Ask Chris Tollefsen: An Ethics Advice Column

Editor’s note: The reader’s question has been edited for clarity. 

A reader writes:

I’m wondering if it is ever permissible to use the “new” or chosen name and pronouns of a person suffering from gender dysphoria (that are not in accord with their biological sex) despite this action’s implicitly affirming this incongruence of their thoughts with human anthropology and biological truth? 

The specific situation that comes to mind is if a patient presents to the hospital in a mental health crisis (a suicide attempt) and [hospital staff’s] refusal to use [his preferred] names or pronouns would be counter-therapeutic, diminish patient–physician trust/rapport, and exacerbate the mental suffering of a person in need of acute psychiatric care. 

The difficulty faced here is likely to be met in a variety of other circumstances than in the specific case envisaged by the questioner, such as the workplace, in classrooms, and in other ordinary face-to-face encounters. So I’ll first speak to the broader question of names and pronouns, and then to the more particular situation described in the question.

The Broader Issue

I’ve discussed sex and gender in two previous essays in these pages. I argued that gender identity is a kind of “persona” that a person constructs and adopts as a way of communicating something true or false about him or herself. I also argued that what is communicated are truths or falsities “about one’s sex, and one’s embrace or rejection of the orientation towards the one form of the marital good (husband or wife), and one form of parenting (father or mother), that one’s sex makes possible.” Such communication is necessary because of the considerable importance of the good of marriage and family for personal and social well-being.

Some people adopt gender personae that are at obvious odds with their biological sex, identifying and presenting themselves as women when they are biologically male or vice versa. Unsurprisingly, those who do so often change their given names and ask that pronouns (she/her/hers, he/him/his) matching their gender identity, but not their sex, be used. But, again unsurprisingly, many people believe that using such pronouns in a way that is incongruent with the person’s biological sex is a form of dishonesty, or in some way puts them at odds with recognizable reality.

I think that people feel a greater aversion to using the wrong pronouns than they do to using a newly chosen name. This makes some sense. People change their names for a wide variety of reasons. And when others acquiesce in using those preferred names, generally, it is an acknowledgment of a preference, not a commitment to the wisdom and logic behind the choice. No obvious form of falsity exists when one person uses the preferred name of another.

Thus calling someone by their newly chosen name seems a reasonable way of showing them respect and fostering personal communion with them, even in spite of other differences one might have with them. It does not threaten the speaker’s integrity, as lies and other forms of dishonesty do.

The case seems different to many people where personal pronouns such as “he” and “she” are concerned. These are typically used, and understood, to identify the sex of the person referred to. “He went that way,” for example, is used, and is understood to, tell someone something different than “She went that way,” and the difference primarily seems to concern the sex of the person spoken of.

One might argue instead that personal pronouns such as “he” and “she” are primarily used to identify something about a person’s gender, not their sex, and hence are malleable in relation to the gender identification of the person in question; when the person identifies as male, we use “he/him” and when female, “she/her.” 

I doubt this is true about pronoun use. Newborns do not have genders (for they have not yet constructed a persona), but they are sexed, and it is clear what we mean when we use “he” or “she” of a newborn. Similarly, with our use of “he and “she” for other mammals, none have gender, and we know what we mean by using pronouns to refer to Rex, our dog (“he”) or Clarissa, our cat (“she”).

And the idea that at a certain point in a person’s life, there is a switch, and that personal pronouns no longer identify a person’s biological sex, but now only their self-identified gender, seems very implausible.  So when I say “He went that way,” knowing that it was a female who went that way, I am plausibly thought by others to be saying something untrue, and I might myself be concerned that my using “he” is a failure to speak in a way that adequately expresses what I think is true about the world.

And so many people, again very plausibly, think, from their own first personal deliberative perspective, that it would be wrong for them to use personal pronouns in a way that does not match the known sex of the person of whom they speak. And if that is what they think, i.e., if that is what they judge in conscience, then they should not use pronouns in that way.

Across the variety of situations in which a person identifying as “trans” makes a request for personal pronouns that is at odds with their known sex, then, those who think in the way I have just sketched should not acquiesce and should not be compelled, contrary to their conscientious judgments, to use such pronouns.

But this does not mean that they must or ought to use the correct pronouns when a trans person makes such a request. One is always under an obligation not to lie, and if one thinks using the wrong pronouns is a lie, or in some other way dishonest, one should not do that. But one is only rarely (if ever) obliged to say all that one thinks, and a desire not to offend, or to create unnecessary obstacles to personal communion, or even simply to maintain a peaceful workplace, often reasonably leads us to say much less than we think is the whole truth.

