you a good example.
Please don't do this. Call patients by what they want to be called.
If someone is switching the pronouns, you can have a discussion with them what this means and how they would like to proceed in the future.

I think the feedback is correct, but don't take it very personally. We all mess up, and calling people 'they' can sometimes feel weird and dehumanizing.
However, it's interesting that after the patient identified as non-binary, you chose to ask them whether their partner is a man or a woman. Just food for thought.

 

[Merovinge]

Hi all,

I just had my last standardized patient encounter for medical school before I start as a PGY1 in July. One of my "patients" identified as LGBTQ+ and used they/them pronouns. Sure, no problem. However, after the encounter was over and I was getting debriefed on how I did, I was reprimanded for asking if their partner was a man or a woman. They said that this type of language was harmful as it was gender binary and my patient clearly did not fit into this category. They suggested to ask my patients, "what does your partner identify as," as this type of language is more ambiguous/inclusive. I don't have a problem with it, I try to be as inclusive as possible, but I felt a little off-put that they told me my gender binary language was harmful. I remember when I was on inpatient psych during third year, one of the attendings rarely used pronouns other than the ones assigned at birth. He felt many of the patients frequently switched pronouns as a way to be passive aggressive and difficult, or because gender dysphoria was part of their diagnosis and he did not want to validate the illness. Obviously these are two different patient populations, but it was interesting to see the opposing argument. Ultimately, I just want to do right by the patient. As a soon to be psychiatrist I am wondering how you docs go about this/your view point on the matter.

Thanks!

That logic makes absolutely zero sense, it's frankly embarrassing that a psychiatrist is telling a medical student that. He is saying that someone whos life is so bad that one of the few bastions of agency they have is changing pronouns such that it is "difficult" should not be accommodated by the mere act of changing one's language?

Separately, gender dysphoria is only a diagnosis to allow transgendered individuals access to medical services. No one, beyond the old guard that believe homosexuality is also a mental illness, is using that disorder in any other way. There is a rich historic record of transgendered people throughout time, this is not something new and not a big deal. Now that we can effectively help transgendered folk transition we do see more people identifying as such, but who freaking cares. Are there some people who identify as trans likely as a trauma response to seperate from the person they were when traumatized? I think absolutely there are, but that is for the psychologists at the gender clinic to discuss or an OPP, not for a likely cisgendered heterosexual male to be picking beef with on an inpatient psychiatric unit.

 

[Sushirolls]

Damned if you do. Damned if you don't.
Do what you can to pass and get through the hoops.

Once your done, show kindness, sincerity, empathy.
You'll screw something up sooner or later. I have. And I'm not going to waste my time worrying about.
If a patient gets so hung up on pronouns, they can find another doctor. That is such a miniscule part of the big picture.

 

[MacDonaldTriad]

I have been speaking the queen's English for 6 decades so I'm going to screw this up once and while. Really sorry, I will continue to try.

 

[zenmedic]

Thanks so much for the feedback, everyone. Glad to be somewhat wrong on the issue, and am aware that I have my own unconscious biases I need to work on.

 

[comp1]

Looking a bit more concretely....the OP was in a standardized patient encounter. The actor described themselves as non-binary as part of the script. This should have been a tip off to the OP MS4 that that was likely going to be the (sole?) focus of the encounter. While 25% of Gen Z may now identify as queer in some way, non-binary identification is still quite rare in the general population. As such, every possible statement related to gender identity and sexual orientation was going to be under a very thick microscope, much more so than it would be in anything other than a standardized patient encounter. I'd recommend the OP take this as the hyper-focused episode it was as opposed to some sort of general statement on their character or even the state of the world. Declining to use stated pronouns because of a diagnosis of gender dysphoria is straight up sadistic. I'd like to hear more about this attending.

 

[erg923]

I have been speaking the queen's English for 6 decades so I'm going to screw this up once and while. Really sorry, I will continue to try.

This. I do address patient's by their chosen whatever at initial session. As sessions go by, this may evolve to not be the case. This is part the of the therapeutic process, no?

 

[Stagg737]

Couple of different points here:

However, after the encounter was over and I was getting debriefed on how I did, I was reprimanded for asking if their partner was a man or a woman. They said that this type of language was harmful as it was gender binary and my patient clearly did not fit into this category. They suggested to ask my patients, "what does your partner identify as," as this type of language is more ambiguous/inclusive. I don't have a problem with it, I try to be as inclusive as possible, but I felt a little off-put that they told me my gender binary language was harmful.

Curious what you mean by "reprimanded", however not really that relevant going forward. I wouldn't bother asking about the gender of their partner unless it was somehow relevant to direct patient care, which it most likely is not unless their partner is causing some kind of gender-related distress. So for future reference, I think the question itself is just unnecessary, imo. If they required you to ask about their partner's gender I'd question what they're even trying to teach.

I also think it's pretty ridiculous that they're calling the language itself harmful unless you asked it in a completely tone-deaf manner. If a patient points it out, apologize and correct yourself. If they patient gets so stuck on that single point, then there's a lot more to unpack there. Just try your best to be considerate, empathetic, and accommodate your patient if reasonable (which this situation absolutely is). Most people are reasonable and understand we all make mistakes, listening and showing them you're trying to understand them and work with them can do more for your rapport than acting overly cautious and guarded yourself. Yes, as psychiatrists we should understand language and how it affects our patients at times of increased vulnerability, and you should be aware of your patients who are part of marginalized communities. However, trying to be overly cautious to the point of making an encounter awkward can be just as harmful.

