Pronouns Are a Public Health Issue

In their study published in this issue of AJPH, Perales et al. (p. 482) drew from a 2020 Australian data set to demonstrate a significant association between the use of inclusive language in the workplace and a multidimensional measure of well-being at work in a sample of more than 400 trans- and gender-diverse (TGD) people (including transgender, nonbinary, agender, and other gender minority people) working for more than 100 unique employers. This study is notable both for its relatively large sample size (given the underresearched and often invisible nature of this population) and for its inclusion of workplace-level data (i.e., indicators of inclusive language use from both TGD and cisgender employees in each workplace setting). The resulting findings are the first, to our knowledge, to empirically establish the relationship between trans-inclusive language and mental well-being at work, and they offer important extensions to our knowledge of the contribution of employment-related discrimination to the health of TGD people.¹

Why is trans-inclusive language in the workplace (and beyond) a public health issue? Work and working conditions are widely accepted as important components of the social determinants of health (https://bit.ly/3qsb6Qv). Although less formally acknowledged, many scholars and advocates argue that gender identity, meaning one’s internal experience and sense of gender, should also be considered a social determinant of health: TGD people experience profound health inequities, often associated with exposure to gender-related stigma and discrimination.² Indeed, these disparities are so stark that, in recent years, special sections have been devoted to TGD health in both AJPH and the Lancet.^3,4

These health inequities are linked to economic and other structural inequities. For example, highlighting the disproportionately high prevalence of HIV in TGD populations, Becasen et al. have noted the relevance of recognizing social and economic vulnerabilities systemically affecting this population as factors that likely increase HIV risk.⁵ Indeed, structural and interpersonal discrimination, experienced by TGD people as cisnormativity and transphobia, limit TGD people’s access to the health benefits of work. A national US study identified that TGD people were more than twice as likely to be living in poverty (29%) as cisgender people; this is likely attributable to unemployment rates that are three times the national average, earning lower wages than their cisgender counterparts, and experiencing workplace discrimination and harassment that result in being fired, resigning, or being denied promotion. These patterns are compounded when intersectional marginalization is considered (https://bit.ly/3z7nQjI). Corroborating findings from Canada indicate that TGD people face higher rates of employment discrimination (2.2 times) and harassment (2.5 times) than do their cisgender peers, despite workplace protections.¹ Almost 30% of TGD people reported that they were, or thought they were, fired for being TGD, whereas 50% were, or thought they were, denied a job for being TGD (https://bit.ly/32CvJBm).

To understand the implications of the work of Perales et al., it is helpful to drill down into what was meant by inclusive language in their study. The key explanatory variables in the study centered on using correct pronouns and other associated gender markers (e.g., names). For example, TGD people were asked whether people made an effort to use their personal pronouns, and cisgender heterosexual people were asked if they would be comfortable using “they/them/their” pronouns for a nonbinary person at work. We believe that trans-inclusive language includes any and all measures used to account for the identities of TGD people and that the indicators Perales et al. used are necessarily proxies of a broader concept. However, if we reframe the authors’ findings in the simplest possible terms, we see that TGD people reported improved well-being in workplaces where their co-workers felt comfortable referring to them using the correct pronouns.

Use of trans-inclusive language—including the use of correct pronouns, affirming gendered terms such as honorifics (e.g., Ms., Mr., Mx.), and the promotion of gender-neutral language (“people” instead of “men” or “women”) where appropriate—has a profound impact on the comfort and psychological safety of TGD people in the institutions with which they must interact; this includes, as demonstrated by Perales et al., the workplace. For many TGD people, being referred to by incorrect pronouns is experienced as a microaggression: a seemingly innocuous exchange that contains negative messaging about the group (in this case, the notion that a TGD person’s gender identity does not merit recognition). Ample research has established a strong and negative relationship between exposure to microaggressions and TGD health.⁶ This is because use of trans-inclusive language, including correct pronoun use, is a fundamental component of gender affirmation, that is, the process whereby someone receives social recognition of their gender identity or expression, including via legal, social, or medical means.⁷ For example, Scheim et al. found that TGD people whose gender identity matched their legal documents (correct name and gender marker) had a 32% reduction in serious psychological distress and an approximately 25% reduction in suicidality than did those whose identification did not match their gender identity.⁸

Pronouns—single syllable words that roll off our tongues so many times in a single day—structure what is possible with respect to gender identity and can reinforce a gender binary with their use. This is likely why there is such resistance to using pronouns that do not neatly correspond to how an individual’s gender is perceived or to using pronouns such as “they/them” that do not align with binary gender. Although they are simple words, using pronouns correctly for TGD people challenges the binary gender system that underpins so much of dominant Eurocentric, colonial social structures—the binary system that is necessary to uphold systems of patriarchy and misogyny. These tiny words do so much work and carry so much significance, not just for TGD people but for all who are affected by these systems of oppression. Through this lens, pronouns are truly a public health issue.

At the same time, it really is that simple. As Perales et al. demonstrate, an important step in creating trans-affirming workplaces is to ensure that all employees are able to respect and affirm TGD peoples’ identities through the use of correct pronouns and related gender markers. This could be accomplished through, for example, workplace training, including instruction in using trans-inclusive language and information about its role in addressing health and other inequities for TGD people; regular evaluations of organizational culture with respect to trans-inclusive language; and equity in hiring and promotion to ensure that TGD people are in positions in organizations that enable them to actively participate in these and other necessary interventions (the Appendix provides resources [available as a supplement to the online version of this article at http://www.ajph.org]). As a significant global workforce with an imperative to address health inequities, employers in the public health sector are well positioned to show leadership in this domain. We hope that through such action, the workplace can evolve to affirm the identities of TGD people and serve as a catalyst—rather than an impediment—to reduce social inequities and improve health in this population.