More Than Inclusive: Building Affirming Care for 2SLGBTQ+ Communities

By Emilie K. Clark Ashley “Smash” L. Koenig, PsyD

Editor’s Note: While Canada can sometimes pat itself on the back for its legal protections and the presence of advocacy organizations for 2SLGBTQ+ people, access to competent, quality healthcare is not always guaranteed. 2SLGBTQ+ adults report anxiety, frustration, and isolation when seeking medical care as well as instances of their identity being ignored, misunderstood, or even blamed for their health experiences. It can be tempting to avoid the need for 2SLGBTQ+ competency in healthcare services where gender identity and sexual orientation are not explicitly involved in care delivery, such as audiology. However, this avoidance can reinforce biases, negatively impact patient-provider rapport, and disrupt a patient’s experience of safety. This article offers concrete and manageable recommendations for both patient-facing and internal procedures.

Introduction

In many ways, Canada is ahead of the curve when it comes to protecting the rights of Two Spirit, Lesbian, Gay, Bisexual, Transgender, Queer/Questioning (2SLGBTQ+^[1]) people and promoting equal access to healthcare. The Canadian Human Rights Act recognizes sexual orientation, gender identity, and gender expression as protected categories against discrimination and inequality (Government of Canada, 2025b). Still, issues of healthcare inequality and discrimination persist, exacerbated by health disparities within the 2SLGBTQ+ community and lack of standardized education about 2SLGBTQ+ health needs within medical training institutions (Comeau et al., 2023, Rainbow Health Ontario, n.d.). In fields of medical practice where a patient’s gender and sexual identity do not explicitly impact care delivery, such as audiology, it can be tempting to overlook the importance of 2SLGBTQ+ competency. However, audiologists in Canada have an ethical mandate to avoid causing psychological harm by maintaining competence around diversity and difference (Speech-Language and Audiology Canada, n.d.). Additionally, person-centered care guidelines highlight that this competence and respect for difference are critical to maintaining an effective patient-provider relationship (Clark & English, 2025).

Gender and sexual diversity have been present in all cultures throughout history (Collins, 2021). The government of Canada currently reports that 4.4% of the population aged 15 and older identify as 2SLGBTQ+ and that this percentage reaches 10.5% among the 15-19 age cohort (Government of Canada, 2024b)^[2]. This trend of increasing rates of disclosed 2SLGBTQ+ identity is projected to continue as members of the youngest generations reach adulthood (Jones, 2022).

While the higher rates of 2SLGBTQ+ identity among younger generations demonstrates their cohort’s increasing acceptance and tolerance for self-exploration, the experience of 2SLGBTQ+ elders may be quite different. Years of discrimination have resulted in higher rates of poverty, isolation, and mental and physical health disparities among 2SLGBTQ+ elders (Movement Advancement Project, 2017), and after living through decades of stigma, violence, and legal discrimination, 2SLGBTQ+ older adults may be more reluctant to disclose their identity with their healthcare providers. Since most audiology practices work primarily with older adults, these are important factors to consider, and the recommendations in this article should be adjusted to meet each practice’s patient population with awareness and sensitivity to their unique experiences.

Despite legal protections and the existence of numerous healthcare advocacy organizations and education resources promoting 2SLGBTQ+ people’s access to quality healthcare in Canada (Canadian Virtual Hospice, n.d.; Government of Canada, 2025a; Service Provider Directory | Rainbow Health Ontario, 2025), 2SLGBTQ+ adults still report feelings of anxiety, frustration, and isolation when seeking medical care as well as experiences of their identity being ignored, misunderstood, or even blamed for their health experiences (Pang, et al., 2025). Access to quality, non-discriminatory medical care is even more complicated for 2SLGBTQ+ individuals with multiple minoritized identities, such as those who are Black, Indigenous, people of color, disabled, and immigrants (Pang, et al., 2025; Rainbow Health Ontario. n.d., Government of Canada, 2024a). One study in the United States found that 8% of LGBTQ+ people and up to 22% of transgender individuals avoided seeking healthcare when they needed it (Mirza & Rooney, 2018).