I remember when I was on inpatient psych during third year, one of the attendings rarely used pronouns other than the ones assigned at birth. He felt many of the patients frequently switched pronouns as a way to be passive aggressive and difficult, or because gender dysphoria was part of their diagnosis and he did not want to validate the illness. Obviously these are two different patient populations, but it was interesting to see the opposing argument.

The bolded situation happens. I encountered it frequently on our adolescent unit in residency with a lot of budding borderline patients who made claims about gender to obtain a sense of belonging to a group instead of actually questioning their gender. The appropriate thing to do is to be up front and ask the patient how they would like to be called for the remainder of the hospitalization/visit and stick with that. If there's ongoing conflict, it's something to bring up and discuss tactfully, not by returning a passive-aggressive approach. Using birth sex to determine what pronouns to use without regard for anything else is inappropriate and can cause further distress. Do not follow that attending's example.

In face to face conversation, pronouns shouldn't really be an issue anyway as you're going to be using the patient's name or "you/your" as second person pronouns in English are genderless. If there's issues with their actual names, same thing applies as above.

Separately, gender dysphoria is only a diagnosis to allow transgendered individuals access to medical services. No one, beyond the old guard that believe homosexuality is also a mental illness, is using that disorder in any other way. There is a rich historic record of transgendered people throughout time, this is not something new and not a big deal. Now that we can effectively help transgendered folk transition we do see more people identifying as such, but who freaking cares.

I agree with the point on homosexuality, but completely disagree with the rest of this. I've seen plenty of transgender patients who were severely distressed about their gender state but did not want to transition. There is far more to gender dysphoria than just getting them access to medical services or transitioning, and consigning the idea to those outcomes is too narrow and misses some major psychodynamic aspects to some of these patients.


ETA: I agree with Comp1's statement that having a non-binary/non-cisgender patient in a standardized patient should have been a tip off regarding what would be relevant in this situation. Irl, you'll often get collateral before you see a patient that should direct how you may have to conduct your encounter. If you're going into psych, having a good understanding of your own affect and demeanor during encounters in order to build rapport with your patients is important.

 

[zenmedic]

I agree with the point on homosexuality, but completely disagree with the rest of this. I've seen plenty of transgender patients who were severely distressed about their gender state but did not want to transition. There is far more to gender dysphoria than just getting them access to medical services or transitioning, and consigning the idea to those outcomes is too narrow and misses some major psychodynamic aspects to some of these patients.

To your point, for children and adolescents experiencing gender identity disorder, the literature I've read claims more than half of those patients will have this resolve by the time their psycho-sexual development is complete. Furthermore, I've seen more lawsuits against physicians come up for performing gender reversing procedures on minors, who go on to later regret their decision. As I'm trying to educate myself on the topic (especially since CAP is an interest of mine), it doesn't seem like there's a clear consensus on how to treat the pediatric population who experience this.

 

[Merovinge]

To your point, for children and adolescents experiencing gender identity disorder, the literature I've read claims more than half of those patients will have this resolve by the time their psycho-sexual development is complete. Furthermore, I've seen more lawsuits against physicians come up for performing gender reversing procedures on minors, who go on to later regret their decision. As I'm trying to educate myself on the topic (especially since CAP is an interest of mine), it doesn't seem like there's a clear consensus on how to treat the pediatric population who experience this.

WPATH is the big group that works on this, they offer their guidlines for free and do trainings as well. It's dense and robust but you can narrow in on the parts you want.

https://www.tandfonline.com/doi/pdf/10.1080/26895269.2022.2100644

The literature you are mentioning sounds like right wing talking points more than literature, I would be very interested to see the source. The rate of regret following transition is very low generally and even lower when certain criteria are meet (e.g. transgender apparent since early childhood). Puberty blocking agents to delay time to puberty are reversible and generally recommended if addressing this prior to puberty. The irreversible changes are all done on an individual basis after longstanding engagement with a pediatric gender clinic (and a longstanding period of social transition) or can be tackled during adulthood.

There is certainly some limits to data on this as the ability to reliably physically transition is relatively new and relatively understudied but almost all the data I have seen shows that it overwhelmingly saves lives. You know, the thing we are supposed to do as doctors. I am not sure how this became a partisan issue, but it shares a lot in common with treatment of addiction. Apparently politicians make decisions rather than doctors because it makes some people feel ucky on the inside when it's discussed.

 

[comp1]

Issues with long term gender identity where someone might get put on hormones or have surgery is very different from short term inpatient stays where a patient is changing gender identities within a day or hour. In the latter case, I tend to agree with the poster above that pronouns for 1:1 communication are not gendered and thus I would most often avoid gender as a topic because it's likely re-enforcing something potentially maladaptive. Of course it would also be harmful to actively argue with the patient about this or intentionally misgender them in some sort of punitive manner. Then it would just be negative reenforcement.

 

[zenmedic]

WPATH is the big group that works on this, they offer their guidlines for free and do trainings as well. It's dense and robust but you can narrow in on the parts you want.

https://www.tandfonline.com/doi/pdf/10.1080/26895269.2022.2100644

The literature you are mentioning sounds like right wing talking points more than literature, I would be very interested to see the source. The rate of regret following transition is very low generally and even lower when certain criteria are meet (e.g. transgender apparent since early childhood). Puberty blocking agents to delay time to puberty are reversible and generally recommended if addressing this prior to puberty. The irreversible changes are all done on an individual basis after longstanding engagement with a pediatric gender clinic (and a longstanding period of social transition) or can be tackled during adulthood.

There is certainly some limits to data on this as the ability to reliably physically transition is relatively new and relatively understudied but almost all the data I have seen shows that it overwhelmingly saves lives. You know, the thing we are supposed to do as doctors. I am not sure how this became a partisan issue, but it shares a lot in common with treatment of addiction. Apparently politicians make decisions rather than doctors because it makes some people feel ucky on the inside when it's discussed.

That makes sense. Thanks. I don't think you were suggesting this but to be clear I am definitely not trying to make anything political, just trying to figure out the best way to help these patients.

Here are some of the articles I was looking at if you're interested:

A Follow-Up Study of Boys With Gender Identity Disorder

This study reports follow-up data on the largest sample to date of boys clinic-referred for gender dysphoria (n = 139) with regard to gender identity and sexual orientation. In childhood, the boys were assessed at a mean age of 7.49 years (range, 3.33–12.99) ...

www.ncbi.nlm.nih.gov

Gender Identity Disorders in Childhood and Adolescence: Currently Debated Concepts and Treatment Strategies

Gender identity disorders (GID) can appear even in early infancy with a variable degree of severity. Their prevalence in childhood and adolescence is below 1%. GID are often associated with emotional and behavioral problems as well as a high rate of psychiatric ...

www.ncbi.nlm.nih.gov

 

[annoyedpsychiatrist]

You asked if their partner was a male or female. You were asking the biological gender of the partner. This is not offensive. What someone identifies as is not always congruent with their biological gender, but my point is the actor is in the wrong because they made an assumption based off of your statement. Your statement was not offensive because the intent behind it was to gather more information so you could have more insight into the patient's life. I think we should refer to people based upon the gender they identify as but asking about biological genders of patients and their partners I would think should be relatively standard practice, and understanding how they may differ in their gender identity.

Tbh, I find their response to be somewhat passive aggressive, almost like they're baiting you with that one. I think its kinda dumb the patient didnt reply "they were born male, but dont identify either way". Or something similar. While I believe we should respect gender identity, they're are definitely personality disorder patients who use it as a way to be passive aggressive and condescend others. Those patients are not the majority, but they do exist.

I mean it would be different if you refused to respect gender identity and purposely called someone the wrong thing, but that was obviously not the case here.

 

[G Sheb]

The main take away from this is that whenever it comes to identity, you should ask open ended questions.
Don't pigeon hole anyone into a few or many categories.
How do you identify your sexuality/gender/ethinicity/race...etc. instead of do you identify as a man/woman, or gay/bi...etc.

This is mostly a right wing forum. A lot of people are not happy with the cultural changes, so I would not come here for advice on this frankly... This is not how medicine is moving, and for a very good reason.

 

[erg923]

This is mostly a right wing forum. A lot of people are not happy with the cultural changes, so I would not come here for advice on this frankly... This is not how medicine is moving, and for a very good reason.

Unsupported poppycock, son.

 

[Stagg737]

To your point, for children and adolescents experiencing gender identity disorder, the literature I've read claims more than half of those patients will have this resolve by the time their psycho-sexual development is complete. Furthermore, I've seen more lawsuits against physicians come up for performing gender reversing procedures on minors, who go on to later regret their decision. As I'm trying to educate myself on the topic (especially since CAP is an interest of mine), it doesn't seem like there's a clear consensus on how to treat the pediatric population who experience this.

Not sure you're stating this clearly. Are you talking about permanent gender affirming procedures or reversible treatments? Either way, physicians treating minors when parents don't consent or are against treatment is going to cause issues.

I won't go into actual treatment, but will share what I saw on child rotations. I could basically divide the "non-cis" patients into 3 groups.

The first were the truly transgender/non-cis adolescents. Most of these kids were at least fairly self-aware of their situation and had either started transitioning in some form or had started thinking about how to do so at some level. Most of these adolescents were there for either depression or an adjustment disorder, occasionally d/t hormone-induced mood issues. They seemed to do pretty well overall.

The second group were those who had significant personality disturbances, typically in unstable/bad home environments, who were clearly latching onto whatever group they could to feel like they belonged. In those kids the identity disturbance was much broader and they were clearly unstable on several levels. It was pretty obvious they had much larger issues that needed to be prioritized than their gender and I'd be shocked if even a moderate percentage of these kids didn't develop a full blown PD. These kids were frustrating to work with for a lot of reasons, the biggest one probably being that any attempts to understand why they believed they were non-cis were met with anger and accusations towards those asking even the most gentle questions. A lot of psychoeducation and a lot of patients (and parents) sabotaging their own treatment.

The third group is the question mark group and I could divide that into a bunch of sub-groups. Some probably will end up non-cis/non-binary, but I'm sure many had something else going on. Those were my favorite to work with because oftentimes they really did want to explore what was going on and were open to lots of questions and treatment options. The most interesting sub-group here imo were the non-binary adolescents/teenagers who had undiagnosed autism, and talking to one of that CAP hospital's psychologists who specialized in ASD, there's growing data that there's more of an overlap in those groups than we would have thought.

I'd be interested to hear if those observations line up with the CAP docs on here, especially any who have a strong knowledge of gender identity issues.

 

[Crayola227]

The main take away from this is that whenever it comes to identity, you should ask open ended questions.
Don't pigeon hole anyone into a few or many categories.
How do you identify your sexuality/gender/ethinicity/race...etc. instead of do you identify as a man/woman, or gay/bi...etc.

This is mostly a right wing forum. A lot of people are not happy with the cultural changes, so I would not come here for advice on this frankly... This is not how medicine is moving, and for a very good reason.

