Medical records

Although medical record systems are usually not designed with the needs of the trans and gender diverse community in mind, keeping accurate and clear medical records is an essential part of patient care. Recording a person’s preferred names and pronouns is necessary to avoid inadvertent misgendering, which can and does produce poorer health outcomes for trans patients.1

Patient registration forms are strongest and most inclusive when they:

• Accurately record a patient’s personal information

• Can account for non-binary genders

• Sensitively consider a patient’s gender with the gender presumed for them at birth

• Allow for differences between a patient’s name and what is listed with Medicare

• Ask for pronouns and allow for an Mx. prefix

• Collect information about how a person describes their body

Forms that do not provide adequate options will not only make a patient feel unwelcome or unsafe, but will prevent them from sharing necessary medical information that may then impact health outcomes.

What do you need to know?

Asking and recording only relevant information is paramount and means your patients will be more likely to trust you with big decisions like starting gender affirming hormones.

Whilst clinicians are often very comfortable asking personal questions of their patients and see this as routine practice, trans patients may find these questions highly invasive or confronting, depending on their lived experience.

Providing context and explaining why you are asking personal information is often helpful, for example, when asking about a name that you may require for Medicare purposes.

Names

For many trans people, the name they use is different from the name they were given, which may or may not be their legal name, or the name listed with Medicare. Regardless, there is no legal reason to keep using an older or given name at any time, including in clinical settings.

There is generally no need to request someone’s legal name. If it is necessary, for example to make a Medicare claim for someone who has not changed their name with Medicare, consider options, such as writing it down rather than saying it out loud, only writing the initials (eg. when you are connecting a record in a previous name to their current name), or writing it on a separate piece of paper so it’s not attached to their main paperwork.

It is essential then to use their chosen name and not their legal name, if it’s different, in all other situations, including at reception, on any follow ups or results, or in future correspondence in person or over the phone.

Two-step gender collection

When collecting gender, it is best practice to use a two-step process. These questions are the recommended community indicators for research, based on The Standard for Sex, Gender, Variation of Sex Characteristics and Sexual Orientation Variables 2020 (the Standard).

It is essential that once this information is collected, it is used in how a client is referred to and affirmed.

Understanding gender presumed at birth

While TransHub uses the terms ‘trans’, and ‘trans and gender diverse’ to talk about our community, the language used by community members is as diverse as they themselves are, this question helps to capture their various experiences without asking them to fit into language that might not suit them.

Collecting information about how someone was registered, or what was presumed for them at birth will not tell you about a their current body, hormonal history, genitals, sexual practices or experiences. Consider this as a clear marker to be extra careful to not make assumptions.

If you need to know the answers to any of these questions. It is important to ask these questions sensitively but directly. Trans people are an incredibly resilient population, we notice, and appreciate it when our health professionals are trying to use affirming language.

Pronouns

Pronouns are important to use when affirming your patients, particularly when they are not in the room with you and you are talking or writing notes about them.

It is essential that once this information is collected, and is used to refer to and affirm a patient at every interaction with your service.

For more information about recovering from mistakes, see below.

Different language for body parts

Collecting information about the words a patient uses to describe parts of their body can help trans patients feel like they can talk about sensitive topics that they might otherwise feel are too difficult to talk about.

TransHub uses medical terms like ‘penis’, ‘vagina/front hole’ and ‘anus’ to describe specific body parts. This is just so community members know what we're talking about, as our communities often use similar words for quite different body parts - particularly our genitals. We encourage people, when talking about themselves, or being referred to by others, to use and request the language they feel most comfortable with instead

Whilst the above are important for providing affirming health care to patients, medical software and operating systems are often incompatible with meeting these needs.

One example is pathology forms using only binary gender options of either M or F. So, even if internal processes allow for multiple and affirming gender options, the request forms may misgender the person involved.

Whilst system change takes time, supporting your patients through gender affirming practices while also working within an imperfect system is important. This may include letting them know that this is the case, so they are able to prepare for an experience of being misgendered, rather than having it be a surprise.

Using notes

Developing, and using a system within your practice that seeks to ensure patients are not misgendered will help build patient trust.

Software that doesn’t allow for the complexity and breadth of information necessary to affirm patients often has a work-around. Clinics often opt to use a specific notes section to record affirming information about their patients. This may include their name and pronouns, their gender, the language they like used to describe their body, and any other necessary notes.

Everyone in your practice should know to check the notes section before providing care or following up with all patients to ensure the correct language is used.

Binary markers

If you are working with systems that offer binary markers that misgender a patient, it’s important to make sure that those markers are not visible to patients.

This could include collection equipment, documentation, computer screens, client files, etc. If it is unavoidable that a patient will see these markers, discussion about these limitations can be helpful, as is letting them know that you are working to fix it (and importantly then, working to fix it).

You can also use a sticker to temporarily write their actual gender and details on any physical equipment or forms, or use a sticker to just cover up the gender marker altogether, and remove it after the patient has left.

Confidentiality

It is essential that patient details are kept confidential and that they are informed of this.

This can include letting them know how their information is being stored (e.g. securely, on site or off site), who has access to the information (e.g. only people who work at this clinic), and whether or not they consent to their information being connected to other systems such as MyHealthRecord.

Discussions on maintaining patient confidentiality for trans patients are especially important for clinicians who are part of the LGBTQ+ community themselves. A shared social network can create fear that confidential information may be disclosed outside of a healthcare setting, so even if this is very unlikely to ever happen, it’s a good idea to be upfront.

When working with trans people, you will inevitably make errors. Making errors (so long as they don’t keep occurring) is not necessarily a problem, but acknowledging and apologising for them is important.

When this happens, quickly and sincerely apologise, but then not dwell on the mistake you made. Instead, pick up from where you left off with the correct language, and work to ensure it doesn’t happen again.

False hope

The experience of being promised a degree of literacy and affirming care can help a trans person feel safe in a space, but if that care is not delivered, it can cause harm.

This process, of ‘false hope’ can interrupt a trust-based relationship forming between patient and clinician, as they may feel like they’ve been tricked into thinking they will be affirmed. This can sometimes feel worse than not being affirmed in the first place.

This is why ensuring your whole service, and services you are referring to, are able to provide the level of care you describe, and to be honest and up front with a patient if that will not be the case. A human rights approach to healthcare might take some extra time, but it is always rewarding.