When 2SLGBTQ+ individuals do seek care, they are confronted by a healthcare system that was built on institutional racism and cisheteronormativity (the assumption of cisgender and heterosexual identity as the norm) (Pang, et al., 2025). These foundations continue to impact present-day policies and patient encounters (Pang, et al., 2025). Lack of competency and discriminatory attitudes within healthcare systems do not only affect patients seeking care but can also negatively impact 2SLGBTQ+ healthcare workers, including audiologists, who may face overt and covert prejudice from colleagues, supervisors, patients, and the larger systems of their work environments (Kirjava, 2022).

2SLGBTQ+ people exist in every culture and community. They seek care from and work in all medical practices, whether or not those practices are aware of their presence. Implicit bias - the often unconscious attitudes and stereotypes all people hold - leads many to believe that they know when they are speaking to someone who is a member of the 2SLGBTQ+ community. However, the only way to know someone’s identity is if they have stated it directly, and any assumption otherwise runs the risk of furthering discrimination and erasure. It is for this reason that audiologists, along with any medical practitioner, must make system-wide adjustments so that all patients and staff can experience safety and competence in their medical treatment or workplace. This article offers concrete, manageable recommendations for both patient-facing and internal procedures. These changes, alongside meaningful self-reflection and ongoing learning, can help provide a safe and affirming practice environment.

Patient Interactions

The core of patient-centered practice, and the aspect most critical to patients’ level of comfort and likelihood of following through with practitioner recommendations, lies in the direct interactions patients have during their visits (Clark & English, 2025). This means that all office staff must feel prepared to address patients’ in an affirming way, from front desk staff to billing departments. The suggestions below offer a starting place for creating an environment where 2SLGBTQ+ patients can feel safe in their care.

First encounters

During first interactions with a practice, 2SLGBTQ+ patients are likely already assessing their level of comfort and safety. Staff can begin by avoiding common gendered monikers and suffixes like “sir,” “ma’am,” “Mr.,” “Ms.” and “Mrs.” An equally respectful and exponentially more affirming greeting can be found in a simple “Good morning” or “Welcome,” followed by a confirmation of how the patient would like to be addressed. Irrespective of a person’s gender or sexual identity, having the opportunity to share how one wishes to be addressed can create an experience of comfort and trust. This can be as simple as a brief exchange when a patient checks in for their first appointment: “I see your name listed as Anis Mansouri, is that correct? What would you like us to call you in the office?” With this framing, any response is welcome: a request for the formal use of Mr. or Mrs. before a last name, a nickname, or another name that is not on a patient's legal records - often referred to as an affirmed name in the 2SLGBTQ+ community. By noting the response, the practice ideally removes the burden on the patient of having to correct each individual or answer the same question numerous times.

Pronouns

Audiology practices should also consider how they wish to obtain patients’ pronouns. While putting this on an intake form is a common option, asking it verbally provides an opportunity to clarify the meaning and intent of the question for those who are not familiar. Offering one’s own pronouns during an initial introduction can be a helpful way to introduce this question. (i.e. “Hi, I’m Dr. Robin Hong and I use they/them pronouns. Are you comfortable sharing with me what pronouns you use?”). If patients are unsure of the meaning or purpose of this question, a simple clarification could sound like, “I want to make sure I am referring to you respectfully by using your correct pronouns. Some examples of pronouns are she/her/hers, he/him/his, and they/them/theirs. There are many other pronouns people use and if you’d rather I just use your name instead of any pronoun, you can let me know.”

 Some practices may prefer a more subtle invitation to share pronouns, such as staff wearing pins indicating their own pronouns or prompting others to share theirs. When working with minors, using these subtle approaches or asking about pronouns in a private setting helps avoid putting the patient on the spot in front of a parent or guardian. If the minor is 2SLGBTQ+ and has not shared their identity with their caregiver or is living in an unaccepting family, even seemingly innocuous questions about pronouns could put them in the difficult position to either disclose new information, lie, or risk triggering further rejecting behaviors at home.

