Search Results

This Position Paper provides the evidence-base for speech and language therapists / speech-language pathologists and wider society that the use of preferred pronouns is ableist. It refers to UK and U.S. practice, regulation and law but the clinical evidence-base can be generalised globally. Key words: Preferred pronouns, ableism, disability, discrimination, communication, speech and language therapy, speech-language pathology, sex,  gender We are a Speech-Language Pathologist from the U.S. and a Speech and Language Therapist from the UK. We wrote this paper to: i) request that colleagues always consider the rights, abilities and disabilities of our clients when there is an expectation for preferred pronouns to be used in any context ii) provide evidence-based information for why this matters and so that others may use it when writing policies, making complaints, providing advice, developing Education, Health and Care Plans (EHCPs) and Personal Learning Plans (PLPs) / Individual Education Plans (IEPs) and ensuring Mental Capacity Assessments (MCAs) are correctly carried out and so on We remain anonymous here. We are registered with our respective regulatory bodies. Iyengar 2019 Use of preferred pronouns are ableist against the rights and interests of children and adults with communication, cognitive, sensory, or mental health disabilities and challenges SLP, SLT US, UK download as pdf Correspondence: info@ourrighttospeak.com How to cite this paper: SLP, SLT (anon). 2023. Use of preferred pronouns are ableist against the rights and interests of children and adults with communication, cognitive, sensory, or mental health disabilities and challenges. [Online] Accessed: dd/mm/yy Available from: https://www.ourrighttospeak.com/ Abstract This Position Paper provides the evidence-base for speech and language therapists / speech-language pathologists and wider society that the use of preferred pronouns is ableist. It refers to UK and U.S. practice, regulation and law but the clinical evidence-base can be generalised globally. The promotion and use of preferred pronouns in the clinical environment is counter to establishing an effective and safe therapeutic relationship and is not a functional approach to communication therapy. The uncritical use of preferred pronouns directly and indirectly discriminates against people with communication, cognitive, sensory or mental health (CCSM) disabilities, whose disability involves the processing of regular pronouns. It also affects people who speak another language who may additionally experience a specific communication impairment or are limited in their activity and participation in life as a result of confusing language reducing access to healthcare, education and so on. By extension, people with CCSM disabilities and those who speak another language are also at a disadvantage understanding ‘gender-neutral’ language and ideological terminology. Organisations who promote and use preferred pronouns (and ‘gender neutral’ language) may be open to litigation for discriminatory practice against children and adults with communication disabilities. Any attempts to remediate this, other than to cease the practice as the default, is likely to require multiple staff members, resources, time and money. We recommend that speech and language therapists / speech-language pathologists consider the evidence presented so that they are better informed about the impact of PPrs and can thereby come to a more informed decision on their use. We also recommend this on a society-wide level. Key words: Preferred pronouns, ableism, disability, discrimination, communication, speech and language therapy, speech-language pathology, sex, gender Introduction The promotion of ‘preferred pronouns’ (PPrs) within healthcare in the United States and the United Kingdom has intensified over the past few years (Iyengar, 2019; Willo, 2021). In this paper, we set out why the use of PPrs by those who identify as other than their sex and their ‘allies’, is fundamentally ableist to those with communication, cognitive, sensory, or mental health (CCSM) disabilities or challenges. We are a speech and language therapist from the UK and speech-language pathologist from the US. We entreat our colleagues within the speech and language therapy / pathology profession and beyond to consider the evidence below so that they are better informed about the impact of PPrs and can thereby come to a more informed decision on their use in therapy, social media biographies, email signatures, and so on. We will refer to “regular pronouns” throughout this paper. This is our term for pronouns, that have linguistically evolved over time across all languages and are used spontaneously and without effort by people without CCSM disabilities or challenges. This is the obverse of PPrs, which reflect an ideological belief in gender and are imposed or compelled language and are difficult to use spontaneously by people with and without CCSM disabilities or challenges. Here we provide an explanation of regular pronoun use in English with a few other language examples, and how this is affected in disordered communication. We demonstrate how the claim that PPrs usage is benign and kind is in fact discriminatory, non-functional, ineffective and punishing to those with a CCSM disability or challenge. Regular Pronoun Use English-speaking children develop the use of the third person pronouns ‘he’ and ‘she’ at 31 to 34 months, possessive pronouns ‘his’ and ‘hers’ at between 35 to 40 months and reflexive third person pronouns at 47+ months (Vollmer, E., 2020). Adults with acquired communication disorders can experience difficulties understanding, processing and expressing pronouns (Arslan et al., 2021). People for whom English is learned later in life are also at a significant disadvantage (Towell and Hawkins, 1994). As Sera et al. (2002) points out, English codes natural gender [sex] primarily through lexical items (e.g., girl-boy, sister-brother) and through some pronouns (e.g. she–he, her-him, hers-his, herself-himself). English does not assign a gender to all nouns that refer to animates (e.g. doctor) or to nouns that refer to inanimates (e.g. apple), which occurs in other languages such as Spanish, French, German and Greek. In short, pronouns for living things in English are sexed, not gendered. Languages include different pronoun variables. This is detailed in Arslan et al. (2021) including English and other languages: The following sections do not list every CCSM disorder arising from multiple developmental and acquired conditions. These