Chosen Names and Pronouns

Evidence Review · ER-003

Few clinical gestures are as small as using a person’s correct name, and few are as easy to wave away as merely courteous. The question this review examines is whether that gesture does measurable clinical work — whether getting a transgender or gender-diverse patient’s name and pronouns right changes anything that shows up in health, or whether it is good manners with no evidentiary weight. Answering honestly means holding two bodies of evidence apart: a large, robust literature on the clinical relationship that is almost entirely cisgender or of unspecified gender, and a smaller trans-specific literature that speaks directly to names and misgendering but rests on observational data and, in its single best-known study, on adolescents rather than adults.

The question

Does correctly using a transgender or gender-diverse patient’s chosen name and pronouns produce clinically meaningful benefit — and is the supporting evidence strong enough to treat correct name and pronoun use as a clinically meaningful component of care rather than merely an etiquette? A scoping sub-question runs underneath it: where the evidence is borrowed from an adjacent field or a different population, how far can it legitimately be carried into the adult trans clinical encounter?

Why it matters

The stakes are not abstract, and they are specific to this population. In the 2015 U.S. Transgender Survey — a large non-probability sample of 27,715 transgender adults — 33% of those who had seen a healthcare provider in the previous year reported at least one negative experience related to being transgender, such as being verbally harassed, refused treatment, or repeatedly referred to by the wrong name or gender; 23% reported not seeking needed care at all in that year for fear of being mistreated; and 24% reported having to teach their provider about transgender people in order to receive appropriate care. These figures are descriptive and self-reported, from a US convenience sample, but they establish that mistreatment in the clinical encounter — name and pronoun errors prominently among its forms — is common rather than exceptional.

Avoidance is not a benign endpoint. Seelman et al. (2017), analysing survey data from 417 transgender adults, found that those who delayed needed care because of fear of discrimination had worse self-rated general health and markedly higher odds of poor mental health: roughly 3-fold greater odds of current depression (odds ratio 3.08), of a past-year suicide attempt (3.81), and of past-year suicidal ideation (2.93), relative to those who did not delay or who delayed for other reasons. These associations are observational, and the exposure measured is fear-driven delay rather than name use in isolation; but they place the cost of a hostile or careless encounter inside the clinical encounter, where clinicians and healthcare systems have meaningful influence.

What the evidence says

The quality of the clinical relationship predicts outcomes — but the evidence establishing this is general, not trans-specific. The therapeutic alliance — operationally, the bond between patient and clinician together with agreement on the goals and tasks of care — is among the most studied variables in psychotherapy. Flückiger et al. (2018), synthesising 295 independent samples and more than 30,000 patients, found a consistent, moderate association between alliance and treatment outcome (r ≈ .28 for face-to-face therapy), stable across treatment types. This is one of the field’s most replicated findings. Two features define its reach here. It is correlational: a stronger alliance travels with better outcomes, but the design cannot fully isolate cause from the many things a good alliance co-occurs with. And the populations studied were overwhelmingly cisgender or of unspecified gender identity. The finding establishes that how a patient is treated relationally is not incidental to whether care works; it does not, on its own, speak to transgender patients, and it does not speak to names specifically.

Minority stress theory supplies a mechanism by which a name could matter — as a framework with trans-specific adaptation, not as outcome data. Meyer’s (2003) minority stress model proposed that stigma, prejudice, and discrimination generate a chronic excess stress burden that drives the elevated rates of mental ill-health seen in sexual-minority populations; it was developed and evidenced in lesbian, gay, and bisexual samples, not transgender ones. Hendricks and Testa (2012) adapted the model explicitly for clinical work with transgender and gender-nonconforming clients, and Testa et al. (2015), developing the Gender Minority Stress and Resilience Measure in transgender adults, formalised “nonaffirmation of gender identity” as a distinct proximal stressor alongside discrimination, rejection, and internalised transphobia. Within this framework, being called the wrong name or pronoun is not a neutral slip but an instance of nonaffirmation — a proximal stressor with a theorised path to distress, and a plausible route by which correct name and pronoun use may reduce that proximal stress. The framework is well-developed and genuinely trans-specific. It is a model of how harm propagates; it is not, in itself, proof that a particular name-use intervention moves a particular outcome.

In transgender adults, misgendering is associated with measurable psychological cost — the most directly relevant adult data, and observational. McLemore (2015), across two online studies of transgender-spectrum adults (N = 115; N = 134), found that being misgendered was associated with more negative affect, reduced felt authenticity, and heightened felt stigma, with the effect on self-evaluation strongest among those who were both misgendered frequently and felt highly stigmatised by it. McLemore (2018) extended this through a minority-stress lens, finding misgendering associated with psychological distress and consistent with its operating as a minority stressor for transgender people. These are the most direct adult findings on the harm side of the question. They are cross-sectional and drawn from online convenience samples, so they demonstrate association rather than causation and cannot quantify an effect attributable specifically to the clinical encounter.

The single best-known study linking chosen-name use to mental health is in adolescents, not adults. Russell et al. (2018), working with a community cohort of 129 transgender and gender-nonconforming youth across three US cities, found that the ability to use one’s chosen name in more contexts — home, school, work, and with friends — was associated with lower depressive symptoms, suicidal ideation, and suicidal behaviour, after adjustment for personal characteristics and social support; outcomes were most favourable when the chosen name could be used across all four contexts. This is the study most often cited for the proposition that names matter clinically, and it is a good study. Two features bound how far it can be carried. It is adolescent, not adult. And it is cross-sectional, with chosen-name use functioning as a proxy for gender affirmation across a young person’s life rather than as an isolated, manipulated intervention delivered in a clinic. Its relevance to the adult clinical encounter is real but is an explicit extrapolation, not a direct finding.

