Prompting doctors to ask adolescents and young adults about their gender identity may improve documentation of that information in electronic health records, according to a new study.
Documenting of gender identity “is really going to make a difference in what services are ultimately provided,” said lead author Dr. Stanley R. Vance Jr. of the University of California, San Francisco.
Gender identity is how a people view themselves, that is, as male, female or something less specific. Gender identity may differ from the sex assigned at birth.
Vance and coauthor Dr. Veronika Mesheriakova say it’s necessary to document a person’s gender in order to establish what pronouns to use, maintain records and refer patients to appropriate specialists.
As reported in the Journal of Adolescent Health, Vance and Mesheriakova analyzed medical records from the UCSF Adolescent and Young Adult Clinic, which cares for patients ages 12 to 26.
Starting in early 2016, computer systems at the clinic prompted healthcare providers to ask patients for their current gender identity and their sex assigned at birth.
When the researchers reviewed 125 medical records from the three months before those two questions were added, they found that healthcare providers recorded gender identities for only 11 percent of patients.
But when they reviewed 106 medical records from three months after the questions were added, they found gender identities recorded for 84 percent of the patients.
Vance said there could be many reasons why gender identity wasn’t noted on 100 percent of the records. For example, patients may have had a pressing issue that needed to be addressed during that specific visit.
“I think identification of youth who are exploring their gender identities is really important to help them to thrive,” Vance told Reuters Health.
The healthcare providers at their clinic received two one-hour education sessions or online courses about gender identity and related issues before the questions were added to their computer system.
Other doctors interested in documenting their patients’ gender identities should educate themselves in advance, said Vance.
“Even if you’re not someone who is comfortable providing medication or services, knowing which providers you can refer to is very important,” he said.
Also, he said, it’s important to address confidentiality if patients don’t wish their gender identity to be revealed. And staff members should be trained to be sensitive toward patients and to use the person’s preferred pronouns.
If their pediatrician documents their preferred name and pronouns, transgender youth will be referred to in a way that makes them feel respected when they come into the office, Vance said.
SOURCE: bit.ly/2hu5L9m Journal of Adolescent Health, online December 15, 2016.
By Andrew M. Seaman