Why pronouns matter
Therapy Today, March 2021

I have been reflecting on my relatively recent decision to enable myself to be more authentic within my working environment. I’m non-binary trans and my pronouns are they/them/theirs. So it can be difficult for me personally when a colleague mis-genders me. I can be rendered silent, soaked in shame. It still takes huge courage to correct them. If I don’t correct them, I feel erased. Either way, I have difficult feelings to process.

Over the years, I have worked with several supervisors, peers and colleagues who I have a lot of respect for. Supervision is a place where I hope it will be as safe for me to discuss my clinical work as I aim to make it for the clients I work with. When a client identifies as non-binary (outside the male/female gender binary) and/or trans and asks to be called by a name, perhaps not the name their parents chose for them, and use a particular pronoun, I make the effort to do just that. The frustration for me, at times, has been when I might need to think about the client in supervision (individual or group), and state the client’s pronouns, for example, only to find that the supervisor or peer forgets or doesn’t feel comfortable using that pronoun. Many times gentle correction is all that is needed to get us back on track, but sometimes a supervisor or peer continues to use incorrect pronouns.

While I recognise that change is slow in wider society, I feel we have a duty as counsellors, psychotherapists and supervisors to be robust enough to challenge, be challenged and expand our knowledge and understanding, rather than live in a bygone era of oppression, judgment and ignorance. According to 2017 figures from Stonewall, LGBTQIA+ hate crime increased by 78% in the previous five years.¹ It matters to clients, supervisees and supervisors. Indeed, it needs to matter for change to occur.

I have also experienced a supervisor asking what I felt were somewhat negative questions regarding the possibility of a non-binary client undergoing chest surgery. I’d been meeting with this client for a long time and they’d always identified as non-binary, so surgery felt a natural progression for them. Yet the supervisor appeared to be struggling to accept this as a valid choice. In addition to frustration on behalf of my client, I found this closed down the possibility of speaking openly about my own transition and potential decisions around hormones and surgery.

Prejudice and fear

I no longer engage in ‘debates’ around the existence of different identities. It’s essential that my identity or that of a client/supervisee is simply respected, otherwise we get into the territory of fascist rhetoric masquerading as free speech.^2,3

I have heard fellow therapists say, ‘I’ve always used that language, so I can’t stop now!’ Really? Once upon a time ‘nxxxxx brown’ was a colour referred to all over the world – thankfully, we have learned not to, because it’s offensive and oppressing. I realise that change takes time but don’t we owe it to our clients and peers to do better? There may be therapists who are too afraid to be themselves, even within this caring profession. So, what gives anyone the right to determine whether someone has the ‘right energy’ for a particular pronoun or whether the chosen pronoun works or does not? Isn’t it irrelevant whether it works for us as practitioners? It’s about who the client is.

Maybe there’s an expectation that, as therapists and supervisors, we will be able, miraculously, to be non-judgmental, to not act from a place of assumption or fear. We all have fears, we all have prejudice and we all make assumptions. Perhaps it is in the greater understanding of our fears and prejudice that changes in how we view the world can be achieved. This means having safe enough spaces to explore, to see how our views or language might harm another and to learn not to make assumptions.

There are demands on everyone to express their gender identity in certain ways, otherwise they are not woman or man ‘enough’. In some instances, clients are told they are not even trans, bi or gay enough, such are the limits of understanding. I wonder, are we perpetuating this in the therapy or supervision room?

From the moment a child is born, the first question asked is ‘Is it a boy or girl?’ Even some intersex babies will have been assigned a binary gender label early on. For some intersex clients, therapy will need to be a space to explore identity and sense of self, and/or to manage the knowledge of historical non-consensual surgery. Babies are often put in gender-binary clothing, given binary names, and expected to express the characteristics of their assigned gender. By the time they go to school, they have been conditioned as to what male and female roles should look like, to the exclusion of other genders. If we happen to fit into the boxes, all well and good, but if not, life can be extremely difficult. No wonder there is so much confusion, fear and shame for any client who identifies outside of societal norms. I too have experienced this fear and shame since I was incredibly young, and it inevitably impacts the way I view and react to the world.

Agonising decision

The decision to tell my clients and supervisees about my pronoun and name was not an easy one. I agonised for months, alone and in supervision, about when and how to do it and the level of detail to share. We spoke about clients and supervisees in turn to explore how each individual might respond and what material of theirs might be evoked by my news. I had to lean on those family and friends who knew me well and would support me. Part of my role as a therapist is to engage in self-care and model this for clients. An element of my struggle was that I wasn’t being fully me but, in being fully me, I risked shame, rejection and judgment.

I had to embark on a process of discovery of who I could discuss this with. I enlisted additional supervision with someone with a shared experience. I needed to talk it through with someone who had a shortcut to understanding and for this not to be about justifying my identity. I knew who I was – this was about enabling me to simply be me at work.

I realised I’d need to hold the balance between telling clients and supervisees enough but also not making it about me. I didn’t need to discuss with clients my identity and what it means to me, I simply needed to inform them of the correct name and pronoun to use and work with whatever this raised for them. It sounds simple, but I was fearful of the impact on my clients, of their rejection of me, of the impact on my career and the business I have worked so hard to build.

I knew some, as with some family and friends, might not have the capacity to hold who I am (who I have always been, it’s simply that people have operated from an assumptive place and I have been too scared to correct them), and this generated fear, shame and anxiety in me.

For months I thrashed it out and finally had a plan I was happy with. Then COVID-19 struck. I pressed pause for a while but I could see that it wasn’t going to be possible for me to wait until the pandemic was over, so, again with the support of my supervisors, I set about telling clients and supervisees.

Authentic self

It was both scary and liberating. Most people I work with simply embraced it. A few needed time for us to explore and process it further and fewer still found it too difficult to cope with and decided to end our work.

One of the positives of being my authentic self at work now is that I feel less shame and I can model for my clients that it’s OK to be who we are. It’s particularly useful for my gender-diverse clients. This in turn reduces some of their shame.

I do not have all the answers and there is still much personally for me to learn about difference. If we can all be more willing to ask questions rather than make assumptions, it would be a great start. My feeling is that much of the discomfort is based in fear – fear of ‘being different’. Might it be possible to explore our own fears about people, beliefs and processes different from our own in a way that helps us evolve and to better respect ourselves and those around us? This in turn could help us to be better therapists and supervisors and a more compassionate society in general.

Gender diversity

Many therapists and supervisors, myself included, advertise that we are inclusive in our practice, but what changes do we make to incorporate gender diversity? One change we have made in my practice is to label both our single-occupancy toilets as ‘all gender toilets’ – this way, anyone can feel comfortable using them. For those of us outside the gender binary, as for many trans and intersex people,⁵ public toilets can be incredibly difficult to navigate. I have personal experience of being spoken to aggressively for using women’s, men’s, and toilets for disabled users. This generates so much shame simply from using a public toilet, something that most cis-gender people will not have to consider.

Other suggestions would be to make greetings inclusive, so ‘Hello all/everyone/folks’ rather than ‘ladies and gentlemen’, which excludes those of us outside the binary (in addition to being outdated, patriarchal and class-centric language). Forms could be more inclusive simply by having boxes for pronouns and other genders, while computer systems can be updated to incorporate the gender-neutral prefix Mx. I could write a whole piece just about the difficulties in getting my documentation changed to this prefix! And email signatures that incorporate pronouns will help normalise the use of diverse pronouns.

If a supervisee or colleague mis-genders me, I will correct them. With clients, I feel much more able to let a mistake pass. Occasionally my old name will be used and, while uncomfortable, it doesn’t feel like an attack. However, if a client continually used the wrong name or pronoun, I would explore this with them.

Negative experience

In my practice, I find some clients seek me out specifically because they have had a previous negative experience of therapy – for example, the client told by their therapist that chest surgery amounted to disfiguration; a therapist refusing to use the client’s chosen name or pronoun, encouraging the client to fit a ‘norm’ for an easier life, disclosing the gender identity of another client in the waiting room, and pathologising identities. Some of the stories I have heard make me shudder; how can a fellow practitioner respond in this way?

As CN Lester points out, we are all shaped by cultural forces beyond our personal control.⁴ For example, pink has only been associated with girls in the past 100 years. Pink equals girl isn’t a given, it is a social construct. Rather than less stereotyping, I wonder if in many ways, we are experiencing more now than ever before. The detrimental impact on all of us is people feeling that they have to fit a certain kind of box. If we can truly encourage our clients to be who they are with the interests and desires they have, rather than buying into ideas about what others want for them or what might be ‘right’ according to the gender assigned to them, we will all be happier and healthier individuals. As Lester says, being trans, non-binary or any other diverse identity isn’t a ‘fate anyone needs saving from. Everyone, every child needs to be loved for who they truly are, without condition’.⁴

It is OK to ask a client how this part of their identity impacts them but certainly not OK to start from a pathologising stance. Affirmative therapy doesn’t simply happen, it takes time and thinking and talking about difficult things; something that even qualified therapists and supervisors can find hard to do.

We are allowed to make mistakes as long as we acknowledge and apologise (and learn from it). There is something incredibly empowering for clients to hear us apologise when we get something wrong, like using the wrong pronoun; it can validate who they are. If we cover it up or hope they haven’t noticed that we just used the wrong pronoun, we erase them right in front of us.

Explore your feelings

I would urge all practitioners to assess the thoughts and feelings that arise when working with any gender-diverse clients and explore them with someone you can trust to challenge you. Irrespective of the area of difference involved, I wonder if it’s enough to ‘do no harm’ – a guiding principle within BACP’s Ethical Framework. Maybe we all need to be more actively ‘working until every one of us is freed from this most pernicious, divisive, and destructive insanity called gender-based stereotypes’.⁶ Both clinical observation and personal experience have shown me that being more aware, compassionate and inclusive in our approach is beneficial to all our clients, whatever their gender.

I also encourage a greater understanding of the impact on our clients of being marginalised by the use of outdated, excluding language and knowledge. To not do so risks perpetuating previous trauma and feelings of oppression, which may result in internalised shame. Some of this work is potentially difficult and challenging as we consider that, as therapists and supervisors, we may inadvertently add to the oppression of our clients in terms of their identity – be that gender, sexual, relationship, ability, race, religion, class or any other aspect. But oppression is only lessened when we recognise and acknowledge our place/s of privilege in society and continue to reflect on what we do with this knowledge, both inside and outside of the therapy room.

Someone once said to me, ‘People are simply people’. Whether you’re a counsellor, psychotherapist or supervisor, I would like to think that together we could be more inclusive and enable people to simply be people, wear whatever they feel comfortable wearing, use names and pronouns that they feel most comfortable with, do jobs and hobbies that make them feel fulfilled, love whoever they happen to love. It’s a vision I still hold most dear but fear we as a profession are not there yet.

*All identifiable details of clinical material have been changed.