Just as race is a social and political construct, so is gender.1 As we continue to work toward eliminating inequities and health disparities experienced by patients and families in the neonatal intensive care unit (NICU), we need to be more purposeful in our inclusion of LGBTQ+, specifically gender nonconforming, perspectives. One strategy to increase purposeful inclusion is using inclusive language. The importance of gender-neutral language is recognized and supported internationally. However, word choice can be complicated, sensitive, and personal, especially for families experiencing the trauma of an NICU admission. A delicate balance between providing representation for the LGBTQ+ population and avoiding alienation of the majority, cisgender people who feel wholly represented by the terms "mother" and "father" is required. This editorial is meant to begin a conversation with the goal of ensuring inclusivity through mindful, expansive language, both in the NICU setting and in our publication.

There is a biological basis upon which sex is determined, but this is not as simple as the binary terms "male" and "female" imply. An example of this is the intersex population. As NICU nurses, we may see infants diagnosed with ambiguous genitalia. Historically, these infants would undergo extensive testing, consultation with the family and healthcare providers, and genital surgery. It was assumed that the child's gender identity would conform to the genitalia they had been assigned. This assumption was later challenged by reports of long-term follow-up of children who had sex reassignment surgery in infancy struggling throughout childhood with nonconforming gender wishes and behaviors, with up to 40% rejecting the gender assignment they had been given at birth.2,3 Approximately one in 58 people can be classified as intersex, with at least 40 variations in biological sexual characteristics ranging from genes to hormones to internal and external genital appearance.4 The current recommendation for infants born with ambiguous genitalia is to provide genetic and hormonal testing so that parents can have a sense of the direction in which gender identity may go, but to forgo unnecessary genital surgery until the child is at an age to make the decision for themself.4,5

With our growing understanding of the complexities of biological sex, we have come to realize that gender identity is similarly complex. The recognition that gender identity is determined by more than psychosocial experiences during childhood and/or genitalia exposes the inherent expectations and biases associated with being identified as male or female. The acknowledgment of these biases, as well as the need to respect the rights of the individual to self-identify, is reflected at a basic level by asking people to state their preferences for their pronouns (eg, she/her/hers, he/him/his, they/them/their, etc). The need for patient-specific gender inclusive language has only recently been reflected in policies of several perinatal healthcare organizations and publications.6-10 The health inequities associated with the lack of knowledge surrounding LGBTQ+ issues and needs demonstrate a need for policy change; examining language for inclusivity is a necessary first step. Gender nonconforming and LGBTQ+ individuals are marginalized and discriminated against in healthcare.11 This can be especially true when seeking reproductive care.12

Not all people who give birth identify as women. Likewise, not all people who have given birth want to be referred to as mothers. We acknowledge that motherhood and fatherhood have cultural and personal significance, and we are not suggesting that we erase these terms. Traditional gender expectations play a role in the experiences of parents in the NICU and to ignore this would be a disservice to providing individualized family-centered care. One of the most important aspects of the use of inclusive language is to avoid making assumptions. It is best practice to establish and maintain open communication and to increase comfort for all participants by first discussing preferred terms and pronouns for individuals. However, we must also adapt our language when speaking broadly about families to ensure that our words reflect a culture of inclusion in the NICU.

Within healthcare systems, the use of nongendered terms surrounding the perinatal period must be considered best practice. This could include using "postpartum unit" rather than "mother-baby unit" or "perinatal center" instead of "maternity center." This change in language could provide gender nonconforming individuals with the reassurance that they would find sensitive and appropriate care within our facilities. The implementation of these changes, as well as when and how to begin the conversation with parents, can be the next steps in increasing inclusivity.

The publication policies of journals concerning the use of inclusive language must be consistent with practices in healthcare organizations. When reporting demographics regarding infants, it should be considered standard to report sex rather than gender, as gender would require speculation and assumptions. Language concerning infant feeding can follow the guidelines suggested by the Academy of Breastfeeding Medicine and may include terms such as "breastfeeding," "chestfeeding," "lactating," or "human milk feeding."9 "Parent" would be the preferred term for a parent of any gender unless using the terms "mother" or "father"" would be needed to provide clarity. When necessary, combining the use of gendered terms with gender-neutral language (eg, "mothers and gestational parents," "lactating mothers and parents," "fathers and nongestational parents," etc) aligns with recommendations from national and international organizations9,13-15 and allows for representation that is both inclusive and expansive.

Currently, there is a lack of research regarding the experience of LGBTQ+ families in the NICU. As we expand our knowledge and aim for inclusivity and equity, we must continue to advocate for this population and include language that represents all the families that we serve. To ensure that the language we use reflects the needs of these families, we should work directly with groups and individuals that represent those interests. Neonatology is an evolving field, as is the study of sex and gender. Our language must evolve along with the science.

Brittany L. Kyle, BSN, RNC-NIC, C-ELBW,

C-NNIC, C-ONQS

Staff Nurse and Editorial Board Member;

Advances in Neonatal Care

Donna A. Dowling, PhD, RN

Section Editor, Original Research;

Advances in Neonatal Care

References