are highly numerous and various. However, all conditions are summarised as disorders of; • Speech sounds (articulation and phonology) • Language (how well we understand or use words, spoken and written) • Social communication (pragmatics) • Voice • Fluency (stammering or stuttering) • Cognitive communication (how well the mind works) (ASHA, 2022) Claim 1 Children Shotwell and Sheng (2021) assert that it is ethical for speech language pathologists to target what they call ‘gender-neutral pronouns’ in language treatment if such pronouns were found to be a functional communication target for the individual receiving services. This could perhaps be the case if it were found to be functional. There is no evidence for this. They provide no concrete definition for the term ‘gender-neutral pronouns’, only that it includes “those personal pronouns that fall outside of a binary system (i.e., he/him/his and she/her/hers) ” or neopronouns such as xe/xem/xyr (p1141), which in effect could mean any made up word, even those that do not follow the phonotactic rules of English. They admit that, “determining the amount of change that can take place in typically developing children and how many exposures to the pronouns are required for change to take place ” (p1144) is yet to be discovered. To date, there is no evidence that so-called gender-neutral pronouns are being used functionally consistently by children or adults in English or any language. They do not take into account that the use of PPrs is not a natural language change over time but rather an authoritarian imposed ideological tool (Kerr, 2019) and that it is used by conversation partners at the behest of individuals who do not wish others to use sexed pronouns about them. Nounself or neo-pronouns have not proved sustainable in everyday English usage and carry more than sexed identification of an animate being but also “reflect aspects of their referents’ identities through connotations” (Miltersen, 2016, p50) [our emphasis]. This requires extra cognitive processing than the learned use of English third person sexed pronouns. Shotwell and Sheng note that pronouns are used in place of a noun. However, they do not take into account that the imposed nature of PPrs is such that they add to the cognitive processing demand, which in turn become neurologically akin to nouns or names and lose all of the neurological advantages of sexed pronouns (Weir, 2021). This contrasts with the assertion that PPrs could be a functional communication target. Communication disorders in children - some examples The following (non-exhaustive) list of disorders and their characteristics affect the developing brain’s ability to process regular pronouns: 1. Any condition which affects attention or working memory , including Attention Deficit/Hyperactivity Disorder, concussion, seizure disorders, diabetes (low blood sugar will reduce attention span temporarily) will make it more difficult for an individual to self-monitor and edit pronouns in an anti-grammatical fashion, in order to accommodate arbitrary and ever-changing preferences of an unlimited number of peers in a school or other setting of compulsory attendance. This has been linked in research to theory of mind deficits, perspective-taking deficits, and inhibition, all of which are implicated in ASD, AD/HD, and post-concussion syndrome, and other neurodevelopmental disorders (Kuijper et al., 2021). 2. Conditions that impact social judgment , which may include autism, will impact an individual’s ability to anticipate the consequences for not participating in another person’s role-playing as the opposite sex or as a “nonbinary”, “gender identity,” and so such individuals will be less likely to comprehend the significance of these linguistic performances socially. This is due to perspective-taking and theory of mind deficits (Finnegan et al., 2021; Kuijper et al., 2021). 3. Conditions which impact language function directly are characterized and diagnosed based on their impact on function words, including pronouns, in the native language or languages. A child with a developmental language delay, a fluency disorder such as cluttering, or an acquired loss of language such as from a seizure disorder (Landau-Kleffner Syndrome) will be less capable neurologically of using pronouns correctly in accordance with observable sex. (Alm, 2011; Alpern, 2010; Perovic et al., 2013). Asking them to then memorize “identities” that have no physical, observable correlation will be more difficult to impossible for them due to the nature of their disability. 4. Conditions which restrict articulation and the movement of the tongue , such as dysarthria and ankyloglossia (“tongue-tie”), may make “she” and “they” anatomically far more difficult to say than “he” (Bommangoudar et al., 2020). It may not be physically possible for a child to call a male “she.” Claim 2 Adults Pert (2021) asserts that speech and language therapists must be visible allies to “signal that you have sought information and training and will challenge discrimination in the workplace, whether an LGBTQ+ person is present or not ” (p21) [our emphasis]. Davies (2022) reports that, “At times I may be in full SLT mode, but always from the perspective of my lived queer experience ” (p20) [our emphasis] and that each SLT should bring their whole self to work. Use of PPrs in social media biographies and email signatures of speech and language therapists is increasingly common as is the expectation to use this convention throughout one’s work in both verbal and written form including in the NHS (Phillips, 2020). Communication disorders in adults - some examples The following (non-exhaustive) list of disorders and their characteristics affect the brain’s ability to process regular pronouns. 1. Aphasia including agrammatism Difficulties in pronoun processing in aphasia (Arslan et al., 2021) include: ▪ Slower-than-normal syntax ▪ Resource reduction ▪ Delayed lexical integration ▪ Increased interference ▪ Structural interveners ▪ Discourse-linking impairment ▪ Grammatical vs lexical The individual with aphasia may not understand or be able to express regular pronouns effectively. In some cases, they may also make semantic errors, confusing the words ‘man’ with ‘woman’ and ‘boy’ with ‘girl’, which could result in the use of a pronoun grammatically matched to the sex of the referent but that the incorrect sex of the referent was understood or expressed in the first instance. In addition, it becomes ever more difficult to process words regarding an absent referent than a present one. There is a significant heterogeneity of pronoun processing in the context of aphasia (Martinez-Ferreiro et al., 2019). 2. Alzheimers Disease Dementia Difficulties in regular pronoun processing in Alzheimer’s Disease (AD) (Almor et al., 1999) include: ▪ Impaired comprehension (especially compared to noun phrases) ▪ Abnormally frequent use of pronouns ▪ Working memory impairment; the representation of referents in working memory is degraded, leading to the loss of some distinguishing semantic features and thus affecting pronoun use It has long been advocated that conversation partners avoid words such as ‘‘this,’’ ‘‘these,’’ ‘‘he,’’ and ‘‘she” in favour of “concrete, specific and simple words” when caring for and treating people with AD (Rau, 1993, p. 77). This is aided by talking about referents present in the shared environment. 3. Learning Disability Difficulties in regular pronoun processing for people with learning disability: ▪ Subject bias (order-of-mention-bias) required for effective regular pronoun processing is weaker in individuals with a learning disability than the robust bias seen in typical adult language processing. Subject bias displayed by the participants with a learning disability was consistent with that previously reported for 5-year-old children of typical development according to Hawthorne and Loveall (2021). ▪ Deficit in the referential use of pronouns in narrative secondary to pragmatics inferences processing difficulties in individuals with high-functioning autism or Asperger Syndrome (Colle et al., 2008) It is not unusual for people with learning disability to consistently misunderstand or (over)use the incorrect pronouns, especially as language becomes more complex or social-pragmatic situations are more difficult to comprehend and thus fully apprehend. 4. Schizophrenia Difficulties in regular pronoun processing for people with schizophrenia (Kuperberg et al. 2018, Chaves et al. 2020): ▪ Ambiguous use of pronouns, no clear referent ▪ Overall increase in the use of pronouns ▪ Struggle with linking anaphors ▪ Proactive mechanisms of establishing referential cohesion are impaired Schizophrenic speech has a reduced semantic-pragmatic load, with a general difficulty in using pronouns within a contextually framed discourse. Sensory impairment - hearing loss The capacity to hear which pronoun was used is a physical capacity. There is difficulty in (pronoun) auditory processing for people with hearing loss (Briscoe et al., 2001; Lesicko and Llano, 2017). In English, all third person pronouns all require the initial production of a fricative. A fricative sound is one in which the air continues to move (i.e., they are continuants) and is also produced with an increased rate of air flow resulting in audible airstream turbulence, which is perceived as a band of white noise (Neel, 2010). The distinction, then, between “he,” “she,” and “they,” is found in which pitch this turbulent airflow is banded. “She” is acoustically distinguished from “he” due to the pitch of this turbulent airflow, with “she” being wider-band than “he.” “Th” in “they” is lower pitched, due to being a voiced sound. Jongman et al. (2000) in their research on the acoustic properties of English fricatives also found a difference in the values of the four spectral moments they analysed as a function of voicing and the speaker’s sex. Further, Fox and Nissen (2005) report significant sex-specific differences in fricative articulation (of /f/, /θ/, /th/, /ʃ/ ) were found in all groups of speakers they researched. An individual with a particular hearing loss pattern, which could be age-related, will likely hear a production of “she” as “he,” even if it was produced accurately as “she.” Without an audio recording and evaluation from a qualified linguist, an employer with hearing loss could create job consequences for an individual accused of creating a hostile environment, simply because the accuser is not aware of their own hearing loss. A person cannot hear what they cannot hear and high-frequency hearing loss may not be noticed immediately. It is also more difficult to hear fricatives spoken by medical mask wearers (Nguyen, 2022). In addition, those experiencing hearing loss may make articulatory errors and be unaware including for children who may not master the sibilants /s/ and /ʃ/ (“sh” as in “she”) until preadolescence (Reidy et al, 2017). In this spectrogram, “he” is on the left, and “she” is on the right. The differences are extremely subtle. Figure 1 Spectrogram still of “he” (Left) and “she” (Right) – female voice. Recorded on: https://musiclab.chromeexperiments.com/spectrogram/ Figure 2. Audiogram of Familiar Sounds. Note how close “h” and “sh” are. From: https://www.texasdeafed.org/cms/lib/TX50000592/Centricity/Domain/198/Audiogram_What_Does_Child_Hear.pdf Augmentative and Alternative Communication Many children and adults with communication disability use augmentative and alternative communication (AAC). This can come in forms of no-tech, low-tech and high-tech (Communication Matters, 2022) from gestures to alphabet charts, picture cards, communication books to complex electronic devices using eye gaze or head switches or similar. Binger and Light (2009) report that many AAC users experience difficulties with receptive and expressive grammar. They found that individuals tend to use brief, grammatically incomplete messages to communicate; this may arise from their communication disability and/or a means to speed up a laborious process. Intrinsic factors that affect mastery of grammar by AAC users may include: • developmental/cognitive level • literacy level • motor capabilities • speech intelligibility • and/or presence of a receptive and/or expressive language disorder Extrinsic factors may involve: • single word or non-grammatical phrases to speed up the process • grammatical markers missing from the device • graphic symbols indicating multiple concepts • input-output asymmetry (complete language by conversation partner, reduced by AAC user) Different ways of accessing AAC require differing levels of cognitive load (Waller, 2019). The speech and language therapist works with the patient or child to optimise AAC use and language (re)learning. To add further cognitive loading in the form of replacing regular pronouns with PPRs/neopronouns, or making frequent changes to PPrs when an individual is also learning and optimising access to AAC, is non-functional and counter to achieving therapy goals and improving outcomes. It will also require extra effort, time and resources to update systems to reflect an increasing number of PPr