Gender Identity in Medical Records

The more your healthcare providers knows about you, the more they can give you appropriate care. This also includes knowing and validating your gender identity, which is both the gender you identify with and how you express your gender.

Because we know many healthcare providers do not routinely discuss or collect information about their patients’ gender identity and sexual orientation, it is important to be your own advocate to ensure the information is correct in your medical records.

From a public health perspective, we also know gender and sexual orientation can put you at a higher risk of certain health issues, such as the risk of contracting HIV/AIDs and having breast cancer. Healthcare providers need all the facts to make informed and evidence-based recommendations for treatment and care.

Here we explain best practices for collecting gender identity information and how trans patients can be better included and provide ways you can go about changing your gender identity within your medical records.

Explaining the Importance of Collecting Gender Identity Information

If you are transgender, healthcare rules such as needing to have a form of identification that matches your legal name for hospital records can cause harm and frustration. Notably, the Center for American Progress found 66% of trans patients reported having difficulty obtaining documentation with their correct name and pronouns.

Validating someone’s identity is only the first step in providing good care to trans and nonbinary patients, with gender-affirming care also being incredibly important. A 2022 investigation published in JAMA Open Network found that after receiving gender-affirming care, such as hormones and puberty blockers, trans and nonbinary youths had a 60% lower chance of experiencing severe depression.

A report published in the Journal of the American Medical Informatics Association also emphasized the importance of not assuming the pronouns that people may have, and not limiting which pronouns a person can say that they have.

Options for Collecting Gender Identity in an Electronic Health Record

Researchers suggest a form includes the following gender identity options:

• He/him/his
• She/her/hers
• They/them/their
• Use all pronouns
• Try to avoid pronouns
• Unsure of what my pronouns are
• Use other pronouns (Here you would give an option for people to fill in their pronouns).

Is My Healthcare Provider Allowed to Ask for My Gender Identity?

Your healthcare provider may ask you for your gender, sex assigned at birth, and your pronouns, but there is no legislation requiring you to disclose this information. (Considering the anti-transgender legislation many states have enacted or are considering, it is nevertheless understandable if you are uncomfortable answering).

Keep in mind knowing more about you can help your healthcare providers give you better care. For example, the U.S. Department of Veteran’s Affairs notes:

• The medical record system uses sex assigned at birth to determine your lab ranges, for example hormone levels and kidney function.
• Sex is used to automatically remind your provider what health screenings are due, such as prostate screening and pap smears.
• Sex along with height, weight, and age are used to determine doses for your medication(s).

A Message to Professionals Working with Youth Who are Transgender

If you work with youths who are transgender in states with anti-transgender legislation, here are some questions to investigate regarding the protection of personal health information:

• What are your hospital’s policies in dealing with anti-transgender legislation?
• Under what circumstances do you share youths’ information with governmental parties and/or the police?
• Do you and/or your hospital consider gender-affirming care for minors to be a form of abuse?
• What training do people in your hospital receive on being inclusive of transgender and nonbinary patients?

How to Change Your Gender in Your Medical Records

If you want to change your own gender identity on your medical records, there are a variety of steps that you can take, depending on your healthcare provider.

• Your healthcare provider may allow you to update your name, gender identity, and pronouns from your online portal. This could be easily done in the privacy of your home.
• You may have to contact your healthcare provider’s office to ask them to update your gender identity and any other related information via phone, a portal or in person.
• You may be asked to provide legal documentation that your name and pronouns are legally changed if you wish for your dead name to no longer be in your healthcare records. It’s understandable if this is frustrating for you, as updating documents can take a lot of time.

If you find that your current healthcare provider has too many hoops to change your gender identity in medical records, you could provide this feedback or look for a new provider that has a more inclusive practice.

Additional Information:

• AHIMA supports the AMA’s call for Inclusivity in EHRs for the Transgender Patient Population (AHIMA.org)
• Treating LGBT Status as a Patient Safety Issue (AHIMA.org)
• Improved Patient Engagement for LGBT Populations: Addressing Factors Related to Sexual Orientation/Gender Identity for Effective Health Information Management (AHIMA.org)
• Capturing Sexual Orientation/Gender Identity Data through HIT (Journal of AHIMA)
• In a win for trans veterans, VA adds gender identity to medical records (NBCnews.com)
• Electronic health records as an equity tool for LGBTQIA+ people (Nature)