There can be a discrepancy between health science students’ intent to ask for and share preferred pronouns with classmates, colleagues, and patients and their actual performance of this skill. One way to bridge that gap is the use of Pronoun Pins.
BACKGROUND
Sexual and gender minority (SGM) patients face more health disparities and higher rates of discrimination in healthcare settings compared to their heterosexual and cisgender counterparts (Clark et al., 2023; Cooper et al., 2023). SGM medical trainees similarly encounter greater discrimination, isolation, and mental illness than their peers, and often fear sharing their identity during training (Clare et al., 2024). These inequities negatively impact the health and safety of both patients and trainees (Clark et al., 2023). However, few medical schools have developed comprehensive programs to adequately educate their students about working with SGM patients, with a median training time of only five hours on SGM content at U.S. and Canadian medical schools (Obedin-Maliver et al, 2011; Cooper et al., 2023).
Peer-reviewed literature on SGM education in medical training is limited, but some studies identify discrete areas where educators struggle to promote gender inclusivity. Some authors suggest specific interventions targeting these areas, including implementing peer teaching, increasing gender inclusive terminology, and standardizing SGM education across all M.D.-granting programs (Baecher-Lind et al., 2023; Filimonov et al., 2023; Gomez & Gisondi, 2020). One study goes further and describes the implementation of Harvard Medical School’s Sexual and Gender Minority Health Equity Initiative, designed to improve SGM-related stakeholder engagement, curriculum, faculty development, student life and educational climate. (Keuroghlian et al., 2022). Aside from the Harvard report, however, thorough evidence-based guidance for medical schools to effectively improve their SGM education is lacking (Danckers et al., 2024).
With few robust data, many institutions have turned to pronoun badges as a simple intervention to improve gender inclusivity (Shields et al., 2023). At Emory Healthcare facilities, administrators approved the distribution of nearly 11,000 pronoun badges to faculty, staff, and residents in 2023. Anecdotal conversation suggests the badges were received positively; however, no formal evaluation of the initiative, or similar initiatives at peer institutions, has been published. Emory Medical Pride Alliance (EMPA), the affinity group for the LGBTQ+ community and allies at Emory University School of Medicine (EUSOM), received a grant from the university Office of LGBT Life to support this initiative at the undergraduate medical level by distributing pronoun pins to students along with a survey designed to evaluate experiences of gender inclusivity at EUSOM and perceptions of the intervention.
METHODS
An eighteen-question survey was administered to EUSOM students via Google Forms (Appendix 1). The survey aimed to assess 1) student perceptions of gender inclusivity at EUSOM and affiliated clinical sites, 2) student behaviors related to asking for and sharing pronouns with peers, patients, and educators, and 3) opinions on the pronoun pin intervention. Respondents answered nine questions that required them to rate their opinions on a 5-point Likert scale. The survey additionally collected respondent demographic information including gender identity, pronouns and class year. The Emory University IRB determined this survey to constitute program evaluation and therefore not require IRB review.
The survey was distributed through one email by the president of EMPA in March 2024 to all 607 medical students enrolled at EUSOM in 2024, with additional details on picking up a pronoun pin in the SOM admissions office. For students in their first year (M1) and second year (M2), both the pronoun pins and a link to the survey were distributed in regularly scheduled didactic sessions that are part of their required curriculum.
RESULTS AND DISCUSSION
Respondent Characteristics
A total of 191 medical students participated in the survey, with a response rate of 31.5%. Half (48.2%) of respondents were M1s, 37.1% were M2s, 10.5% were M3s, and 4.2% were M4s. Most respondents (72.6%) identified as cisgender women, roughly reflecting the gender makeup of EUSOM (66.8%). Approximately one quarter (25.3%) identified as cisgender men and 2.1% identified as non-binary/genderqueer /gender nonconforming. Similarly, most respondents (72.3%) reported using she/her pronouns. One quarter (25.1%) reported using he/him pronouns, 2.1% using she/they pronouns, and 0.5% using he/they pronouns.
Exact numbers of pronoun pins distributed were not collected. However, each of the 143 M1s and 162 M2s was given a pronoun pin in their didactic session, meaning that at least 305 pronoun pins were distributed directly to students. M3 and M4 students retrieved pronouns pins from the SOM admissions office in unknown numbers, and program directors of the internal medicine and the obstetrics and gynecology residencies at Emory University requested 100 pronoun pins each to distribute to their trainees. In all, we can safely estimate that over 500 pronoun pins were distributed in spring 2024.
Pronouns in Patient Care
Almost half (44.5%) of survey respondents reported that it is either important or very important for them to share their pronouns with patients. However, only 12.0% of respondents reported that they share their pronouns with their patients either often or always, highlighting a discrepancy between student conviction and practice. Of the 68 respondents who explained their answers, most said they share their pronouns if the patient asks them, if the patient is younger (“I usually share with younger patients, I’ve noticed that older patients are confused sometimes”), if they feel the patient would be receptive (“If they look like they would say something like “what’s a pronoun I don’t believe in those” I do not”), or the patient’s pronouns are ambiguous (“Any indication or uncertainty from the patient and I’ll use them”) (Figure 1).
Similarly, 84.3% of respondents reported that it is either important or very important for them to know their patients’ pronouns, while only 27.8% of respondents reported that they ask for their patients’ pronouns either often or always. Of the 57 respondents who explained their answers, most responded that age (“Younger patients usually feel more comfortable sharing their pronouns”), ambiguity of gender presentation (“If I see a patient’s gender presentation isn’t cis normal”), and opportunity during introduction were primary factors in determining whether to elicit patient pronouns (Figure 1).
Pronouns in the Educational Environment
Few (13.1%) respondents report sharing their pronouns with classmates either often or always. Rather, most (58.6%) respondents report sharing their pronouns with classmates either rarely or never. Of the 78 respondents who explained their answers, most responded that following the lead of others (“If other people are sharing”), setting (“I usually only share if we’re all formally sharing in a group”), context (“If I am meeting someone for the first time”), and alignment of perceived gender presentation with their pronouns (“I use the pronouns people would assume I use, so I’ve never had to clarify”) were primary factors in determining whether to share their pronouns (Figure 2).
Similarly, very few (4.6%) respondents report sharing their pronouns with their clinical team either often or always, compared to the majority (69.1%) of respondents who report sharing their pronouns with their clinical team either rarely or never. Of the 69 respondents who explained their answers, most responded that following the lead of others (“Whether my preceptor does or not”), assessment of supervisor’s acceptance (“My perception of how attendings would receive it”) and perceived hierarchy (“Careful not to immediately make the team look at me differently since the power dynamic is so strong”) were primary factors in determining whether to share their pronouns. Notably, most respondents (85.3%) were M1 and M2 students with limited clinical education (Figure 2).
Perceptions of Inclusivity
Results regarding gender inclusivity of EUSOM non-clinical and clinical environments varied. Most respondents (42%) responded that they felt Emory’s clinical environments were neither inclusive nor non-inclusive. Of students who specified, more selected inclusive (31%) or very inclusive (17%) over non-inclusive (9%). Only 1% of respondents selected very non-inclusive. Comments made by students reflected this variability. One student wrote regarding gender inclusivity, “I’ve heard some doctors laugh at it, I’ve heard some doctors honor it.”. Another wrote: “I haven’t seen a ton of inclusivity but also haven’t seen exclusivity. More just neutral.” However, other comments expressed observing non-inclusivity: “It is not the norm to ask for pronouns or to have a dedicated spot in the EMR for a patient’s pronouns or gender identity.” While there were narrative comments describing inclusivity, most were vague.
Pronoun Pin Initiative
Most (76.4%) respondents reported that they were either likely or very likely to wear the pronoun pin. Of the 52 respondents who explained their answer, many responded that they would wear the pin because it was an easy way to show allyship with the LGBTQ+ community. Over half (57.0%) of respondents reported they thought the pronoun pins would have a large or very large impact on improving gender inclusivity at Emory, while 34.0% thought it would have a neutral impact.
CONCLUSION
Our study serves as an initial investigation into medical student perceptions of gender inclusivity at EUSOM and affiliated clinical sites. Additionally, it provides insight on a preliminary intervention. We found that although most respondents believed it is important to ask for and share pronouns, much fewer report doing so in practice. Initial exploration of the reason for this discrepancy suggests use of heuristics in making the decision (i.e., reliance on patient age or appearance). We know that LGBTQ+ identities supersede age and cannot be distilled down to appearance alone. Thus, we hope the pronoun pins help alleviate this decision-making process. This result warrants further investigation into Emory’s SGM education to avoid compounding the health disparities already faced by SGM patients. Additionally, while most of our respondents reported that EUSOM tends to be gender inclusive, most of our respondents (97.9%) were cis women or men, a finding which reflects a lack of gender diversity among the EUSOM student body.
There are two primary limitations of this study. First, the response rate of 31.5% means that there is a nonresponse rate of 69.5%. In other words, even though a large number of students (191) participated in the survey, the majority of medical students did not respond. Second, the majority of respondents (85.3%) were M1s and M2s, who have much more limited exposure to clinical settings compared to M3s and M4s. This discrepancy is likely due to more direct promotion of the survey to M1s and M2s in their in-person didactic sessions, which M3 and M4 classes do not have. Having a low response rate overall and a particularly low response rate from patient-facing students could have produced data that is less informed and less accurate.
Our results call for a needs assessment that examines gender inclusivity within EUSOM non-clinical and clinical learning environments to direct further interventions and better serve our students and patients. Furthermore, these results have implications beyond medical students and may apply throughout the health professions: we would be interested in seeing similar work done in other health professions as well.
Acknowledgments
The authors would like to thank Mia White for assistance with the literature review. The authors received no grant support for this work and declare they have no conflicts of interest in regard to this work.
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Abigail LeCates, BA*
Medical Student, Emory University School of Medicine
Brendan H. Pulsifer, BA*
Medical Student, Emory University School of Medicine
Jason S. Schneider, MD
Professor, Emory University School of Medicine
*Authors contributed equally as senior author