options, many of which lack an adequate, effective symbol. Bilingual Children and Adults It is predictable that individuals from various language backgrounds will have difficulty adapting to the English paradigm, especially if there is no visual referent. In no language do individual entities self-select into the pronoun gender of their choice. In the U.K., 1.3% of the population of England and Wales (726,000 people) speak English but not well, and 0.3% of the population (138,000 people) report that they cannot speak English at all (Office for National Statistics, 2018). The population 5 years and older who speak a language other than English at home in the U.S. account for 21.5% of the population and those who speak English “less than very well” are 8.2%. People who speak Spanish at home in the U.S. make up 13.2% of the population (United States Census Bureau, 2019). Different languages have different pronoun and agreement rules. In Spanish, for instance, both nouns and adjectives are gendered as either masculine or feminine, and pronouns must be in agreement. Therefore, native Spanish speakers are more likely to make errors on production of pronouns in English. “Spanish speakers produced significantly more gender errors than any other type of pronoun error.” (Anton-Mendez, 2010). There is further evidence that discordant gender-noun combinations prime an individual to require additional time to identify the target words. This demonstrates the increased demand on attention that is required in order to self-edit speech in order to overrule grammatical class assignments that are happening on an automatic and subconscious level (Alcock and Ngorosho, 2004). In other languages, such as Turkish, there is no differentiation between males and females in pronouns, and instead has a tripartite distribution of “o,” which is gender-neutral he/she/it, kendi, and kendisi, which both refer to the body, and therefore function similar to the English himself/herself/itself. A speaker of Turkish will predictably make pronoun errors when speaking English, and it is a violation of a Turkish person’s civil rights to punish them for the fact that they were not raised within a linguistic context that attended to that semantic quality in its pronominal system. Chinese speakers who are learning English also show a differential difficulty in processing the use of “they” as a gender-neutral singular form, meaning that policies that require this sort of processing will discriminate against students and employees who speak a dialect of Chinese as a native language, which is a proxy for national origin and race (Ma et al., 2022). It is predictable that individuals from various language backgrounds will have difficulty adapting to the English paradigm, especially if there is no visual referent. Bilinguality and communication disability are often co-occurring (Kohnert et al., 2020) and so these effects will be amplified in a child who has a developmental disability and multiple language exposures. Children with ASD who speak Italian were found to make increased errors on pronoun production than their non-ASD counterparts, as Mazzaggio and Shield, 2020 report, “We found that Italian children with ASD were less accurate than typically-developing (TD) Italian children in the production of first-, second-, and third-person singular pronouns, avoiding pronouns in favor of nouns or names more often than controls. Moreover, children with ASD produced more overt pronouns than null pronouns in marked contexts, compared to TD children ” (p1425). Pragmatics is the area of language which encompasses social language and communication, including theory of mind and perspective-taking. Italian children with specific language impairment were also found to have difficulty including a gender-specifying pronoun. When they did include it, they tended to include the one they had heard most recently rather than the one that was grammatically appropriate for the sentence (Leonard and Dispaldro, 2013). Law and Regulation United Kingdom HCPC In the United Kingdom, speech and language therapists are regulated by the Health and Care Professions Council (HCPC). The relevant standards that speech and language therapists must follow are detailed in “Standards of proficiency - Speech and language therapists” (2023) – see Appendix 1. As outlined above in the CCSM disorders’ presentation in the processing difficulties of regular pronouns, it places an extra cognitive burden on the individual with such disability to understand and use PPrs. This is directly counter to the therapeutic aims of speech and language therapy. It is enforcement, not therapy. To engage in the use of PPrs with children and adults who experience difficulties processing regular pronouns is therefore not evidence-based, is ineffective, unfair and unethical. It may also be unlawful. The Equality Act 2010 UK based colleagues must also follow The Equality Act (2010). Not only is Sex a protected characteristic, but also Disability. If a person has a disability, they are being discriminated against if the adult or child is treated less well or put at a disadvantage for a reason that relates to his or her disability in one of the situations covered by the Equality Act. As the Equality and Human Rights Commission (2020) make clear, this could include, “the application of a rule or policy or the existence of physical or communication barriers which make accessing something difficult or impossible. The discrimination does not have to be intentional to be unlawful .” Any changes made within the public sector that could affect people with disability requires an equality impact assessment (Pyper, 2020). If the continued use of PPrs with people with a CCSM disability were deemed appropriate, then significant (and likely expensive) remediation processes would be required. For example, every person with a communication disability would require an assessment and ongoing frequent reviews by an expert clinician such as a speech and language therapist to advise on whether or not they would be able to engage in the use of PPrs. This would unfairly single out people with disabilities, who may not otherwise be singled out as requiring them to use PPrs is the opposite of making reasonable accommodations. Every individual who comes into contact with them would need to appraise if they can use PPrs or not. How would this be highlighted? With a badge or sign on the person’s body? Is a child who cannot use them in school going to be punished? CCSM disability can be invisible to others. Some people with communication disorders return to work following months if not years of intensive therapy. If they ‘misgender’ someone because a member of the public does not know they retain some elements of agrammatic aphasia affecting pronoun use, are they to face dismissal? The Mental Capacity Act 2005 The Mental Capacity Act (2005) also covers the UK. As stated in the Mental Capacity Act Code of Practice (Department of Constitutional Affairs, 2007), “The Act also states that people must be given all appropriate help and support to enable them to make their own decisions or to maximise their participation in any decision-making process.” (1.2, p15) and that the second of the five Statutory Principles states, “A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success.” (p19) [our emphases]. Specifically Principle 2 is detailed in the Code of Practice – see Appendix 2. To assert that individuals with CCSM disability must understand and use PPrs during a Mental Capacity Assessment could be deemed unlawful as well as unethical and poor practice. Anti-discrimination Acts and bilingualism Whilst there are no specific laws in the UK with regard to English as an additional language, children and adults who lack proficiency in English are supported against discrimination via the Equality Act (2010) including the Public Sector Equality Duty of 2011 (Government Equalities Office, 2011), Health and Social Care Act (2012) in health, and in education by legislation giving rise to inspectorates such OFSTED in England, Education and Training Inspectorate in Northern Ireland, Education Scotland and Estyn in Wales (The Education Company, 2022). United States ASHA Code of Ethics The ASHA Code of Ethics (ASHA, 2016a) provides constraints on the practice of speech-language pathologists with respect to clients that may be relevant to the use of PPrs in a clinical setting, especially in a mixed setting such as a group therapy session, in which students may be singled out for negative attention for inability to do the very task they are in therapy to gain help with. Under Principle 1, Rule C states, “Individuals shall not discriminate in the delivery of professional services or in the conduct of research and scholarly activities on the basis of race, ethnicity, sex, gender identity/gender expression, sexual orientation, age, religion, national origin, disability, culture, language, or dialect .” (ASHA, 2016b). Therefore, a provider cannot privilege gender identity accommodations over accommodations for other CCSM disabilities or second language backgrounds with alternative pronoun systems. Title VI and Title VII of the Civil Rights Act of 1964 Title VI and Title VII of the Civil Rights Act of 1964 prohibits discrimination in education and employment on the basis of national origin in programs or activities that receive federal funding. This means that people cannot be subject to negative consequences simply due to the fact that they speak a language associated with a race or national origin that does not distinguish between male or female pronouns, or those which distinguish on the basis of sex and not on gender identity. While students who speak a dialect of English associated with a national origin or religious belief structure that states that pronouns ought to be assigned on the basis of some conception of gender identity, the state cannot enforce this linguistic process because many languages, a proxy for national origins, traditionally assign pronouns on the basis of sex. Language and speech patterns are a major proxy for national origin and race, which is why it has been historically used as a basis for unlawful discrimination. Individuals with Disabilities Education Act of 2004 A child’s right to equal protection on the basis of disability is included under the Individuals with Disabilities Education Act of 2004. This act prohibits discrimination on the basis of the child having disabilities, without reasonable and lawful efforts to provide a Free and Appropriate Public Education (FAPE) to a child via the Individual Education Plan and all necessary special education services and accommodations to facilitate FAPE in the least restrictive environment (LRE). A child with an identified disability impacting their linguistic or social judgment capacity to utilize PPrs of peers and adults therefore has a civil right to FAPE regardless of the fact that they are less able to participate in these cultural-spiritual practices and beliefs of faculty and other students, which is the purpose and intended antecedent for the PPrs. Americans with Disabilities Act Amendments Act of 2008 An employee’s right to equal accommodations in the workplace is included under the Americans with Disabilities Act Amendments Act of 2008, which expanded the definition of disability to encompass any person who “has a physical or mental impairment which substantially limits one or more major life activities,” is regarded as having such an impairment, or has a history of such an impairment. Language function is a major bodily function involving multiple bodily systems which are both physical and mental in nature. This includes neurological functions such as attention. Workers with disabilities affecting pronoun use have a civil right to have their job duties modified in a good-faith, reasonable manner, and to have their essential job functions delineated, and not to be subject to disciplinary action purely on the basis of having a disability that affects PPrs. It is not possible to make an exception for an employees’ speech disability regarding these expectations without forcing disclosure of disability to coworkers. Recommendations We recommend that the use of PPrs is neither compelled, mandated nor encouraged in any organisations given its seriously discriminatory nature to individuals with CCSM disability or challenges who are unable to process regular pronouns. This was supported by the then Attorney General, Suella Braverman, in the UK who stated in her speech clarifying Equality law that, “The problem is that many schools and teachers believe – incorrectly - that they are under an absolute legal obligation to treat children who are gender questioning according to their preference, in all ways and all respects, from preferred pronouns to use of facilities and competing in sports. […] In my view, this approach is not supported by the law […] it can be lawful for schools to refuse to use the preferred opposite-sex pronouns of a child […] It is therefore wrong for schools to suggest that they have legal obligations which mean that they must address children by their preferred pronouns […] Further, no child should be made to fear punishment or disadvantage for questioning what they are being taught, or refusing to adopt a preferred pronoun for a gender questioning child ” (Attorney General’s Office, 2022) At the time of writing, the Government’s guidance on how to manage pupils who wish to transition has not yet been published. Without this guidance, some schools (and some speech and language therapists and their employers) may find themselves involved in legal proceedings for discrimination at some point in future. It is notable that there has been a chilling effect on attempts to challenge this issue, for example, in the case of Binns and Arnold (2022), who had their paper on reporters’ language use in court cases unpublished by the University of Central Lancashire* within one day. CCSM disabled people and those who speak English as a second language require the justice system, and clarity of reporting in the justice system, too. Whilst this paper focuses on pronoun use, its fundamental tenet of the use of appropriate language that does not increase cognitive burden (with or without a CCSM disability but especially when considering those with such disabilities) can also be generalised to so-called ‘gender-neutral’ language use (Gribble et al., 2022; Miller, 2017) and other obscurantist language examples such as the addition of the prefix ‘cis-‘ and changes in the semantic meaning of words to achieve a political aim (Robillard, 2021). Therefore, we also recommend that gender-neutral language is avoided and sex-specific words are used to provide clarity and accessibility of information. Summary In summary, there is no evidence to date that the use of PPrs for and around individuals with CCSM disabilities and challenges is indicated in speech and language therapy as a matter of course. Indeed, its inherent requirement of extra cognitive burden for those unable to process regular pronouns reflects its use as ineffective, unethical and possibly unlawful due to its discriminatory nature. It is likely to harm rather than support the therapeutic relationship between the speech and language therapist or speech-language pathologist and their patient/client. There is no evidence of widespread use of equality impact assessments to ensure the use of PPrs does not discriminate. Were an organisation to deem it necessary to implement the use of PPrs, a large scale remediation programme involving communication and disability expert personnel would be required on an ongoing basis. This would entail an increase in staffing, time and resources and likely result in increased costs to the organisation. Based on the evidence presented in this paper, it is our position that English speakers including those with English as an additional language with particular CCSM disabilities or challenges are, more likely than not, unable to comprehend, process or express PPrs consistently and effectively such that the expectation of PPr use is ableist and impairs recovery, function, social integration, and well-being and is fundamentally discriminatory and likely unlawful. ‘Gender neutral’ language poses similar problems. PPrs should not be used or encouraged to be used as the default over regular pronouns in speech and language therapy or in society at large. *Se e: http://clok.uclan.ac.uk/42563/ now only available via archive: https://web.archive.org/web/20220627114351/http://clok.uclan.ac.uk/42563/23/trans%20media%20reports%20FINAL%20with%20title%20page.pdf References Alcock, K.J. Ngorosho, D. 2004. Interaction between phonological and grammatical processing in single word production in Kiswahili. Language and Speech . 47(Pt 1):1-30. https://doi.org/10.1177/00238309040470010101 Alm, P.A. 2013. ‘Cluttering: a neurological perspective’. In: Ward, D and Scott, K.S. (Eds) Cluttering A Handbook of Research, Intervention and Education . East Sussex: Psychology Press, Pt1, 17-43. Almor, A., Kempler, D., MacDonald, M. C., Andersen, E. S., & Tyler, L. K. 1999. Why Do Alzheimer Patients Have Difficulty with Pronouns? Working Memory, Semantics, and Reference in Comprehension and Production in Alzheimer's Disease. Brain and Language , 67(3), 202–227. https://doi.org/10.1006/BRLN.1999.2055 Alpern, C.S. 2010. Identification and Treatment of Landau-Kleffner Syndrome. The ASHA Leader . 15:11. https://doi.org/10.1044/leader.FTR3.15112010.34 Americans With Disabilities Act Amendments Act, 2008. Pub. L. No. 110-325 Anton-Mendez, I. 2010. Gender Bender: gender errors in L2 production. J Psycholinguist Res . Apr.39(2):119-39. https://doi.org/10.1007/s10936-009-9129-z Arslan, S., Devers, C., Ferreiro, S.M., 2021. Pronoun processing in post-stroke aphasia: A meta-analytic review of individual data. Journal of Neurolinguistics. 59, 101005. https://doi.org/10.1016/j.jneuroling.2021.101005 ASHA (American Speech-Language-Hearing Association). 2016a. Code of ethics (Ethics) [Online]. Available at: www.asha.org/policy/ [Accessed 10 September 2022] ASHA (American Speech-Language-Hearing Association). 2016b. Code of ethics (Ethics) [Online]. Available at: https://inte.asha.org/Code-of-Ethics/ [Accessed 10 September 2022] ASHA (Association of Speech-Language-Hearing Association). 2022. Who Are Speech- Language Pathologists, and What Do They Do? [Online]. Available at: https://www.asha.org/public/who-are-speech-language-pathologists/ [Accessed 03 September 2022] Attorney General’s Office. 2022. Speech. Equalities and rights: Conflict and the need for clarity. Attorney General Suella Braverman spoke at Policy Exchange about equalities and human rights. [Online]. Available at: https://www.gov.uk/government/speeches/equalities- and-rights-conflict-and-the-need-for-clarity [Accessed 27 August 2023] Binger, C., Light, J. 2008. The Morphology and Syntax of Individuals who use AAC: Research Review and Implications for Effective Practice. Augmentative and Alternative Communication . 