A few years ago, Ginger Marshall needed to replace a headlight bulb on her car. When she visited a mechanic, a worker pointed to the selection of bulbs: “Right over there, ma’am!” Two minutes later, he “materialized” next to her, eager to help her choose the right product — and to install it for her.
This never happened to Marshall before she transitioned.
“I was categorized as a woman without question,” Marshall, the administrative coordinator for the pride network at metroHealth in Cleveland, said. “It felt excellent.”
But the opposite experience can derail the day — and the mental well-being — of a transgender person.
Research shows that being misgendered — the act of using the wrong name, pronoun or language for a trans or gender diverse person — can have deleterious effects on mental health. One 2023 study on gender diverse people living in Canada found that people misgendered daily had higher anxiety scores compared to those misgendered less frequently.
Transgender people already die by suicide at higher rates than the general population and, by one metric, are 1.7 times more likely to experience intimate partner violence than cisgender people, cisgender referring to those whose gender identity aligns with the sex assigned at birth.
“We can unequivocally say that using the correct pronouns for gender diverse patients is incredibly important,” said Kristen Eckstrand, the medical director of the UPMC LGBTQIA+ health quality program, an assistant professor of psychiatry at the University of Pittsburgh and a physician. “Using the correct pronouns improves a patient’s experience in the health care system — and we have received this feedback directly from patients.”
Due in part to negative experiences within health care, trans patients may also take longer to find a primary care doctor, or may delay care altogether until situations are urgent, which can impact health long term.
“Pronouns are the first thing a provider can say to make a person feel safe and secure,” said Ava O’Brien, a care navigator for the transgender health program at Allegheny Health Network’s Center for Inclusion Health. “This can be the difference between a good and bad health care experience.”
At Central Outreach Wellness Center on the North Side, mental and behavioral health director Lisa Pietrusza, who uses they/them pronouns, is working to ensure the latter doesn’t happen. A registered nurse, Pietrusza knows how being misgendered can impact a patient’s experience.
“Pronouns matter because they affirm who we are, just like our name,” Pietrusza said. “People can work really, really hard to be accepted and seen as their gender. It can be very minimizing to be misgendered.”
Ginger Marshall, who is 64 and has been out publicly as a woman and on hormone replacement therapy for about nine years, has experienced this dissonance.
“Being misgendered feels really bad,” she said. “It feels vulnerable. It feels diminishing. … It feels like I failed being who I am.”
She likened the feeling to that common embarrassing dream of going to school or giving a presentation and realizing you forgot to put pants on.
“It’s a feeling that I’m being seen differently than I am, different than I try to be,” she said. “If I’m going to be part of society, quite honestly, there are certain games I have to play. For me to blend in and look like a middle-aged woman going down the street … I wear a touch of makeup, and stuff that makes people see me how I want to be seen.”
Pietrusza said that can make being misgendered feel especially disheartening.
“People dress certain ways to signal to society, in order to fit stereotypes to be affirmed,” said Pietrusza. “It’s like, ‘I spent two hours this morning getting ready, and it still didn’t work.’”
Both Marshall and Pietrusza recognized that the impact of hearing the wrong pronoun depends on context. If it happens, say, over the phone, or out in public where the mistake may be unintentional and not malicious, both said it tends to sting less — they understand that society is continuing to adapt and that signaling remains a part of it.
But both have also experienced malicious misgendering, in which a person doubles down on the wrong pronoun to make a point. For Pietrusza, it’s happened in their role as a Mount Oliver borough council member.
“I’ve had people who will go out of their way to misgender me as ‘he’,” said Pietrusza, who was assigned female at birth. “It wasn’t that they forgot, but that they wanted to be offensive.”
And this can lead to harmful effects.
“Being not seen and not heard, and then not having support, these are big risk factors for suicide,” said Pietrusza.
Despite this knowledge, little slips are not unheard of, even within the queer community. Pietrusza said they did it once when referring to a friend of multiple years.
How one responds to being misgendered can compound its physiological toll or quell the sting. Those interviewed said the best course of action when accidentally misgendering someone is to quickly correct yourself, apologize and move on. Going on about your true intentions, apologizing profusely or repeatedly bringing up the incident are unnecessary and can compound negative feelings.
“This happens; it’s to be expected,” said O’Brien, of AHN. “It doesn’t benefit either party to make a long, drawn-out apology.”
“Not only do I have to deal with the incident, but I have to deal with your emotions about the incident,” said Pietrusza.
Marshall likened the experience to, “If you step on my toe accidentally, and two hours later, you’re still apologizing, it’s no longer about my toe: it’s about you.”
In response to poor mental health rates of transgender patients, high suicide rates and a record number of anti-trans legislation introduced throughout the country, local health systems are working to improve and maintain the experiences of their trans and gender diverse patients.
O’Brien often holds training sessions with nurses, front desk staff and other providers within AHN about best practices and inclusive language.
She said the most common reservations that people express are along the lines of, “I don’t want to say the wrong thing,” or, “I want to show support, but I don’t know how.”
O’Brien’s response? Say the wrong thing. Not on purpose, of course — but simply correct yourself and move on if it occurs. It’s OK if you don’t understand how hormone replacement therapy works, or why someone uses they/them pronouns, she said.
“I want to shift the conversation away from understanding trans people, because I don’t think you need that to show empathy to patients,” said O’Brien.
UPMC, too, holds regular trainings on inclusive language and trans rights, said Eckstrand, earning UPMC Children’s Hospital of Pittsburgh, as well as seven other locations, the title of “leader” in the 2024 Human Rights Campaign Healthcare Equality Index, which measures health facilities’ commitment to LGBTQ+ rights and health equity.
Pietrusza left Central Outreach in 2020 and returned in 2022, and said they have seen a lot of growth at the center, hearing staff use pronouns more often. They encourage, broadly, cisgender people to offer up their pronouns first before asking a stranger theirs.
“It helps to normalize it,” they said. “It’s not just people in the LGBT community who get misgendered. This is an important human right.”
Hanna Webster: hwebster@post-gazette.com.
First Published: June 1, 2024, 9:30 a.m.
Updated: June 2, 2024, 1:46 a.m.
