Clinical Review
Transgender Care in the Primary Care Setting: A Review of Guidelines and Literature
For patients who desire transgender care, providers must use appropriate language, know the basics of cross-sex hormone therapy, and understand...
Case Examples
An important element of EHRs facilitating the goal of patient-centered care is that patients have their EHR validate their sense of self, and their providers can use names and pronouns that correspond to the patient’s SIGI. Some patients have spent a great amount of effort altering their name and sex in legal records and may want their birth sex field to conform to their gender identity. To that end, patients may seek to alter their birth sex information so that it is congruent with how they see themselves to affirm their identity, despite patient safety risks. Several scenarios below demonstrate the potential costs and benefits to patients altering birth sex and SIGI in the EHR.
Case 1 Presentation
A young transman is working with his therapist on engaging in self-validating behaviors. This veteran has met with his PCP and informed the provider of his decision to alter the birth sex field in his EHR from female to male.
Ideally, the patient would begin to have regular conversations with his HCPs about his birth sex and gender identity, so that medical professionals can provide relevant screenings and affirm the patient’s gender identity while acknowledging his right to list his birth sex as he chooses. However, particular attention will need to be paid to assuring that natal sex–based health screenings (eg, pap smears, mammograms) are conducted on an appropriate schedule and that the veteran continues to discuss his current anatomy with providers.
Case 2 Presentation
A veteran has a male birth sex, identifies as a transwoman, and uses nongendered plural pronouns “they/them/theirs.” The word “they,” used as a singular pronoun may feel uncomfortable to some providers, but it validates the veteran’s sense of self and helps them feel welcome in the treatment environment. This patient communicated proactively with their HCPs about their transition goals and current hormone use.
They opted to have their birth sex field continue to indicate “male” because they, after a discussion with their PCP, are aware of the health implications of receiving an incorrect dose for their diabetes medication. They understand that having open communication and receiving input from their HCPs is part of good health care.
Case 3 Presentation
A patient with a sexual development disorder (intersex condition) identifies as a man (indicated as “male” in the SIGI field) and had his birth sex field changed to match his gender identity. He now seeks to change his birth sex field back to female, as he has complicated health considerations due to breast cancer.
The veteran thinks it is important that providers know about his intersex condition so that his breast cancer care is as seamless as possible. In particular, although this veteran is comfortable talking about his intersex condition and his identity with his PCP and oncologist, he wants to ensure that all people involved in his care (eg, pharmacists, radiologists) use the correct values in interpreting his medical data. Providers will need to use the female birth sex field for interpreting his medical data but use male pronouns when interacting with the veteran and documenting his care.
These case examples illustrate the need for HCPs to have patient-affirming education and appropriate clinical tools available when speaking to patients about birth sex, SIGI, and the implications of changing birth sex in the EHR. Moreover, these cases highlight that patient health needs may vary over time, due to factors such as perceived costs/benefits of a change in the sex field of the EHR as well as patient comfort with providers.