I vehemently disagree with the part about the forum. It is true that as a whole medicine is considered a conservative profession, and in the context of the practice of medicine this is not said as a political statement or pejorative.

 

[zenmedic]

Not sure you're stating this clearly. Are you talking about permanent gender affirming procedures or reversible treatments? Either way, physicians treating minors when parents don't consent or are against treatment is going to cause issues.

I won't go into actual treatment, but will share what I saw on child rotations. I could basically divide the "non-cis" patients into 3 groups.

The first were the truly transgender/non-cis adolescents. Most of these kids were at least fairly self-aware of their situation and had either started transitioning in some form or had started thinking about how to do so at some level. Most of these adolescents were there for either depression or an adjustment disorder, occasionally d/t hormone-induced mood issues. They seemed to do pretty well overall.

The second group were those who had significant personality disturbances, typically in unstable/bad home environments, who were clearly latching onto whatever group they could to feel like they belonged. In those kids the identity disturbance was much broader and they were clearly unstable on several levels. It was pretty obvious they had much larger issues that needed to be prioritized than their gender and I'd be shocked if even a moderate percentage of these kids didn't develop a full blown PD. These kids were frustrating to work with for a lot of reasons, the biggest one probably being that any attempts to understand why they believed they were non-cis were met with anger and accusations towards those asking even the most gentle questions. A lot of psychoeducation and a lot of patients (and parents) sabotaging their own treatment.

The third group is the question mark group and I could divide that into a bunch of sub-groups. Some probably will end up non-cis/non-binary, but I'm sure many had something else going on. Those were my favorite to work with because oftentimes they really did want to explore what was going on and were open to lots of questions and treatment options. The most interesting sub-group here imo were the non-binary adolescents/teenagers who had undiagnosed autism, and talking to one of that CAP hospital's psychologists who specialized in ASD, there's growing data that there's more of an overlap in those groups than we would have thought.

I'd be interested to hear if those observations line up with the CAP docs on here, especially any who have a strong knowledge of gender identity issues.

I was referring to lawsuits against doctors that treat patients with hormonal therapy or surgery, with consent from their parents, who are later sued because once the child becomes an adult they realign with their biological sex. A quick google search brings up a lot of cases in recent years. The point I was trying to make is that it seems that many of these patients will realign with their biological sex if given the time to mature and treating these patients with irreversible treatments can be catastrophic. I guess my question is, is it ethical to give minors hormonal therapy or surgeries to change their sex if the data says most gender dysphoria resolves once maturation is achieved? The answer is probably dependent on each individual patient, it just seems like a gamble for minors. But again, what do I know I'm just a soon to be intern 🤷‍♂️

The way you break down each group is very interesting. I'll definitely keep that in mind when I do my CAP rotations.

 

[Crayola227]

Look, point taken, open ended questions are good, when your patient expresses they do not conform to a gender binary, not asking a binary question probably makes sense.

It was probably fair to point this out to you as a way to improve.

HOWEVER sex assigned at birth, and the degree to which someone has made a transition, like surgery or hormones, or heck, even tucking or breast binding, (and no, I will not give up the medical term breast for chest, they are not equivalent and either sex/gender can have actual anatomic breasts so it makes zero sense to pretend like all everyone has is a chest), has numerous medical health implications.

And, further, it was always said to me that one needs to know the sex of sex partner and the sex acts engaged in to assess various risks primarily STIs.

Two people AMAB having anal sex with a penis is not the same risk as two AFAB having anal sex with no penis being used.

Sex with a trans vagina, same sort of idea, the parts involved makes a difference for guiding symptom and STI screening ways that are relevant, but also, thinking further, probably in ways many of us are may not really know to what extent. Sort of interesting to assess risk of transmission of various STIs not only by acts such as, dildo in rectum or say finger in trans vagina, but also, the relative risks in a trans vagina vs a trans penis, because the tissues are not the same as cis organs but I digress.

I suppose you could ask these questions by asking, do you have penis in blank sex, or what have you. Talking about parts as opposed to biological sex or gender expression of the individuals in question.

But then again, I did have someone who wanted me to refer to their anus/rectum as their "boy p****" and people want their breasts called chest so this might not work either.

I will admit that I find some of this not only cumbersome but perhaps a tad ridiculous at times. I don't advocate treating a patient as though that were the case.

 

[Crayola227]

Unsupported poppycock, son.

How do you know you are talking to a son?

 

[G Sheb]

I vehemently disagree with the part about the forum. It is true that as a whole medicine is considered a conservative profession, and in the context of the practice of medicine this is not said as a political statement or pejorative.

So you 'vehemently' disagree, and then you actually say you agree that it is conservative?

I mean, my hunch is that this is going to be an interesting thread.
Issues quite a few have with gender identification are already on display.
But let's sit back, let things take their natural course, and watch.... lol

 

[Stagg737]

You asked if their partner was a male or female. You were asking the biological gender of the partner. This is not offensive. What someone identifies as is not always congruent with their biological gender, but my point is the actor is in the wrong because they made an assumption based off of your statement.

This is outdated/incorrect in terms of our current understanding and definitions of gender. Sex is biological (though specific definition is still debated), and so is sexual orientation outside of some extreme exceptions but you could even argue a biological basis in those situations (individual becomes asexual due to chronic and severe sexual traumas, which persists after extensive therapy d/t fixed neuronal changes during development). However, gender likely has more of a multi-axial basis which has been seen as more of a psychological/social construct, but more recently there's more of a thought that there is a biological (genetic/hormonal) component that also contributes. I still don't know why sex or gender of the patient's partner was relevant in OP's scenario...