24:2, 123-138, DOI: https://doi.org/10.1080/07434610701830587 Binns, A. Arnold, S. 2022. He or She: Reporting court cases of trans-identified defendants in the UK. Journalism Practice. (Submitted) Bommangoudar, J.S., Chandrashekhar, S., Shetty, S., Sidral, S. 2020. Pedodontist's Role in Managing Speech Impairments Due to Structural Imperfections and Oral Habits: A Literature Review. Int J Clin Pediatr Dent . Jan-Feb;13(1):85-90. https://doi.org/10.5005/jp-journals- 10005-1745 Briscoe, J., Bishop, D., Frazier Norbury, C. 2001. Phonological Processing, Language, and Literacy: A Comparison of Children with Mild-to-moderate Sensorineural Hearing Loss and Those with Specific Language Impairment. The Journal of Child Psychology and Psychiatry and Allied Disciplines , 42(3), 329-340. https://doi.org/10.1111/1469-7610.00726 Chaves, M., Mota, N., Ribeiro, S., Copelli, M., Rodrigues, C. 2020. M190. Use of null pronouns in schizophrenia. Schizophrenia Bulletin , 46 (Suppl 1), S208. https://doi.org/10.1093/schbul/sbaa030.502 Civil Rights Act of 1964; 7/2/1964; Enrolled Acts and Resolutions of Congress, 1789 - 2011; General Records of the United States Government, Record Group 11; National Archives Building, Washington, DC. Colle, L., Baron-Cohen, S., Wheelwright, S., van der Lely, H.K.J., 2008. Narrative Discourse in Adults with High-Functioning Autism or Asperger Syndrome. J Autism Dev Disord. 38, 28–40. https://doi.org/10.1007/s10803-007-0357-5 Communication Matters. 2022. What is AAC? [Online]. Available at: https://www.communicationmatters.org.uk/what-is-aac/ [Accessed 27 August 2023] Davies, J. 2022. Pride in the profession. Focus on Diversity. RCSLT Bulletin. Issue 831, Summer 2022. 20. Department of Constitutional Affairs. 2007. Mental Capacity Act 2005. Code of Practice. [Online]. Available at: https://www.gov.uk/government/publications/mental-capacity-act-code-of-practice [Accessed 27 August 2023] Equality Act 2010. [Online]. Available at: https://www.legislation.gov.uk/ukpga/2005/9/contents [Accessed 27 August 2023] Equality and Human Rights Commission (EHRC). 2020. Disability Discrimination. [Online]. Available at: https://www.equalityhumanrights.com/en/advice-and-guidance/disability- discrimination [Accessed 27 August 2023] Finnegan, E.G., Asaro-Saddler, K., Zajic, M.C. 2021. Production and comprehension of pronouns in individuals with autism: A meta-analysis and systematic review. Autism . Jan;25(1):3-17. https://doi.org/10.1177/1362361320949103 Fox, R.A., Nissen, S.L., 2005. Sex-related acoustic changes in voiceless English fricatives. Journal of Speech, Language, and Hearing Research . Vol. 48, 753–765, August 2005. https://doi.org/10.1044/1092-4388(2005/052) Government Equalities Office. 2011. Equality Act 2010: Public sector equality duty. What do I need to know? A quick start guide for public sector organisations. [Online] Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_ data/file/85041/equality-duty.pdf [Accessed 27 August 2023] Gribble, K.D., Bewley, S., Bartick, M.C., Mathisen, R., Walker, S., Gamble, J., Bergman, N.J., Gupta, A., Hocking, J.J. Dahlen, H.G. 2022. Effective communication about pregnancy, birth, lactation, breastfeeding and newborn care: the importance of sexed language. Frontiers in Global Women's Health . V3. https://doi.org/10.3389/fgwh.2022.818856 Hawthorne, K., Loveall, S.J., 2021. Interpretation of ambiguous pronouns in adults with intellectual disabilities. Journal of Intellectual Disability Research 65, 125–132. https://doi.org/10.1111/jir.12801 Health and Care Professions Council (HCPC) 2023. Standards of Proficiency. Speech and language therapists. [Online]. Available at: https://www.hcpc- uk.org/globalassets/standards/standards-of-proficiency/reviewing/slts---new-standards.pdf [Accessed 27 August 2023] Health and Social Care Act. 2012. [Online] Available at: https://www.legislation.gov.uk/ukpga/2012/7/contents/enacted [Accessed 27 August 2023] Individuals With Disabilities Education Improvement Act of 2004. 2004 Pub. L. No.108–446. Iyengar, R., 2019. Doctors should ask all patients their preferred pronouns. The Hill. [Online]. Available at: https://thehill.com/opinion/healthcare/464233-doctors-should-ask-all- patients-their-preferred-pronouns [Accessed 27 Mar 2022] Jongman, A., Wayland, R., Wong, S. 2000. Acoustic characteristics of English fricatives. The Journal of the Acoustical Society of America. 108. 1252-63. http://dx.doi.org/10.1121/1.1288413 Kerr, B. 2019. Pronouns are Rohypnol. Fair Play for Women. [Online blog]. Available at: https://fairplayforwomen.com/pronouns/ [Accessed 27 August 2023] Kohnert, K., Ebert, K.D. , Pham, G.T., 2020. Language disorders in bilingual children and adults. 3rd Ed. San Diego, Plural Publishing. Kuijper, S.J.M., Hartman, C.A., Hendriks, P. 2021. Children's Pronoun Interpretation Problems Are Related to Theory of Mind and Inhibition, But Not Working Memory. Front Psychol. Jun 4;12:610401. https://doi.org/10.3389/fpsyg.2021.610401 Kuperberg, G.R., Ditman, T., Choi Perrachione, A., 2018. When Proactivity Fails: An Electrophysiological Study of Establishing Reference in Schizophrenia. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging 3, 77–87. https://doi.org/10.1016/j.bpsc.2017.09.007 Leonard, L.B., Dispaldro, M. 2013. The effects of production demands on grammatical weaknesses in specific language impairment: the case of clitic pronouns in Italian. J Speech Lang Hear Res. Aug;56(4):1272-86. https://doi.org/10.1044%2F1092-4388(2012%2F12-0295) Lesicko, A.M.H., Llano, D.A. 2017. Impact of peripheral hearing loss on top-down auditory processing. Hearing Research, 343, 4-13.https://doi.org/10.1016/j.heares.2016.05.018 Ma, Z, Wu,S., Xu,S. 2021. Acceptance and Online Interpretation of "Gender-Neutral Pronouns": Performance Asymmetry by Chinese English as a Foreign Language Learners. Front Psychol. Mar 2;12. https://doi.org/10.3389/fpsyg.2021.765777 Martínez-Ferreiro, S., Ishkhanyan, B., Rosell-Clarí, V., Boye, K. 2019. Prepositions and pronouns in connected discourse of individuals with aphasia. Clinical Linguistics & Phonetics. 33:6, 497-517, https://doi.org/10.1080/02699206.2018.1551935 Mazzaggio, G., Shield, A. 2020. The Production of Pronouns and Verb Inflections by Italian Children with ASD: A New Dataset in a Null Subject Language. J Autism Dev Disord .Apr;50(4):1425-1433. https://doi.org/10.1007/s10803-019-04349-7 Mental Capacity Act. 2005. [Online] Available at: https://www.legislation.gov.uk/ukpga/2005/9/contents [Accessed 27 August 2023] Miller, Geoffrey, 2017. The Neurodiversity Case for Free Speech. [Online]. Available at: https://quillette.com/2017/07/18/neurodiversity-case-free-speech/ [Accessed 18 July 2022] Miltersen, E. H. 2016. Nounself pronouns: 3rd person personal pronouns as identity expression. Journal of Language Works - Sprogvidenskabeligt Studentertidsskrift, 1(1), 37–62. https://tidsskrift.dk/lwo/article/view/23431 Neel, A. 2010. Using Acoustic Phonetics in Clinical Practice. Perspectives on Speech Science and Orofacial Disorders . 20. 14-24. http://dx.doi.org/10.1044/ssod20.1.14 Nguyen, D.D., Chacon, A., Payten, C., Black, R., Sheth, M., McCabe, P. et al. 2022. Acoustic characteristics of fricatives, amplitude of formants and clarity of speech produced without and with a medical mask. International Journal of Language & Communication Disorders, 57: 366– 380. https://doi.org/10.1111/1460-6984.12705 Office for National Statistics. 