Clinical Anatomy 31:136–139 (2018)
ORIGINAL COMMUNICATION
An Approach to Discussing Personal and Social Identity Terminology with Patients ALEXANDER SLOBODA
,1* AESHA MUSTAFA
,2
AND
JUSTINE SCHOBER
1
1
University of Pittsburgh Medical Center-Hamot, Erie, Pennsylvania 2 Michigan State University, East Lansing, Michigan
As the United States of America becomes more socially diverse, it is more important now than ever for health care providers to become more aware of their patients’ social identities. It is imperative that providers engage with their patients and see how each of them identifies personally in relation to social construction terminology. As with the terminology of human anatomy, there is a vast and diverse vocabulary concerning the anatomy of society, which is also clinically relevant to health care providers. If health care providers take the initiative to discuss how their patients identify, they can understand better how those patients experience the world, and this can significantly affect many facets of their health and health care experience. Giving respect fosters the creation of a strong relationship within which patients can share very personal and intimate information, which in turn allows health care providers the possibility of providing the best healthcare. This discussion will build upon and integrate current academic research and opinion for tangible clinical use while discussing various social and personal identities, including but not limited to race, gender, gender expression, sex, sexual orientation, religion, ethnicity, socioeconomic class, and physical and mental abilities. Clin. Anat. 31:136– 139, 2018. VC 2017 Wiley Periodicals, Inc. Key words: social identification; communication; patient care; terminology; LGBTQ persons; gender identity; race; sexuality; clinical medicine; ethnic groups
For health care providers to initiate more discussions with their patients concerning their social identities and how they personally identify, it is important to understand what social identities are and where they might come from. Social identities are based on the division of groups for several social, cultural, and historical reasons. These identities can include, but are by no means limited to, sex, gender, gender expression, sexual orientation, race, ethnicity, socioeconomic class, physical ability, cognitive ability, and religion. Power and privilege are central to the production of certain social identities and differences. These aspects must always be further explored and kept in mind during discussions with patients. This discussion includes both social and personal identity since society often creates categories, which can vary widely by culture and geography. It is important for health care providers to ask individuals how they personally identify because this often cannot be assumed on the
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2017 Wiley Periodicals, Inc.
basis of appearance alone. Engaging patients in selfidentification helps health care providers to use appropriate terminology in the patient-provider relationship. Much attention has been given to research on this topic in public health and medicine. The literature concerning discussions of identity terminology with patients explores the areas of gender, sex, and sexual orientation. It is important for providers to realize that all social identities and their terminologies are affected by prejudice from personal to institutional levels *Correspondence to: Alexander Sloboda, University of Pittsburgh Medical Center-Hamot, Erie, Pennsylvania. E-mail:
[email protected] Received 19 October 2017; Revised 10 November 2017; Accepted 22 November 2017 Published online 10 December 2017 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/ca.23022
Personal and Social Identity Terminology with Patients (Rossi and Lopez, 2017). Just as it is critical for health care providers to explain medical terminology to patients so that they understand, so it is also crucial for health care providers to understand the social and personal identity terminology of patients for better two-way communication. Many of the social identity terms used in the medical field come from research and documentation, especially in this age of electronic medical records, aimed at facilitating the categorization of patients for the analysis of data and differences or code for billing. Therefore, health care providers should re-examine their terminology generated by society, research, and academia to understand their patients better. Even fundamental reference ranges of test results and medications have been developed on the basis of sex or gender, which is no longer a purely biological identity term (Gupta et al., 2016). Public health and surveillance research has contributed much to the medical field’s terminology history as social category subgroups are essential for studying differences and disparities. Some of the terminology must be used with caution as it is not always purely scientific or biological, regardless of how much researchers want it to be, such as racial identity (Hahn and Stroup, 1994). Terminology and categorization in public health research needs to be constantly re-evaluated as demographics in the United States change and society grows, as this research affects clinical practice and patient-provider relationships. Free response identities can be a nightmare in analyzing research data. However, by not addressing the breadth and depth in social identity terminology and how an individual experiences the world, researchers are not capturing reality because they continue to use conventional biased terminology and social categories (Aspinall, 1997). One specific area of public health terminology that has been assessed in this respect concerns “men who have sex with men” (MSM) and “women who have sex with women” (WSW). These labels were developed by researchers and are not necessarily used by patients. It is an attempt to make an identity biological for research purposes while obscuring its important social and community aspects (Young and Meyer, 2005). A clinical example that has been studied is of pediatric urologists working with transgender and gendernonconforming children. Such patients are at high risk for mental health problems and other health disparities associated with gender identity uncertainties. When pediatric urologists create a safe and welcoming environment, patients can share how they personally identify so health care providers can provide the appropriate treatment and support, which improves health outcomes (Conard, 2017). Certain medical specialties can be more relevant to the discussion of social identity terminology, such as urology, obstetrics and gynecology, psychiatry, pediatrics, or primary care, but there is no field of medicine in which it is not important or relevant. In aspects of psychology concerning disability there is also debate about sentence structure and terminology, such as “identity” first or “person first” language. Both structures have been promoted to address the