This is mostly a right wing forum. A lot of people are not happy with the cultural changes, so I would not come here for advice on this frankly... This is not how medicine is moving, and for a very good reason.

There are a couple of posters who are clearly on the right, and a few who clearly lean quite left. Part of why the psych forum is enjoyable and not a dumpster fire like some of the other sub-forums is that it is fairly moderate overall and even those who are more extreme generally engage in reasonable conversation.

 

[zenmedic]

I still don't know why sex or gender of the patient's partner was relevant in OP's scenario...

The scenario was a family medicine clinic (even though I am going into psych) where they presented as a new patient and I had to take a detailed history. I asked the question about their partner when I was inquiring about their social history.

 

[Candidate2017]

When your PGY-1 IM rotation starts, you will be too busy doing actual medicine, trying to keep patients (nowadays, clients) alive and then discharged ASAP to care about anyone's names, pronouns, gender, sexual orientation, ethnicity, religion, partners, or S1/S2 heart sounds. You will adopt the wisdom of our medicine colleagues and refer to everyone by their room-bed number, geri status, and disease, i.e., "47-2, the geri DKA with AKI on CKD IV. Intern, why haven't you ordered a stat psych consult?! 47-2 needs to DC home today or to geri psych!"

Nowadays, I refer to everyone by my preferred pronoun, "Hey!"

Thanks so much for the feedback, everyone. Glad to be somewhat wrong on the issue, and am aware that I have my own unconscious biases I need to work on.

One of the fundamental practices of communism is criticism-self criticism, or struggle session, where comrades, one by one, stand up and confess his/her/zir shortcomings in front the cadre, while being critiqued.

 

[Stagg737]

The scenario was a family medicine clinic (even though I am going into psych) where they presented as a new patient and I had to take a detailed history. I asked the question about their partner when I was inquiring about their social history.

Meh, imo you could just ask if they have an SO and if they say yes ask about sexual activity. If they're not sexually active then you're done. If they are, you can decide what extent of hanky panky details you want to enquire about to obtain adequate info for STI screening.

 

[Ceke2002]

I have been speaking the queen's English for 6 decades so I'm going to screw this up once and while. Really sorry, I will continue to try.

Honestly this is a really good response. My husband came out as non binary a couple of years ago, I've spent 18 out 20 years referring to them as 'he', so yeah there's been some adjustment & sometimes I slip up and revert back to he/him pronouns. I apologise, correct myself, and try to do better in future. Most trans and non binary folks I know don't go into fits of the vapours if you unintentionally misgender them, and it's obvious that it's a genuine mistake/slip of the tongue. As long as you're not repeatedly misgendering someone on purpose, I'd say just give a quick apology, use the correct pronouns and let it go.

 

[Ceke2002]

This is mostly a right wing forum. A lot of people are not happy with the cultural changes, so I would not come here for advice on this frankly... This is not how medicine is moving, and for a very good reason.

Sorry, forgot to unfurl my socialist libertarian flag. *raises fist in workers solidarity*

 

[Ceke2002]

The scenario was a family medicine clinic (even though I am going into psych) where they presented as a new patient and I had to take a detailed history. I asked the question about their partner when I was inquiring about their social history.

Obviously I can't speak for every trans or non binary person out there, but when my husband was having an initial intake with a specialist they were asked if they were married, and then if their partner was husband or wife. They answered 'wife', and if I had also been non binary, rather than cisgender, they would've mentioned it at that point. There was no, 'ZOMG how dare you assume my partner's gender is binary', it was a simple question that got answered with whatever extra information (in this case none) may have been relevant.

Having said that, just to avoid any issues going forward I would ask the question more like, "Do you have a partner?" and if yes then, "How does your partner identify?"

 

[TheRightMedication]

I'm fairly conservative, and have some misgivings about the trans phenomenon. However I've been able to have a fine time with people identifying as transgender by being respectful and treating them like plain ol' humans.

In some ways I think my conservative-ness helps as I'm not obsequious about pronouns and what have you, and can get to the task at hand, person to person. People seem to have responded well to that.

Since you seem to be pretty rational and not without compassion, OP, I think you'll be fine. Real patients know when they're being respected.

 

[nexus73]

Any reasonable person would just say, "Oh, my partner is non-binary."

 

[Liquid8]

Honestly this is a really good response. My husband came out as non binary a couple of years ago, I've spent 18 out 20 years referring to them as 'he', so yeah there's been some adjustment & sometimes I slip up and revert back to he/him pronouns. I apologise, correct myself, and try to do better in future. Most trans and non binary folks I know don't go into fits of the vapours if you unintentionally misgender them, and it's obvious that it's a genuine mistake/slip of the tongue. As long as you're not repeatedly misgendering someone on purpose, I'd say just give a quick apology, use the correct pronouns and let it go.

This is generally what I’ve found as well. One of my patients recently came out as non-binary, but I knew them for almost a decade as a female so mistakes were inevitable initially. When admitted to hospital for an unrelated matter, the nurses were quite anxious and treading very carefully around the pronoun issue – however, the patient has always been laidback and easygoing, noting that even their mother got it wrong sometimes. It then came to light that there had recently been another patient doing the gender switching/personality stuff described by other posters.

For patients undergoing transition, I will always attempt to use their preferred name and gender where possible, although for formal items like scripts and documents I point out that I am legally required to use their birth names until they’ve officially changed their names and I’ve never had a bad response to this.

 

[VA Hopeful Dr]

The main take away from this is that whenever it comes to identity, you should ask open ended questions.
Don't pigeon hole anyone into a few or many categories.
How do you identify your sexuality/gender/ethinicity/race...etc. instead of do you identify as a man/woman, or gay/bi...etc.