2018. English Language Skills. [Online]. Available at: https://www.ethnicity-facts-figures.service.gov.uk/uk-population-by- ethnicity/demographics/english-language-skills/latest [Accessed 18 July 2022] Perovic, A., Modyanova, N., Wexler, K., 2013. Comprehension of reflexive and personal pronouns in children with autism: A syntactic or pragmatic deficit?. Applied Psycholinguistics , 34(4), pp.813-835 https://doi.org/10.1017/S0142716412000033 Pert, S. 2021. Hold my hand. Focus on Diversity. RCSLT Bulletin. Issue 827, Summer 2021. 20-21. Phillips, E., 2020. NHS England - Wearing our pronouns with pride: small words, big impact [Online]. Available from: https://www.england.nhs.uk/blog/wearing-our-pronouns-with- pride-small-words-big-impact/ [Accessed 05 Feb 2022] Pyper, D. 2020. The Public Sector Equality Duty and Equality Impact Assessments. Briefing Paper. Number 06591. [Online]. Available at: https://researchbriefings.files.parliament.uk/documents/SN06591/SN06591.pdf [Accessed 18 July 2022] Rau, M. T. 1993. Coping with communication challenges in Alzheimer’s disease . San Diego, CA: Singular. Reidy, P.F, Kristensen, K., Winn, M.B., Litovsky, R.Y., Edwards, J.R. 2017. The Acoustics of Word-Initial Fricatives and Their Effect on Word-Level Intelligibility in Children With Bilateral Cochlear Implants. Ear Hear . Jan/Feb;38(1):42-56. https://doi.org/10.1097/AUD.0000000000000349 Robillard, M. 2021. The Incoherence of Gender Ideology. Quillette.[Online]. Available from: https://quillette.com/2021/08/04/the-incoherence-of-gender-ideology/ [Accessed 02 June 2022] Sera, M.D, Elieff, C., Forbes, J., Burch, M.C., Rodríguez, W., Dubois, D.P. 2002. When language affects cognition and when it does not: an analysis of grammatical gender and classification. J Exp Psychol Gen . Sep;131(3):377-97. https://content.apa.org/doi/10.1037/0096-3445.131.3.377 Shotwell, S., Sheng, L., 2021. Making a Case for Studying Gender-Neutral Pronouns in Speech-Language Pathology. LSHSS 52, 1141–1145. https://doi.org/10.1044/2021_LSHSS- 21-00021 The Education Company. 2022. Inspections. [Online] Available at: https://www.educationcompany.co.uk/knowledge-bank/uk-education-data/inspections/ [Accessed 27 August 2023] Towell, R., Hawkins, R., 1994. Approaches to second language acquisition. Multilingual Matters, Clevedon, Avon, England; Philadelphia. United States Census Bureau. 2019. Why We Ask Questions About... Language Spoken at Home . [Online]. Available at: https://www.census.gov/acs/www/about/why-we-ask-each- question/language/ [Accessed 15 August 2022] Vollmer, E., 2020. Pronoun Acquisition | Child Development | TherapyWorks [Online] Available from: https://therapyworks.com/blog/language-development/speech- strategies/pronoun-acquisition/ [Accessed 27 August 2023] Waller, A., 2019. Telling tales: unlocking the potential of AAC technologies. International Journal of Language & Communication Disorders , 54(2), 159-169. Weir, S., 2021. What’s in a Pronoun? The American Mind. [Online] Available at: https://americanmind.org/salvo/whats-in-a-pronoun/ [Accessed 31 Dec 2021] Willo, J., 2021. Why pronouns matter | NHS Confederation [Online] Available from; https://www.nhsconfed.org/articles/why-pronouns-matter [Accessed 27 Mar 2022]. Appendices Appendix 1 HCPC - Standards of proficiency - Speech and language therapists (2023) Some examples of relevant standards: 7.3 understand the characteristics and consequences of verbal and non-verbal communication and recognise how these can be affected by difference of any kind including, but not limited to, protected characteristics, intersectional experiences and cultural differences 7.5 modify their own means of communication to address the individual communication needs and preferences of service users and carers, and remove any barriers [our emphasis] to communication where possible 7.8 understand the need to provide service users or people acting on their behalf with the information necessary in accessible formats to enable them to make informed decisions 11.1 engage in evidence-based practice 12.1 understand the structure and function of the human body, together with knowledge of physical and mental health, disease, disorder and dysfunction relevant to their profession And all of SOP 13 including: 13.10 critically evaluate research and other evidence to inform their own practice 13.14 apply knowledge of communication impairment, linguistics, phonetics, psychology and biomedical sciences to the identification, assessment and differential diagnosis of a range of communication [and swallowing impairments] 13.16 recognise the influence of situational contexts on communicative functioning and swallowing status 13.17 evaluate the effects of communication difficulties [and swallowing status] on the psychosocial wellbeing of service users, their families and carers 13.19 use knowledge of speech and language therapy to assess and work with people with the following impairments: – acquired speech and language impairments – developmental or acquired cognitive impairments – developmental speech and language disorders [– dysfluency – dysphagia – voice disorders or voice modification needs] 15.3 empower and enable individuals (including service users and colleagues) to play a part in managing their own health Full list here: https://www.hcpc-uk.org/globalassets/standards/standards-of-proficiency/reviewing/slts---new-standards.pdf Appendix 2 Principle 2 – Mental Capacity Act Code of Practice, 2005 Willo 2021 Vollme 2020 Arslan 2021 Towell Hawkis 1994 Sera et al 2002 ASHA 2022 Shotwell Sheng 2021 Kerr 2019 Miltersen 2016 Weir 2021 Kuijper 2021 Finnegan et a 2021 Alm 2011 Alpern 2010 Perovic 2013 Bommangoudar et al 2020 Pert 2021 Davies 2022 Phillips 2020 Martinez Ferreiro et al 2019 Almor et al 1999 Rau 1993 Hawthorne Loveall 2021 Colle et al 2008 Kuperberg et al 2018 Chaves et al 2020 Briscoe et al 2001 Lesicko and Llano 2017 Neel 2010 Jongman et al 2000 Fox Nissen 2005 Nguyen 2022 Reidy et al 2017 Communication Matters 2022 Binger Light 2009 Waller 2019 ONS 2018 USCB 2019 Anton Mendez 2010 Alcock Ngorosho 2004 Ma et al 2022 Kohnert et al 2020 Mazzaggio Shield 2020 Leonard Dispaldro 2013 HCPC 2023 EQA 2010 EHRC 2020 Pyper 2020 MCA 2005 Dept Const Affairs 2007 Govt Equalities Office 2011 HSCA 2012 The Education Co 2022 ASHA 2016a ASHA 2016b CRA 1964 IDEA 2004 ADAAA 2008 AG Office 2022 Binns Arnold 2022 Gribble et al 2022 Miller 2017 Robillard 2021

We Are Coming SOON