Original article
“It'd Be Great to Have the Options There”: A Mixed-Methods Study of Gender Identity Questions on Clinic Forms in a Primary Care Setting

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Abstract

Purpose

Transgender youth experience significant barriers to health care. Asking patients about gender identity on clinic intake forms is recommended to improve care in adult populations. Little is known about how to implement these recommendations in adolescent populations. This study aimed to evaluate the addition of gender-related questions in an adolescent primary care setting and to determine if adding these questions to clinic forms could improve documentation of gender identity in the electronic health record (EHR).

Methods

We conducted cognitive interviews with 21 adolescents (n = 11 transgender, n = 10 cisgender) to examine gender-related questions (name, pronoun, gender identity, assigned sex at birth). These questions were added to a clinic intake form. We conducted a retrospective chart review of patients who came to the clinic for a physical examination visit three months before (n = 615) and after (n = 827) the form change and used chi-square tests to examine the differences in EHR documentation of gender identity.

Results

In interviews, the new questions were acceptable and interpretable to adolescents of diverse gender identities. Participants described the questions as beneficial to all patients and perceived them as an indicator of a welcoming clinic environment. The retrospective chart review found that provider documentation of gender identity in the EHR significantly increased after the form change from 51.3% to 66.3% (p < .0001).

Conclusions

This intervention was acceptable to adolescents and associated with a significant increase in EHR documentation. Future studies should investigate how the form change may have facilitated discussion about gender and health and implications for provider training and support.

Section snippets

Methods: semistructured interviews

The first phase of this Quality Improvement Project (following the plan-do-study-act approach) [17] was qualitative to adapt existing methods for gathering gender identity information [13,18,19]. The specific questions we tested were chosen based on best practice methods to assess gender identity [[20], [21], [22], [23]]. The method, sometimes known as the “Two-Step” approach, involves asking patients about assigned sex and current gender identity. This method had been shown to be both highly

Themes from qualitative patient interviews

Twenty-one adolescents participated in qualitative interviews between March 2018 and January 2019. Participants had a mean age of 18.8 years (range: 15–25 years) and reported a range of gender identities (Table 1). By design, half the sample identified as cisgender and half as transgender with three participants (14.3%) who identified as genderqueer/nonbinary. Over half of participants (62%) were assigned a female sex at birth. The majority of participants (29%) identified as Black or

Discussion and Implications

Emerging evidence demonstrates that collection of gender identity information can improve health outcomes. For example, the use of a transgender adolescent's chosen name at home, at school, at work and with friends is associated with lower depression, suicidal ideation, and suicidal behaviors [27]. In this study, all patients found the name, pronoun, and gender identity questions to be acceptable and relevant to their health care. Cisgender adolescents expressed positive sentiment toward the

Acknowledgments

Portions of this project were presented at the Society for Adolescent Health and Medicine Annual Meeting in 2019. The authors would like to thank the Sexual Orientation and Gender Identity and Expression (SOGIE) research group and our study participants, including people of color.

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    Conflicts of interest: The authors have no conflicts of interest to disclose.

    Disclaimer: Anqa Khan's author's affiliation is included for informational purposes only; this work was not conducted under the auspices of the Guttmacher Institute. The views expressed herein are those of the authors and do not necessarily reflect the views of the Guttmacher Institute.

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