Information privacy

If a patient shares information about their identity (including their affirmed name or pronouns) in a private encounter, it is best not to assume this information is known to others who may accompany them to appointments. Plan to keep information regarding sexual orientation or gender identity private and confirm which name and pronouns are to be used if the practice interacts with others in the patient’s life. This is especially important when working with 2SLGBTQ+ minors as disclosure of this information without a patient’s desire or consent (called “outing”) can put them at risk of maltreatment, abuse, and even homelessness (Stokl et al., 2024). While it may be difficult initially to utilize more than one name or set of pronouns for the same patient, this ability becomes more natural over time and with practice.

Avoiding Assumptions

Due to implicit bias one is likely to make assumptions about the nature of observed relationships. It is critical to identify these assumptions and ask patients directly and openly about the people in their lives relevant to their audiological care. For example, asking a young patient, “Who takes care of you at home?” rather than inquiring about “mom and dad” is a supportive practice for children with same sex or nonbinary parents, as well as children with single parents or who are in the care of other family members or in foster care.

In counseling adults about communication strategies with loved ones, one might ask, “Who do you communicate with most at home?” rather than defaulting to “your husband” or “your wife.” Once patients share about the relationships in their lives, using their language is a helpful way to communicate respect and care (e.g., referring to “your partner” if that is the language an adult patient uses, or “your Pépé” for a child). When patients arrive for an appointment accompanied by someone the practice is not familiar with, a simple open question like, “Who is here with you today?” can go a long way toward building comfortable patient rapport.

Acknowledging mistakes

Practicing on one’s own and being conscientious about these suggestions during patient interactions is a significant step. Still, it is only human to err and mistakes should be expected. Instead of dwelling on the mistake with a prolonged apology (which can often feel ingenuine or burdensome for the one who has been faulted), consider the following steps: 1) accept the feedback, 2) apologize for the harm caused, and 3) end by acknowledging what you will do differently in the future. For example, “Thank you for reminding me of your pronouns. I am sorry for getting it wrong today. It is important to me that you feel comfortable and respected here. I will make sure to be conscious of using the right pronouns in the future and will ask my staff to do the same.” Remember that these words are not enough unless they are followed by thoughtful reflection on the potential biases that led to the mistake and meaningful action to prevent the same mistake in the future. This action could look like continuing education, practicing correct names and pronouns when a patient is not present, or making necessary system-level changes.

Administration and Operations

Practitioners are often mindful of the interpersonal elements of client interactions; however, people also interact with audiology practices through their online presence, physical environments, and administrative paperwork. Because of a long history of stigma and violence, members of the 2SLGBTQ+ community are often attuned to indications of discrimination or acceptance and may seek out practices that specifically communicate recognition, respect, and support. The below are some examples of changes practices can make to communicate safety and respect to prospective and existing patients. If considering implementing one of these patient-facing changes, it is imperative that the practice can ensure the competent treatment of 2SLGBTQ+ patients.

Digital Space

Prospective patients may make their first introduction to a practice or practitioner by visiting its website, social media, or other online profiles. Consider avoiding gendered pronouns in written text by speaking directly to prospective patients. For example, instead of “Our practice will ensure every patient has his or her hearing needs met!” use, “Our practice is here to meet your hearing needs!” Practices may also choose to adapt online copy by using they/them pronouns in both the singular and plural, or by forgoing pronouns altogether and using client or patient instead (e.g., Our practice is here to meet every patient’s hearing needs).

Consider the impact of not only the text, but also images and videos used in digital spaces. Individuals, including 2SLGBTQ+, may look to see whether their experience is affirmed by what is depicted. Using images that portray a broad range of experiences, including diverse gender presentations, family structures, and relationships, can convey consideration and inclusion. Given that all patients have multiple identities, consider also reviewing representation across identity factors, including race, ethnicity, age, ability, etc.

