Incorporating Pronouns into Professional Communications at the Indian Health Service

During Pride Month, I had the honor of visiting the Transgender Resource Center of New Mexico. The center supports transgender, nonbinary, and gender nonconforming communities through direct services, education, and advocacy. During our tour, we learned about their work providing STI testing, providing mental health services and referrals, and the wide array of other services and partnerships they leverage to provide our transgender relatives the supports and care they deserve. A significant portion of their clients are Native American.

One highlight of the visit was our listening session with center staff who work daily on the frontlines of community care in Albuquerque. Not only were staff incredibly welcoming and informative, but I was also struck by the level of trust they extended to me in sharing their insights, experiences, and ideas about what public health care systems like the Indian Health Service are doing well-and where we still need improvements.

For context, a disturbingly large percentage of Native trans children have experienced mistreatment in K-12 schools due to their gender identity and far too many transgender adults report experiencing "serious psychological distress." The unemployment rate among transgender American Indians and Alaska Natives is nearly five times higher than the national average and housing insecurity is a painful daily reality for many.

As providers of health care, we need to be aware that the same health disparities experienced throughout Indian Country are often exacerbated in the transgender community due to prejudice, discrimination, and violence. These disparities include higher rates of mental health issues, substance abuse, and suicide than the general population.

During our listening session, I was proud to assert that IHS endeavors to build the policies, protocols, opportunities, and partnerships necessary to ensure that Two-Spirit and LGBTQI+ Indigenous people are respected, protected, and provided with the care they deserve. I shared these examples, which all IHS staff should be keenly aware of:

• To ensure a welcoming experience from the outset at IHS-operated facilities, front desk staff ask everyone for their chosen names and pronouns and our clinic staff are trained to recognize and acknowledge names and pronouns in all patient interactions.
• IHS supports gender-affirming care for everyone. If one of our clinics is not equipped to provide a specific service, our staff offers resources to help them find services and support groups in their respective communities.
• Our partners at the Northwest Portland Area Indian Health Board created the Paths (Re)Membered Project, which offers no-cost virtual mental health services for Two-Spirit and LGBTQI+ Indigenous people in 32 states.
• IHS continues to support youth-focused Two-Spirit and LGBTQI+ work by funding the Project Red Talon National Network, which provides outreach, education, and technical assistance to improve HIV prevention and care.

I also assured our hosts that I know that some health care settings can be so inhospitable that many, many of our trans relatives just opt to not pursue care. Not only did the center's staff corroborate this fact, but their personal experiences also illustrated just how far we have yet to go.

Based on countless experiences, many of our transgender relatives would rather forego seeking care than trust their health to systems that have historically made them feel disrespected, judged, mistreated, and unsafe. And based on what was shared with me, I do not blame them for feeling this way.

While their personal stories included many examples of the lack of both training and familiarity that some health care providers still possess when it comes to the transgender community that illustrate wide systemic deficiencies in this country, I was struck by just how many of the center's staff emphasized what I consider a shockingly modest request. One after another, they told me of their wish to simply use their correct pronouns in a health care setting, and to have those pronouns respected.

What a remarkable realization for someone in my privileged position to learn that in 2024, it is still absolutely commonplace for transgender patients to be misgendered within the health care systems entrusted to provide them care! It is no wonder, then, that mistrust and a reluctance to proactively seek health care impacts the transgender community so significantly.

I appreciated the gracious candor they extended when I asked, "What can and should I do about this?"

Heeding their input and honoring their willingness to share what were often painful recollections, today I'm asking all staff of the Indian Health Service to adopt the practice of including the use of pronouns in their professional communications, starting with email signatures. For example, our own HIV/HCV/STI Branch Chief Rick Haverkate uses this format, that includes a resource link for those needing further explanation.

Rick Haverkate, MPH (he/him)What's this?
(Enrolled: Sault Ste. Marie Tribe of Chippewa Indians)
Branch Chief, HIV/HCV/STI Branch
[email protected] | www.ihs.gov
Work Cell: 240-678-2873

In the spirit of One IHS, adopting this practice across all areas and positions affords everyone the most basic level of respect and inclusiveness. It steers us away from making incorrect assumptions that can prove harmful and inflict distress. It also fosters the kind of safe environment that so many of the transgender community members that I met have not yet experienced in their encounters with the public health system.

I encourage everyone to explore the myriad of ways we can build upon this first step, from including pronouns in on our Teams screennames and adding into routine introductions during in-person meetings, to seeking further training on the specific health care needs of our transgender relatives.

For now, I hope you join me in celebrating this modest initial action that aligns us better with our agency values, adheres to U.S. Department of Health and Human Services policy, and brings us all further under the umbrella of One IHS.

Roselyn Tso, a citizen of the Navajo Nation, is the director of the Indian Health Service. As director, Ms. Tso administers a nationwide health care delivery program that is responsible for providing preventive, curative, and community health care to approximately 2.7 million American Indians and Alaska Natives in hospitals, clinics, and other settings throughout the United States. She previously served as the director of the IHS Navajo Area, where she was responsible for providing leadership in the administration of a comprehensive federal, tribal, and urban Indian health care system for over 244,000 American Indians and Alaska Natives throughout Arizona, New Mexico, and Utah.