Pressure on Therapists to Declare Preferred Pronouns: An Example from South Africa

The usage of preferred pronouns in the therapy professions is on the way to becoming an established practice (see Jenkins on ethical and legal objections). Sensitivity to transgender clients is being used to exert moral pressure on therapists to comply. Here is an example of how this is being encouraged in a South African context. Below is an article in an international newsletter sent out by a large mental health services charity to its members. The article is complete and unedited apart from the redaction of the author’s name and the bolding of the final point which recommends that therapists state their preferred pronouns in order to create a safe space. The encroachment of transgender ideology and activism into mental health services does not bode well for other groups of vulnerable clients – see previous posts on Edinburgh Rape Crisis and UK-based Survivors’ Network.

Dear Counsellors and Support Group Leaders,

The first article is a very helpful article on,‘LGBTQ+ basics: 10 things your queer patient wishes you knew’.




LGBTQ+ basics: 10 things your queer patient wishes you knew

xxxxxxx MD  | May 22, 2022 

Several months ago, I wrote a post on a Facebook community of over 17K Black physicians. The post asked them what they would do and how they would react if their child told them they were gay. The responses I received ranged from “I will love and accept them” to “Heaven forbid!” to “I will beat it out of him!”

When I got over my shock, I realized that even as a queer person myself, I had experienced the full gamut of internalized homophobia as a Nigerian-born Catholic woman. I was raised in Nigeria, one of the most homophobic countries globally. As a result, I didn’t create a safe enough space for my child to share their true gender identity until they were much older.

I also noted that medical schools have begun pushing for more LGBTQ+ inclusion, from increasing the hours of LGBTQ training (up to five hours in some) to admitting more medical students who identify as LGBTQ+ (15 percent at Harvard). Though a start, it is hardly enough as evidenced by the persistent health disparities amongst the LGBTQ+ community.

Disparities stem from delay or avoidance of medical treatment by LGBTQ+ persons for the following reasons: fear of encountering bias in health care settings, being turned away (despite state laws prohibiting discrimination), receiving suboptimal treatment in medical encounters with practitioners who feel uncomfortable, insufficiently knowledgeable, or even biased toward LGBTQ+ patients, and difficulty with obtaining health insurance.

A pair of studies in 2019 and 2021 carried out amongst residents and faculty in the ED of the United States and Canada, respectively, showed that the overall accuracy of knowledge of their LGBTQ+ patients was only 51%. 6% of respondents did not agree that LGBTQ+ patients deserve the same quality care as others, while 2.5% felt uncomfortable around other LGBTQ+ physicians.

I decided to do my part and educate my peers from my vantage point as a Black, queer, female physician-mom of a non-binary transgender young adult. I realize that there are several things you might not know that your patient would like you to know, so here is a list of the top 10 that I came up with.

  1. The acronym is long and will continue to grow as knowledge, understanding, and vocabulary continue to expand. Currently, it is LGBTQQIAAP2S (lesbian, gay, bisexual, transgender, questioning, queer, intersex, ally, asexual, pansexual, 2-spirit). And AMAB and AFAB (assigned male at birth and assigned female at birth).
  1. Sexuality is different from gender. Sexuality refers to physical, sexual, emotional attraction, etc., while gender is divided into identity and expression. Expression is how one shows up in society outwardly, while identity is how they feel inside. Gender identity also refers to the binary of male or female, non-binary, agender, bigender, etc. Meaning masculine, feminine, neither male nor female, or both.
  1. No age is too young or too old to become aware of one’s sexuality or gender. Since your patient is born that way, it is only internalized homophobia, lack of understanding, and fear that prevent them from sharing with you.
  1. While there is no “gay gene” confirmed yet, there has been unequivocal evidence that it tends to be familial. So, when you find one queer person in a family, you often find others.
  2. Up to 55% to 77% of adult LGBTQ+ persons in the United States are bisexual. That means that some who lead heterosexual lives are LGBTQ+. 21% of today’s Gen Zs are LGBTQ+. They are the incoming workforce, so we must be prepared. Only 48% of 13- to 20-year-olds are straight. 10% of LGBTQ+ are transgender, so enough of your patients are indeed queer.
  1. Transition 101: This refers to the process of gender affirmation for a gender-diverse person to feel more comfortable in their own skin.
  • Social transitioning is when the person becomes aware of their transgender identity, accepts it, invites others in, and only chooses to change their name, pronouns, hair appearance, binders, clothing worn, etc. It also involves behavior training.
  • Medical transitioning involves medically blocking puberty (the prepubertal child has no need for any hormones. Because pubertal changes (deepening voice, facial hair, breasts, etc.) are irreversible, cause distress and intense gender dysphoria, the recommendation is to use puberty blockers to temporarily suppress puberty. It also involves hormone replacement for older teens and young adults. The age of onset of hormone replacement depends on the child, parental support, physician, mental readiness, etc. This is why therapy is highly recommended.
  • Surgical transitioning entails, surgically reconstructing/removal of body parts to align with gender identity.
  • Legal transitioning means the person has their name, gender and pronouns changed on legal documents like passports, birth certificates, work identification paperwork, etc.
  1. Dead names, pronouns, new names. Why the fuss? It is all about respect and affirmation. Recognizing that the transgender person can make adult decisions, and you, on the other hand, can respect them, period.
  1. Parents and caregivers do struggle with fear, shame, and guilt. Their journeys are quite different from those of their queer children and must also be validated. Parents are the most influential persons in their kids’ lives, so their mental well-being directly affects their children.
  1. ABCDEF of creating safe spaces:
  • Acknowledge, accept, and affirm your patient.
  • Believe your patient if/when they share their sexual/gender identity with you.
  • Compassion, empathy, and vulnerability on your part will go a very long way.
  • Decide to support them and learn as much as you can on your own to become a #queerpatientally
  • Engage in open-ended communication with them.
  • Find local, virtual/in-person support for yourself and your staff, as that makes a huge difference in the long run.
  1. The best way to begin any conversation is, “Hello, my name is Dr. Lulu, and my pronouns are she/her. May I ask what yours are?” This sends a subtle message to your patient that you are a safe space.


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