Practices may also consider explicitly stating their approach to 2SLGBTQ+ affirming care. This may include publishing any written non-discrimination and inclusivity policies, listing inclusivity and identity-related trainings that staff have received, and naming any affiliations the practice may have with community resources and professional organizations. To avoid creating a false sense of security for 2SLGBTQ+ patients that the practice cannot uphold, symbols of inclusivity and statements directed to the 2SLGBTQ+ community should reflect ongoing meaningful efforts to provide affirming care.

The Physical Space

The physical office space communicates a plethora of information to new and returning patients. Some opportunities to communicate affirmation of 2SLGBTQ+ experience include posting “safe space” symbols and incorporating images that represent 2SLGBTQ+ communities in resources already present in the office (photos, pamphlets, advertisements, etc.). Further steps include updating any magazines in the waiting room to include those featuring 2SLGBTQ+ stories or published by 2SLGBTQ+ publishers, ensuring that patient materials use non-gendered or gender-neutral language, and providing written resources from 2SLGBTQ+ organizations and local groups. Adopt a habit of reviewing and updating these materials as needed to remain current with inclusive practices.

Additionally, all patients should have easy access to washrooms that align with their gender identity. By protecting gender identity and expression against abuse, harassment, and discrimination, the Canadian Human Rights Act implies that all people have the right to use the washroom that corresponds with their gender identity and expression (Public Service Pride Network, 2024). Two Spirit, nonbinary, transgender, and gender expansive people may experience anxiety as well as harassment and abuse when using gendered washrooms, making the availability of non-gendered and ideally private washrooms an important component of patient safety when serving this community (Public Service Pride Network, 2024). Whether or not practices can provide ungendered washrooms, posted signage reiterating a patient’s right to access the washroom that corresponds with their gender identity can aid in communicating support to Two Spirit, transgender, nonbinary, and gender expansive people, as well as reinforce expectations of safety and respect from other patients.

Paperwork

Even before a clinical interview, paperwork can be used to gather a wealth of information while affirming a patient’s identity. While collecting a patient’s legal name may be necessary for insurance billing, remember that many patients (not exclusively 2SLGBTQ+) use an affirmed name that differs from their legal name. Paperwork should include spaces to collect both. It should be noted that there are many reasons an individual who uses a name different from their legal name may be uninterested or unable to pursue a legal name change, including financial and logistical barriers.

If collecting pronouns, avoid the word “preferred” and utilize an open-ended, fill-in-the-blank question format to avoid forced choice options that communicate a hierarchy of identity and are inherently inexhaustive. If an open-ended format is not possible, practices can make an inclusive list of options and include the option to check “something not listed here.” This language is more inclusive and affirming than “other,” which can ascribe stigma to identities not included. Practice administrators and staff should be well-versed in the language used on forms in case patients have any questions.

Practices should regularly review their paperwork to ensure they use the most up-to-date language and to determine which questions are pertinent. For example, forms may collect a patient’s “gender” but are actually asking for the patient’s “sex assigned at birth.” Forms may also inquire about marital status out of institutional habit rather than clinical relevance. If collecting a patient's relationship status is necessary, use open-ended questions or provide inclusive options such as “partnered” or “multiply partnered,” and ensure patients can select more than one response and write in their own answer. Unless required for insurance billing, clinical utility, or medical necessity, consider omitting extraneous questions from practice forms.

Being mindful of inclusivity in paperwork and forms alone is insufficient; the practice must ensure this information is consistently and respectfully used throughout the patient's treatment. This includes using affirmed names and pronouns in clinical and administrative interactions. It is important to obtain informed consent from a patient before identity-related information is uploaded to a medical record, as this information can be accessed by individuals beyond the provider (such as a legal guardian of a minor, other practice personnel, or other providers if the patient requests their medical records be shared). Practices should establish clear internal protocols delineating the process for when patients would like providers to use but not officially document identity-related information.