Getting names and gender wrong in healthcare carries a documented downstream cost in transgender adults. Returning to the clinic-level data above, the convergence is the point: the 2015 U.S. Transgender Survey locates name and gender errors among common, named negative experiences in care, and Seelman et al. (2017) link fear-driven avoidance of care to worse general and mental health in transgender adults. Neither study isolates “using the correct name” as a single manipulated exposure — name use is one element of a respectful encounter rather than the sole variable measured — but together they establish that the interpersonal conduct of the encounter has measurable downstream associations with whether trans adults engage with care at all and how they fare.

Where evidence is uncertain

Correlation is not causation. Every directly relevant study here is observational and, with the partial exception of cohort recruitment, cross-sectional. Misgendering travels with distress; chosen-name use travels with better adolescent mental health; fear-driven avoidance travels with worse outcomes. None of these designs rules out reverse causation or confounding. A supportive environment, for instance, may both enable chosen-name use and independently protect mental health; Russell et al. adjusted for social support, which strengthens the inference but does not settle it. The honest reading is a consistent, theory-congruent association across multiple studies and populations — not a demonstrated causal effect of a discrete intervention.

“The intervention” and “best-supported” are claims worth qualifying. It is defensible to call correct name and pronoun use one of the best-supported low-risk interpersonal practices in transgender healthcare: the direction of evidence is consistent, the theoretical grounding is coherent and trans-specific, and the risk of using a person’s stated name is effectively nil. It would overstate the evidence to call it best-supported in absolute terms — hormonal and surgical interventions, whatever one’s view of them, carry more direct outcome data. The strong, well-evidenced claim is asymmetric: high confidence that correct name use does not harm and is plausibly beneficial; moderate, not high, confidence about the magnitude of benefit and only theory-level confidence about the causal pathway.

Term precision matters when borrowing the alliance literature. “Therapeutic alliance” is a measured construct — bond plus agreement on goals and tasks — not a synonym for “being kind” or for any single act. Correct name use is best understood as a component and precondition of a respectful encounter, not as the whole of the alliance; the alliance–outcome r should not be read as the effect size of getting a name right. Likewise, “nonaffirmation” in the Gender Minority Stress and Resilience Measure is a specific scored construct, broader than name and pronoun errors alone, and “affirmation” in this evidentiary sense refers to social and interpersonal recognition, not to any particular medical pathway.

The operational specifics are untested. The evidence does not tell us whether asking at the first contact outperforms asking later, whether a prompt correction after an error offsets the error’s effect, whether systems-level supports (preferred-name fields in the medical record, routine pronoun-sharing at intake) change outcomes, or how any of this performs outside the mostly US, mostly online samples that supply the data. The principle that names matter is better evidenced than any specific protocol for honouring them.

Key takeaways

• The proposition that the conduct of the clinical relationship affects outcomes is strongly evidenced — but in general, largely cisgender psychotherapy populations, so its application to trans patients is a reasonable extrapolation rather than a direct finding.
• Minority stress theory, adapted to trans populations and operationalised in the Gender Minority Stress and Resilience Measure, names misgendering and nonaffirmation as proximal stressors — a coherent, trans-specific mechanism, not outcome proof.
• The most direct adult evidence (McLemore, 2015; 2018) associates misgendering with negative affect, reduced authenticity, and distress; it is cross-sectional and from convenience samples, so it shows association, not causation.
• The most-cited chosen-name study (Russell et al., 2018) is in adolescents and observational; its link to lower depression and suicidality is real but adolescent and associational, and extending it to adults is an explicit extrapolation.
• Clinic-level data (2015 U.S. Transgender Survey; Seelman et al., 2017) show that mistreatment is common and that fear-driven avoidance of care tracks with worse health — locating the stakes inside the encounter.
• Overall certainty is moderate: convergent, theory-congruent, low-risk, plausibly beneficial, with no trial isolating the effect in adults. The strongest claim the evidence licenses is that correct name and pronoun use is a low-cost, low-risk, well-aligned practice — not a proven-magnitude treatment.

References

1. Flückiger C, Del Re AC, Wampold BE, Horvath AO. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316–340. doi:10.1037/pst0000172
2. Meyer IH. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. doi:10.1037/0033-2909.129.5.674
3. Hendricks ML, Testa RJ. (2012). A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the minority stress model. Professional Psychology: Research and Practice, 43(5), 460–467. doi:10.1037/a0029597
4. Testa RJ, Habarth J, Peta J, Balsam K, Bockting W. (2015). Development of the Gender Minority Stress and Resilience Measure. Psychology of Sexual Orientation and Gender Diversity, 2(1), 65–77. doi:10.1037/sgd0000081
5. McLemore KA. (2015). Experiences with misgendering: Identity misclassification of transgender spectrum individuals. Self and Identity, 14(1), 51–74. doi:10.1080/15298868.2014.950691
6. McLemore KA. (2018). A minority stress perspective on transgender individuals’ experiences with misgendering. Stigma and Health, 3(1), 53–64. doi:10.1037/sah0000070
7. Russell ST, Pollitt AM, Li G, Grossman AH. (2018). Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. Journal of Adolescent Health, 63(4), 503–505. doi:10.1016/j.jadohealth.2018.02.003
8. Seelman KL, Colón-Diaz MJP, LeCroix RH, Xavier-Brier M, Kattari L. (2017). Transgender noninclusive healthcare and delaying care because of fear: Connections to general health and mental health among transgender adults. Transgender Health, 2(1), 17–28. doi:10.1089/trgh.2016.0024
9. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. (2016). The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality.