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. 2015 Jun;30(6):843-7.
doi: 10.1007/s11606-014-3148-7. Epub 2015 Jan 6.

Electronic health records and transgender patients--practical recommendations for the collection of gender identity data

Madeline B Deutsch  1 , David Buchholz
Affiliations

Electronic health records and transgender patients--practical recommendations for the collection of gender identity data

Madeline B Deutsch et al. J Gen Intern Med. 2015 Jun.

Abstract

Transgender (Trans, Trans*) persons may have a gender identity and a preferred name that differ from those assigned at birth, and/or those listed on their current legal identification (Gender ID, Birth-assigned Sex, Legal Sex). Transgender people who are referred to in a clinical setting using the wrong pronoun or name may suffer distress, ridicule or even assault by others in the waiting area, and may not return for further care. Furthermore, failure to accurately document (and therefore count) transgender identities has negative implications on quality improvement and research efforts, funding priorities and policy activities. The recent announcement that gender identity data may be included in Meaningful Use Stage 3 has accelerated the need for guidance for both vendors and local implementation teams on how to best record and store these data. A recent study demonstrated wide variation in current practices. This manuscript provides a description of identifiers associated with gender identity, and makes practical and evidence based recommendations for implementation and front-end functionality.

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Figures

Figure 1.
Figure 1.
Gender ID and preferred name differ from birth-assigned and legal data for a transgender patient who has not made any legal document changes. Asterisks serve to denote that preferred name and pronoun which are displayed in the banner differ from those on legal documents. In this case, Gender ID = Male or Transgender male, Birth Sex = Female, Legal Sex = Female, Preferred Name = John, Pronouns = He/Him.
Figure 2.
Figure 2.
Legal documents have been changed to reflect the legal name and gender ID in a transgender patient with a gender ID that maps to polar (i.e., M/F) pronouns. No asterisks are present; information relevant to their transgender history is contained in the medical history section of the chart. In this case, Gender ID = Female, Birth Sex = Male, Legal Sex = Female, Pronounds = She/Her.
Figure 3.
Figure 3.
Legal name has been changed in a genderqueer patient whose gender ID maps to neutral pronouns (regardless of birth sex). Legal sex may or may not have been changed. Asterisk denotes that legal sex differs from gender ID.
Figure 4.
Figure 4.
Preferred name displayed in banner (JB) differs from legal name (John), as indicated by an asterisk. Patient may or may not be transgender; however, gender marker is aligned with legal sex, as indicated by a lack of an asterisk in the gender field.
Figure 5.
Figure 5.
Collection logic flow. Note that the inclusion of a fourth gender ID field for direct entry of preferred pronoun would require additional functionality.
See this image and copyright information in PMC

Comment in

  • Opening the door to transgender care.
    Callahan EJ. Callahan EJ. J Gen Intern Med. 2015 Jun;30(6):706-7. doi: 10.1007/s11606-015-3255-0. J Gen Intern Med. 2015. PMID: 25743431 Free PMC article. No abstract available.

References

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