This is mostly a right wing forum. A lot of people are not happy with the cultural changes, so I would not come here for advice on this frankly... This is not how medicine is moving, and for a very good reason.

Ha, not even close. About every other week we get accused of being either too liberal or too conservative. It just depends on the person that we're chastising.

 

[clausewitz2]

This is generally what I’ve found as well. One of my patients recently came out as non-binary, but I knew them for almost a decade as a female so mistakes were inevitable initially. When admitted to hospital for an unrelated matter, the nurses were quite anxious and treading very carefully around the pronoun issue – however, the patient has always been laidback and easygoing, noting that even their mother got it wrong sometimes. It then came to light that there had recently been another patient doing the gender switching/personality stuff described by other posters.

For patients undergoing transition, I will always attempt to use their preferred name and gender where possible, although for formal items like scripts and documents I point out that I am legally required to use their birth names until they’ve officially changed their names and I’ve never had a bad response to this.

Not too long ago I had a patient who was a trans man whom I had to give a lab slip to with their legal, non-gender-affirming name. I told them I would have to and they had no problems with this. They were actively psychotic at the time and thought they had a mission from the universe to save people from concentration camps by reciting certain prayers in Latin but they had no objections whatsoever to an inconvenient administrative reality. This should be the normative response when there is any kind of rapport in place.

 

[MacDonaldTriad]

I'm clearly humbled and feel horrible about not being progressive as much as some people on this platform. Please go with your best heart and look at me as not moving forward enough. I'm not proud of my stance but I'm doing better. None the less, I'm not a conservative and it has become weird to know where to stand and I'm rethinking a lot of things. I truly like everyone on this crazy social platform and value the input.

Honestly, I like all of you and if you wish to rain down on me with all of the vitriol you can, bring it on. It has been nice. SDN has been very good to me. I guess I have become a fossil, so not very congruent with this social trend. I can treat and agree with trans gender, gay and most sexual identities that are on the list of non-conforming. I just want everyone to see that this is difficult and needs our understanding if we are going to be good mental health providers. I will not use any pronoun that subjugates anyone away from our collective social constructs, but the group I am talking about has every right to be part of our social milieu, and should be welcomed into our lives.

 

[WisNeuro]

Ha, not even close. About every other week we get accused of being either too liberal or too conservative. It just depends on the person that we're chastising.

These days anyone to the left/right of someone is whatever pejorative the speaker is aiming for. It's all ideological purity testing and is ignorant of the reality of the situation of where most people stand on issues. But, for some people, black and white thinking is a comfortable ignorant reality in which to reside.

 

[G Sheb]

Ha, not even close. About every other week we get accused of being either too liberal or too conservative. It just depends on the person that we're chastising.

HAHA. Sure. You have weird definitions of 'conservative' and 'liberal'.
We all remember that Yale thread.
Let's not even go there.

I stand by what I said. It's good to get a broader spectrum of what psychiatrists believe in the real world; however, this is absolutely not how the academic world is moving.

BTW, I only mentioned this because many posters are giving the impression that the remarks the preceptors made about the OP's interaction with the patient were inappropriate or that they should ignore them.

 

[MacDonaldTriad]

I had a snow flake student who complained about our system's treatment of a particular personality disorder, and then went to an other intern basic level didactic and said the same thing and two of my faculty resigned from these teaching opportunities. My faculty are more afraid of students than they are of the university promoting them with enough "significant imaginative contribution" towards education. When did this train get this far off the rails? Jesus Christos! Something is very wrong. Grow up everyone, microaggressions are fairly subjective and medicine has macro aggressions everywhere. Gosh help this MS when he/she does rotations outside of psych.

 

[zenmedic]

I had a snow flake student who complained about our system's treatment of a particular personality disorder, and then went to an other intern basic level didactic and said the same thing and two of my faculty resigned from these teaching opportunities. My faculty are more afraid of students than they are of the university promoting them with enough "significant imaginative contribution" towards education. When did this train get this far off the rails? Jesus Christos! Something is very wrong. Grow up everyone, microaggressions are fairly subjective and medicine has macro aggressions everywhere. Gosh help this MS when he/she does rotations outside of psych.

I made the post because I genuinely wanted to know the best way to approach these patients. I had never had a trans patient before and wanted unfiltered advice. Nothing more nothing less. Definitely not trying to make waves or trigger anyone. And the input has been really helpful for me so thanks everyone!

 

[Merovinge]

The main take away from this is that whenever it comes to identity, you should ask open ended questions.
Don't pigeon hole anyone into a few or many categories.
How do you identify your sexuality/gender/ethinicity/race...etc. instead of do you identify as a man/woman, or gay/bi...etc.

This is mostly a right wing forum. A lot of people are not happy with the cultural changes, so I would not come here for advice on this frankly... This is not how medicine is moving, and for a very good reason.

Can't be that right wing, I got 5 likes and zero vitriol for posting WPATH's latest guidelines and they are vanguard for transgender individuals.

There are a few right wing posters who post a lot, but I would say it's mostly center and left wing as is typical in psychiatry, the most liberal field of medicine.

 

[Stagg737]

BTW, I only mentioned this because many posters are giving the impression that the remarks the preceptors made about the OP's interaction with the patient were inappropriate or that they should ignore them.

