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Case Reports
. 2024 Oct;15(5):1093-1096.
doi: 10.1055/s-0044-1791488. Epub 2024 Dec 18.

Reference Ranges for All: Implementing Reference Ranges for Transgender and Nonbinary Patients

Anthony B Cardillo  1   2 , Dan Chen  2 , Nina Haghi  2 , Luke O'Donnell  3 , Jeffrey Jhang  2 , Paul A Testa  1 , Nicholas Genes  1   4
Affiliations
Case Reports

Reference Ranges for All: Implementing Reference Ranges for Transgender and Nonbinary Patients

Anthony B Cardillo et al. Appl Clin Inform. 2024 Oct.

Abstract

Objectives: This study aimed to highlight the necessity of developing and implementing appropriate reference ranges for transgender and nonbinary (TGNB) patient populations to minimize misinterpretation of laboratory results and ensure equitable health care.

Case report: We describe a situation where a TGNB patient's abnormal laboratory values were not flagged due to undefined reference ranges for gender "X" in the Laboratory Information System (LIS). Implementation of additional reference ranges mapped to sex label "X" showed significant improvement in flagging abnormal lab results, utilizing sex-invariant reporting as an interim solution while monitoring developments on TGNB-specific reference ranges.

Conclusion: Informatics professionals should assess their institution's policies for registration and lab reporting on TGNB patients as nonimplementation poses significant patient safety risks. Best practices include using TGNB-specific reference ranges emerging in the literature, reporting both male and female reference ranges for clinical interpretation and sex-invariant reporting.

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Conflict of interest statement

None declared.

Figures

Fig. 1
Fig. 1
The top panel represents the nonbinary patient's LFT lab results, for which gender was marked as “X” in the EMR. For comparison, the bottom panel is a cisgender male patient's lab results, for which gender was marked in the EMR as “M” (male). Note that the male patient's report, which resulted only minutes after the transgender patient, contains reference ranges and an abnormal results flag. EMR, electronic medical record; LFT, liver function test.
Fig. 2
Fig. 2
An example, using AST, of sex-invariant reporting. This process calculates the “safest range” for an unspecified sex “X” using previously established sex-specific reference ranges. The new reference range is the intersection of male and female ranges, creating a narrower “normal” range from the highest lower bound and lowest upper bound. Intuitively, this method flags values as normal if it would be normal in both males and females and is thus invariant to sex. AST, aspartate transferase.
See this image and copyright information in PMC

References

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    1. Cheung A S, Cook T, Ginger A, Zwickl S. Sex specific reference ranges and transgender care. BMJ. 2022;376:e069874. - PubMed
    1. Humble R M, Greene D N, Schmidt R L et al. Reference intervals for clinical chemistry analytes for transgender men and women on stable hormone therapy. J Appl Lab Med. 2022;7(05):1131–1144. - PubMed
    1. Cheung A S, Lim H Y, Cook T et al. Approach to interpreting common laboratory pathology tests in transgender individuals. J Clin Endocrinol Metab. 2021;106(03):893–901. - PMC - PubMed
    1. Davis D. ASCLS; 2022. The Importance of Accurate Laboratory Reference Intervals for Transgender Patients.

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