So, I should not tell my wife that I like her dress if I do not, but it would often (very often!) be reasonable not to say anything about the dress at all if I do not care for it. And, in a world in which we will quite frequently disagree morally about many important things with those with whom we work, those we teach, and even with our close friends, we are not obligated to air each of those disagreements, particularly when doing so would create or foster animosity to no good effect.

So refusing to use false pronouns does not require that we use correct ones if there is reason not to, and if there is an alternative way to communicate clearly. And I believe that in almost all circumstances there is such an alternative: one might use no pronouns, instead using or reusing a person’s name or other indicator when necessary in order to make one’s reference perspicuous.

Is this awkward and occasionally obvious as an attempt to avoid using the wrong pronouns? In some cases, it will be. And perhaps one will then be challenged, as one’s interlocutor demands that one use their preferred pronouns. It seems to me that is probably the time at which one will need to be more forthcoming about what one thinks.

Under such circumstances, one might say something along these lines:

I hope you know that I respect you as a person, and do not wish to offend you needlessly. At the same time, it is important to me that I speak honestly with everyone I talk to. And for me to use pronouns that are discordant with known biological reality is for me to speak falsely, which I am unwilling to do. I hope you will accept as a necessary compromise that I will not use pronouns that offend you, while you will not require me to say what I think is false.

For those who have pushed you to give an account of your language use, this will probably not be received well, but I think it is both honest and would show your goodwill. You would not be responsible, in my view, for any alienation or bad feeling that might emerge from such a conversation, and your honesty might prove to be a good witness to the truth.

An important question, then, is this: do things change in any morally relevant way when we move from the workplace to the classroom, a clinical context, or a casual face-to-face encounter? What about, as the question describes, a circumstance in which a patient presents in a serious mental health crisis?

The Specific (Medical) Context

There is indeed a morally relevant change in that a person presenting in the ER after a suicide attempt has an especially significant need for human support, friendship, and love. For the reasons I identified earlier, I think such a person should be addressed by the name that he or she prefers. And using biologically correct pronouns in this situation seems potentially alienating and counterproductive. It should certainly not be an attendant’s top concern, which rather is to help manage the patient’s crisis and discover what contributing factors need to be addressed.

But I question whether not using preferred pronouns, as opposed to using biologically correct pronouns, would indeed “be counter-therapeutic, diminish patient–physician trust/rapport, and exacerbate the mental suffering of a person in need of acute psychiatric care.” For it does not seem to me that validating the false belief of a person in a mental health crisis can truly be supportive, respectful, or genuinely therapeutic (this seems especially true if the patient is a minor).

Indeed, a person in such a crisis seems like he or she has a deep need for truthful communication. Once more, not every truth needs to be communicated. But the important truths that they are loved, that their life is of value, and that they have much to live for, can only be convincingly imparted by one whose trustworthiness is manifested by his or her unwillingness to speak falsely. The beginning of a clinical relationship seems to me precisely the wrong time to lead by saying what one thinks is false.

So my general advice seems sound in this particular situation as well: seek both to speak truly and also not to offend in ways that are contrary to the possibility of personal communion.

This response to the questioner brings to mind another submitted question, which was perhaps intended to be somewhat critical of my approach in previous columns:

The enemy is looking for nice, polite people, is he not? Are we not commanded to “fight the good fight of faith?” (1 Timothy 6:12). And, are we not to “occupy until Christ comes?” (Luke 19:13). Where righteousness meets evil, is righteousness just to play the [likable] guy and roll over?

I wonder whether the questioner has gotten the full sense of these passages. For example, the immediately preceding verse urges Timothy to “pursue righteousness, godliness, faith, love, endurance and gentleness.” So it is not clear that Timothy is being urged to be bellicose in his manifestation of faith. And “occupy” in Luke requires a form of stewardship that brings more out of less, not a typical outcome of fighting.

One could also quote other Biblical passages whose sense goes contrary to this question: 

You have heard that it was said, “Eye for eye, and tooth for tooth.” But I tell you, do not resist an evil person. If anyone slaps you on the right cheek, turn to them the other cheek also. And if anyone wants to sue you and take your shirt, hand over your coat as well. (Matthew 5:38–40)

Christ’s words in Matthew (and even, I think, in Luke) are best understood as a demand of Christian mercy, which always seeks to bring good out of evil. Sometimes evil requires that one fight; I will fight for the safety of my family, for example, against marauders when necessary. But the Christian must always be ready to meet evil with good, as Christ himself did. One might see his carrying of the very cross on which he was to die for our sake as his “rolling over.” But that is because his ways are not those of the world. I am sure I do not well understand Christian mercy, much less live up to its demands; but I am equally sure those demands must not be neglected even in the face of a hostile world.

Submit your own ethical questions to Chris or read his previously published ethics advice columns here, here, and here.

Image by Feng Yu and licensed via Adobe Stock.