I'm guessing I'm as one of the people you're referencing. I didn't say the remarks themselves were inappropriate unless there were specific circumstances like requiring students to ask about gender (not sex) of their partner. That information is absolutely unnecessary and that is where I'd question the school's lesson. I'm also in the camp of most other reasonable people here (not just the physicians) that a reasonable patient would just correct the statement and move on as long as the physician tries to make basic accommodations and respect the patient.

As far as I saw, only one person made explicitly "right wing" comments. Out of curiosity, where do you see yourself on the political spectrum? I feel like you're making assumptions about people's statements that are kind of baseless...

 

[MacDonaldTriad]

With just a few exceptions, I find most everyone is very open to opinions on this forum. Unless I'm an exception, I believe almost everyone feels welcome here for the most part. Nothing will be perfect with such open availability of participation, but an open forum has enough other advantages to allow for virtues that might be worth the cost.

 

[Ceke2002]

With just a few exceptions, I find most everyone is very open to opinions on this forum. Unless I'm an exception, I believe almost everyone feels welcome here for the most part. Nothing will be perfect with such open availability of participation, but an open forum has enough other advantages to allow for virtues that might be worth the cost.

If you're the exception, then so am I, because I've felt quite welcome here over the years & have enjoyed many respectful conversations with folks on the opposite political spectrum to me.

 

[DOswag]

I'm fairly conservative, and have some misgivings about the trans phenomenon. However I've been able to have a fine time with people identifying as transgender by being respectful and treating them like plain ol' humans.

I would consider myself in this same boat. I am on the conservative end of the political spectrum and within the field of psychiatry I feel as if I'm in the minority. I would say having "misgivings" about the trans phenomenon would describe me. I have had limited experience with transgender patients but I try to remain respectful of them as they are a human being just like me. I also feel the limited interactions I've had were with one of the groups described above where there's clearly other stuff going on such as personality disorder so my experience may be skewed even more by this.

 

[Merovinge]

Not sure you're stating this clearly. Are you talking about permanent gender affirming procedures or reversible treatments? Either way, physicians treating minors when parents don't consent or are against treatment is going to cause issues.

I won't go into actual treatment, but will share what I saw on child rotations. I could basically divide the "non-cis" patients into 3 groups.

The first were the truly transgender/non-cis adolescents. Most of these kids were at least fairly self-aware of their situation and had either started transitioning in some form or had started thinking about how to do so at some level. Most of these adolescents were there for either depression or an adjustment disorder, occasionally d/t hormone-induced mood issues. They seemed to do pretty well overall.

The second group were those who had significant personality disturbances, typically in unstable/bad home environments, who were clearly latching onto whatever group they could to feel like they belonged. In those kids the identity disturbance was much broader and they were clearly unstable on several levels. It was pretty obvious they had much larger issues that needed to be prioritized than their gender and I'd be shocked if even a moderate percentage of these kids didn't develop a full blown PD. These kids were frustrating to work with for a lot of reasons, the biggest one probably being that any attempts to understand why they believed they were non-cis were met with anger and accusations towards those asking even the most gentle questions. A lot of psychoeducation and a lot of patients (and parents) sabotaging their own treatment.

The third group is the question mark group and I could divide that into a bunch of sub-groups. Some probably will end up non-cis/non-binary, but I'm sure many had something else going on. Those were my favorite to work with because oftentimes they really did want to explore what was going on and were open to lots of questions and treatment options. The most interesting sub-group here imo were the non-binary adolescents/teenagers who had undiagnosed autism, and talking to one of that CAP hospital's psychologists who specialized in ASD, there's growing data that there's more of an overlap in those groups than we would have thought.

I'd be interested to hear if those observations line up with the CAP docs on here, especially any who have a strong knowledge of gender identity issues.

That seems a pretty good summary of the population. I agree that ASD patients find themselves in the NB range more typically than neurotypical children. I found most of those were not interested in any medical/surgical transition but would change name/appearance/use binders etc. Not fitting into current societal norms but not in a personality disturbance type of way and without other significant instability.

The second group is where the difficulty is, finding a way to promote functioning and flourishing while meeting them where they are at with gender is a doable task but takes good clinicians that are not out to promote or punish any agenda. I will often discuss specifically focusing in on other issues while arranging gender therapists for them. I feel like as long as these kids feel genuinely heard you can still make progress moving forward.

 

[Stagg737]

That seems a pretty good summary of the population. I agree that ASD patients find themselves in the NB range more typically than neurotypical children. I found most of those were not interested in any medical/surgical transition but would change name/appearance/use binders etc. Not fitting into current societal norms but not in a personality disturbance type of way and without other significant instability.

The second group is where the difficulty is, finding a way to promote functioning and flourishing while meeting them where they are at with gender is a doable task but takes good clinicians that are not out to promote or punish any agenda. I will often discuss specifically focusing in on other issues while arranging gender therapists for them. I feel like as long as these kids feel genuinely heard you can still make progress moving forward.

Cool, the second group is one of my least favorite groups of patients to work with in psychiatry as a whole. I often found it really difficult to untangle how much of their claims were truly rooted in exploration of gender vs how much of it is just significant personality pathology clinging onto a group where open acceptance without questioning is the norm in their setting. I'm sure some of these patients truly do have significant noncisgender-related distress with co-morbid severe personality traits, but when you can't even ask the most basic questions without them going into a full-blown rage it's impossible to even start to unwrap what's actually going on. It's like dealing with patients who are both severely antisocial and legitimately psychotic reporting HI, untangling the basis of the HI can be a nightmare.

