Inclusive design matters, especially for life-and-death services

Illustration: an open door representing inclusion.

Content that makes people feel excluded, or doesn’t make clear they’re entitled to use a service, can lead to them missing out on vital support.

For example, a report published in January 2022 by the LGBT Foundation found that 30% of trans and non-binary people it surveyed didn’t access any support during pregnancy.

And 54% who ‘freebirthed’ (gave birth without accessing pregnancy care at all) said they would have found the support of a midwife helpful.

What made them opt out of the system, or feel excluded from it?

Some 59% of trans and non-binary people who responded to the survey and did access pregnancy care didn’t feel they were consistently spoken to in a way which respected their gender.

In other words, it felt like a hostile environment.

The report had some clear recommendations around language which, as a content designer, grabbed my attention.

That included the suggestion that some trans and non-binary people are more comfortable with the terms chestfeeding or bodyfeeding, as opposed to breastfeeding.

It highlighted the tendency of official communications and online content to refer to 'pregnant women' by default. That prompted potential users to wonder whether these services would be open to, and able to support, trans and non-binary people.

The report also underlined the need to ask service users about the language they prefer to use, rather than making assumptions based on how they look, or present.

It suggested that online forms for this kind of service in particular should offer the opportunity to specify your gender and your pronouns.

As well as making interactions with medical staff more comfortable, that’s also a signal of an inclusive culture.

Delivering good services in the context of ‘culture war’

Unfortunately, this kind of thinking has become a political football as politicians battle for the ‘anti-woke' vote and strive to avoid critical news coverage.

The past decade has seen the NHS take steps forward, at a national and local level, only to be lambasted by the press eager for stories of “Political correctness gone mad!”

For example, plans to train midwives in line with the LGBT Foundation’s advice were abandoned, partly as a result of pressure from the press.

And a series of leaks revealed tensions within the NHS over guidance around pregnancy for trans and non-binary people. That guidance did eventually go live but only after a year in limbo.

This can be a frustrating environment for human-centred designers who are trained to put users first in every instance.

What we can do is base our advice and work on research and evidence, and keep championing the user in these difficult conversations.

Designing inclusive services in practice

Use inclusive imagery

If there is photography or illustration as part of your content, try to show a diverse range of people and different types of families.

This is a ‘soft’ signifier of inclusion that can be extremely powerful.

If you see people using the service who look something like you, or at least represent diverse experience and identities, it feel more like an open door.

Avoid gender-specific language

This is easier than you might think: most of the time, saying “you” also happens to be clearer, less formal, and more direct.

The NHS service manual (style guide) gives this example:

“You should see the GP if you have persistent symptoms of osteoarthritis so they can confirm the diagnosis and prescribe any necessary treatment.”


Take care when using words such as husband and wife, or mother and father. Partner or spouse are more generally applicable in the first instance.

And in the latter case, you might use specific words depending on the context, such as parent, guardian or carer.

This can also be helpful in reflecting the fact that not everyone who cares for a child is necessarily their parent.

Again, this isn’t about policing how people refer to themselves – you’re absolutely free to talk about your mum and dad, or husband or wife.

It’s about saying that services which are for everyone shouldn’t shut anyone out through a careless choice of words.

Think carefully about forms

When creating forms first check whether you really need to ask a user to specify their gender or sex.

It’s often there purely out of habit, or because it’s built into the template.

Will the answer a user gives improve the service they receive (see above re: pregnancy) or how they’re routed through the system? If not, leave it out.

The same goes for salutations. Unless you’re ever going to address someone formally, you don’t need to know whether someone goes by doctor, reverend, mx, mister, and so on.

If you really do need to ask, try to include a line explaining why. Otherwise, a reasonable response might be: “Mind your own business.”

And a poor outcome would be that they abandon the process altogether, having been made to feel unwelcome, stressed or disrespected.

Don’t force people into narrow categories

There’s an entire website dedicated to forms that ask users for their gender in various clumsy ways – “man, woman, skeleton” is a favourite of mine.

But the biggest problem is forms that give two options (male/female) or three, with ‘other’ as the third option, and no free-text field in which to be more specific.

The best solution, based on various surveys and pieces of research, seems to be:

  • a free text field where people can use the words that work for them (ideal)
  • a dropdown including gender neutral options, if you must limit their choices
  • the ability to opt out altogether (“prefer not to say”)

One form from Google I used recently offered:

  • male
  • female
  • prefer not to say
  • custom

Think about it, research, test

Ultimately here, as in most aspects of design services, it’s about taking time and care over your choices.

We need to treat each project, and each user group, as unique. We also need to avoid making assumptions, or using off-the-peg content and copy.

Remember, if we get it wrong, people might feel frozen out of services that could help them live longer, happier lives.

And isn’t that what motivates many of us to work in design in the first place?