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specific concerns of disability groups while also promoting human dignity (Dunn and Andrews, 2015). It is also important to have these discussions concerning a patient’s care within healthcare teams or between professional colleagues while preserving privacy, so everyone can learn more about that patient and about how to approach other patients in the future. Nevertheless, the focus remains on simply attempting to have open and non-judgmental dialogs with patients about their terminology and language preferences. One example of this type of discussion in academic medicine concerns the race of a patient, along with the age and sex, during a presentation to a health care team. Race is often considered a biological fact, like age, but it could be more appropriately addressed as a social construct and how it affects the patient’s life, health, and health care experience. The other concern about race is that it is often based on the health care provider’s observations rather than being self-identified, which is problematical, especially when multiracial patients are considered (Anderson et al., 2001). For example, a patient could appear to belong to a certain race to a health care provider, which could influence risk assessments for certain diseases associated with that race or ethnic group. However, the patient could in fact be biracial or multiracial, so the health care provider could overlook certain screening or disease considerations through never having asked. The patient could even identify as a single race, so the health care provider might need to ask more probing questions about their identity. Talking over this process with a patient and the health care team can help providers recognize their possible biases and discriminatory tendencies and become more conscious and better health care providers. This process can also lead to discussions of intersectionality between identities, and prevent the use of certain identities as proxies for others that can lead to assumptions and biases (Anderson et al., 2001). This process can be used for many different social identities when health care providers and teams are learning how a patient personally identities. The more this process is performed, the more natural it can become, leading to improved patient interaction, trust, and care. A terminology discussion is also important during interactions with other individuals accompanying the patient in terms of their relationship. The person could use spouse, partner, significant other, or various other terms. A study in Massachusetts looked at the kinship terms among gay and lesbian couples. Survey and interview data showed that terms are used discriminatingly, are chosen consciously, and are context specific. All the terms also depended on the participant’s other identities and the intersectionality between them (Ould and Whitlow, 2011). This can be important for building a relationship with the patient and upholding the patient’s right to privacy as to what the provider has permission to discuss in front of the accompanying individual. There can also be generation differences in the terminology used. Health care providers can be generations removed from the patients in either direction, and a term used by one generation could be offensive
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Fig. 1.
Acronym INCLUDES
to a newer one, or on the other hand possibly more acceptable. There is much fluidity in identity terminology that can change over decades or even within a few years depending on current events in society
(Oswalt et al., 2016). It is also important to revisit the discussion of identity and preferred terminology with the same patient, especially in longitudinal patientprovider relationships. This can be particularly true for
Personal and Social Identity Terminology with Patients younger patients as they continue to experience the world and how the world sees them (Bosse and Chiodo, 2016). This discussion is also why diversity of social identities is critical within the medical and health care profession, so patients can connect with providers through different identities. Working in socially diverse healthcare environments and discussing a patient’s identity terminology will hopefully lead providers, who may not identify socially as the patient does, to learn about themselves, their ideology, and their biases during discussions with patients and coworkers about patients’ preferences for or objections to certain terms. One particular study looking at mental health services for LGBT communities showed that even though many health care providers in the study also identified with that community, they still would like further training in appropriate care for the identity community to which they themselves belonged. These ideas included terminology and appropriate interview questions to ask so that patients could share their terminology preferences comfortably, so their specific health care needs could be better served (Rutherford et al., 2012). It is also important to remember not to ignore social and personal identities in efforts to treat everyone equally because this can lead to more problems. While stricter social categories are sometime required for research and data analysis so differences and disparities between groups of people and different communities can be understood and addressed, the individual patient-provider encounter and relationship gives us the opportunity to explore the boundaries of these identities. This in turn allows patients to identify themselves and their experience for health care providers to ensure they receive the best care possible. Some health care providers may be concerned that not all patients will care, or consider social identity questions important or appropriate. Providers can ask in the same way they ask about their name or age. Even if a provider asks to confirm a name, they can ask how the patient would like to be addressed. Therefore, providers can also easily ask how patients identify in terms of gender, sex, pronouns, sexual orientation, race, ethnicity, religion, class, or ability, among many other social identities. Not asking how a
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patient identifies to avoid confusing them is illadvised; it is better to ask, since the patient could identify differently from the provider’s perception. This neglect of personal identity can affect a patient’s health negatively; the benefits of the conversation greatly outweigh the risks. Figure 1 demonstrates the acronym “INCLUDES” to facilitate health care providers in initiating personal identity and social identity conversations with their patients. “INCLUDES” is geared toward conversations with transgender patients, but it can be applied to any discussion of social identity with any patient.
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