 

[G Sheb]

I'm guessing I'm as one of the people you're referencing. I didn't say the remarks themselves were inappropriate unless there were specific circumstances like requiring students to ask about gender (not sex) of their partner. That information is absolutely unnecessary and that is where I'd question the school's lesson. I'm also in the camp of most other reasonable people here (not just the physicians) that a reasonable patient would just correct the statement and move on as long as the physician tries to make basic accommodations and respect the patient.

As far as I saw, only one person made explicitly "right wing" comments. Out of curiosity, where do you see yourself on the political spectrum? I feel like you're making assumptions about people's statements that are kind of baseless...

I'm actually surprised that people were taken aback by the 'right wing' comment.
There are at least 5/6 posters (a clear majority) who were either dismissive or expressed exasperation/discontent with the remarks the educators make. They also got a ton of likes as well. Many of them also admit implicitly or explicity admit their struggles with the cultural changes. The thing is, I'm not basing this on this thread only. And I felt it was important to throw that in so that the OP doesn't get an impression that this is the standard, and the school is out of line. I'm kind of surprised no one has said the W word yet.
I'd consider your post one of them as well, even though it was balanced in other ways.

But to answer your question, sure it's not the end of the world if the physician says this, the patient objects and they are 'corrected' and they apologize.
But the whole point of education is to get better at communication skills, make patients feel comfortable and welcome and point out potential biases that can hamper care.
I think your analysis is sort of missing the impact on a non-binary person.
Here's an analogy. Not a perfect one but along similar lines:
"How do you identify racially?"
"I don't really identify with any race"
"Were your parents black or white?"
Again, not the best one. But the point is that if you are talking to someone who identifies as non-binary, and you follow up with a question if their partner is a "man or a woman", that actually sound very invalidating for their identity. In some ways it was dismissed/ignored, which is why this might ring a few bells of 'unconscious bias'.

Is it the end of the world? Does the OP deserve to be burned on the stake? Will the patient crumble when hearing this? Most likely no. But that's the point of education, so the students get better at communication skills, make patients more comfortable because, really, they are the vulnerable ones.

 

[smalltownpsych]

I also am surprised by the perspective that this thread is evidence of this being a right wing forum. It seems like a good way to pick an unnecessary fight. If one disagrees with a point, challenge that point. It’s as sImple as that. The point I disagree with is that this forum is very right wing and it seemed like the consensus was that asking questions in a neutral way makes for better interviewing. Also, one post that criticized the educators feedback seemed be more directed at the word “harmful” than the criticism of the question of itself. In other words, my reading of this thread is that I most of the posters appear to be supportive of using more inclusive language.

I also disagree with the above comments on not liking the second category of younger people that seem to want to use gender identity and pronoun usage as a way to express their personality pathology. What I disagree with is that I find those patients easy to work with because budding Borderlines and angry or defiant teens is one of my specialties!

Also, my patients who are transgender love to talk about this stuff too and I think it is helpful for them to think about their identity and the world and language and different levels of understanding and acceptance both internally and externally and how to navigate all of that. They seem to appreciate that I validate their experience and that I seek to empower their choices and journey and the challenges that this brings as I do with all of my clients. Also, just wanted to add that none of my patients personalities or talents or individual quirks ever fits into any box and getting to know who they are is way more important than whether they have a penis or a vagina or not. In fact, as a psychologist, I never know really what genitalia they were born with or what they have now. I just have to go with what they tell me and that has never really been a problem in 20 years of practice with at least 20 individual clients who identified as transgender. As I think about it now, I’m pretty sure we didn’t explicitly discuss much about their genitalia. The most I recall is patients talking about how different levels of dysmorphia about their body and some of the sex characteristics including genitalia.

 

[Merovinge]

I also am surprised by the perspective that this thread is evidence of this being a right wing forum. It seems like a good way to pick an unnecessary fight. If one disagrees with a point, challenge that point. It’s as sImple as that. The point I disagree with is that this forum is very right wing and it seemed like the consensus was that asking questions in a neutral way makes for better interviewing. Also, one post that criticized the educators feedback seemed be more directed at the word “harmful” than the criticism of the question of itself. In other words, my reading of this thread is that I most of the posters appear to be supportive of using more inclusive language.

I also disagree with the above comments on not liking the second category of younger people that seem to want to use gender identity and pronoun usage as a way to express their personality pathology. What I disagree with is that I find those patients easy to work with because budding Borderlines and angry or defiant teens is one of my specialties!

Also, my patients who are transgender love to talk about this stuff too and I think it is helpful for them to think about their identity and the world and language and different levels of understanding and acceptance both internally and externally and how to navigate all of that. They seem to appreciate that I validate their experience and that I seek to empower their choices and journey and the challenges that this brings as I do with all of my clients. Also, just wanted to add that none of my patients personalities or talents or individual quirks ever fits into any box and getting to know who they are is way more important than whether they have a penis or a vagina or not. In fact, as a psychologist, I never know really what genitalia they were born with or what they have now. I just have to go with what they tell me and that has never really been a problem in 20 years of practice with at least 20 individual clients who identified as transgender. As I think about it now, I’m pretty sure we didn’t explicitly discuss much about their genitalia. The most I recall is patients talking about how different levels of dysmorphia about their body and some of the sex characteristics including genitalia.

If you're ever looking for a new job, let me know, and thank you for the work that you do.

 

[smalltownpsych]

If you're ever looking for a new job, let me know, and thank you for the work that you do.

😂
Definitely wasn’t something I was planning to do when I started this career. I had a great discussion with one of those patients about their cat and what a good job that cat did having the appropriate therapeutic stance with the patients emotional/interpersonal instability. Calm and detached and focused on their own self-care. Maybe I was a cat in a past life.