Internal Support

Changes in the workplace can be overwhelming, and the suggestions above may take time to implement thoughtfully. The staff who will be tasked with taking on new procedures will do so under the potential stress that comes with any change, the challenges of keeping up with constantly evolving information on 2SLGBTQ+ experience and care, and potentially while navigating their own identities. With this in mind, the below are suggestions for supporting teams.

2SLGBTQ+ Staff

The policies and culture of a practice not only set the tone for patients, they also impact whether 2SLGBTQ+ staff feel safe and welcome in their place of work. In a national survey conducted by York University with over 4,000 2SLGBTQ+ participants, approximately 50% reported experiencing discrimination based on their identities at work (Chuang et al., n.d.). Another study by Egale Canada involving a survey of Two Spirit, transgender, and nonbinary participants reported that 72% experienced workplace discrimination (Rodomar et al., 2023). Examples of discrimination in these studies ranged from microaggressions (indirect and subtle forms of discrimination); refusal to use correct pronouns; not having a comfortable washroom that matches employees gender identity; and outright physical, verbal, and sexual harassment and abuse (Chuang et al., n.d.; Rodomar et al., 2023). Safety for 2SLGBTQ+ individuals involves a working environment where being oneself is not met with discrimination, abuse, or harassment from management, colleagues, or patients.

Depending on the existing workplace culture, upper management can support staff’s sense of safety by providing single-stall gender-neutral washrooms, 2SLGBTQ+ inclusivity training for all team members, a non-retaliatory and confidential process for reporting workplace discrimination, and policies to address harassment or mistreatment by patients toward staff. A clear delineation of roles when addressing incidents of harassment can be helpful, though all staff should be empowered to intervene if they witness a colleague being harassed. This can mean making the company’s non-discrimination policies clear to all and equipping staff with appropriate language to interrupt harassment in a direct, professional, and de-escalating manner. Supporting 2SLGBTQ+ employees through intentional resource investment can enhance staff experience and retention (Kirjava, 2022).

Ongoing Work

Building 2SLGBTQ+ affirming practices is an ongoing endeavor that involves self-reflection and thoughtful consideration of how each individual interacts with broader social systems of power, privilege, and oppression. This article has suggested several shifts in clinical practice and systems administration. Beyond this, practitioners are encouraged to continue seeking information and best practices from 2SLGBTQ+ organizations and leaders within and outside the field of audiology, and to remain connected to professional communities for accountability.

Keep abreast of the continually shifting tides of social and political acceptance and/or marginalization of 2SLGBTQ+ communities at both local and international levels, which likely impact the lived experiences of patients and staff. While audiologists may believe they are inconsequential to the larger battle for 2SLGBTQ+ rights, healthcare providers are instrumental to their patients' daily well-being. A practitioner's investment in continued learning, self-reflection, active allyship, and in emphasizing affirming clinical practices is tantamount to patients' help-seeking behaviors and their experience of care, comfort, and safety.

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References

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3. Clark, J. G. & English, K. M. (2025). Counseling-Infused Audiologic Care (4th ed.). Inkus Press/Amazon.com.
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^[1] Throughout this paper, the acronym 2SLGBTQ+ will be used except when in reference to the specific populations described in cited works. The authors recognize that no acronym can be fully inclusive of the many identities held by people with minoritized sexual and gender experiences. Un-named identities represented by the + following this acronym include, but are not limited to, intersex, asexual, demisexual, and pansexual. The term Two Spirit is used by many First Nations peoples to describe a range of identities and cultural roles that may overlap with or are expansive of other LGBTQ+ categories and is placed at the beginning of the acronym to acknowledge their presence as the first of 2SLGBTQ+ people on Canadian soil. For a thorough list of terms and definitions, see https://egale.ca/awareness/terms-and-definitions/.

^[2] International data reviews suggest that most population estimates underreport 2SLGBTQ+ people due to several factors related to inconsistent data collection methods, differing definitions determining who is counted as 2SLGBTQ+, and probable underreporting due to continued stigma (Gates, 2011; Stokl, 2024).