Gender harmony: improved standards to support affirmative care of gender-marginalized people through inclusive gender and sex representation

Improving radiology information systems for inclusivity of transgender and gender-diverse patients: what are the problems and what are the solutions? A systematic review

INTRODUCTION

In medical radiation science (MRS), radiology information systems (RISs) record patient information such as name, gender and birthdate. The purpose of RISs is to ensure the safety and well-being of patients by recording patient data accurately. However, not all RISs appropriately capture gender, sex or other related information of transgender and gender-diverse (TGD) patients, resulting in non-inclusive and discriminatory care. This review synthesises the research surrounding the limitations of RISs preventing inclusivity and the features required to support inclusivity and improve health outcomes.

METHODS

Studies were retrieved from three electronic databases (Scopus, PubMed and Embase). A quality assessment was performed using the Johns Hopkins Nursing Evidence-Based Practice Research and Non-Research Evidence Appraisal Tools. A thematic analysis approach was used to synthesise the included articles.

RESULTS

Eighteen articles were included based on the predetermined eligibility criteria. The pool of studies included in this review comprised primarily of non-research evidence and reflected the infancy of this research field and the need for further empirical evidence. The key findings of this review emphasise how current systems do not record the patient's name and pronouns appropriately, conflate sex and gender and treat sex and gender as a binary concept.

CONCLUSION

For current systems to facilitate inclusivity, they must implement more comprehensive information and data models incorporating sex and gender and be more flexible to accommodate the transient and fluid nature of gender. However, implementation of these recommendations is not without challenges. Additionally, further research focused on RISs is required to address the unique challenges MRS settings present to TGD patients.

Understanding sex and gender: concepts and terminology for gender affirming care

Lesbian, gay, bisexual, trans, queer, intersex, asexual, and other diverse individuals (LGBTQIA+) people face lower healthcare utilization rates due to discrimination, poor experiences in healthcare, and barriers to accessing care. There is an increasing need to improve care and reduce health care disparities for the LGBTQIA+ population. The medical community can begin by educating themselves on LGBTQIA+ terminology, using inclusive language and developing cultural competence in clinical settings. In order to achieve this, it is first important to understand that sex and gender are distinct and that both sex and gender exist on continuums. This article will build on this understanding by introducing basic and widely accepted terminology that will provide a foundation for providing care to LGBTQIA+ populations. By thoughtfully incorporating this knowledge into our research and clinical practice, the radiology community will enhance the healthcare experiences of all patients.

What do measures of gender identity tell us about gender identity over time?

Gender identity is a multifaceted concept and is represented by a wide range of measures and constructs including both self-report and researcher observations of preferences and behaviours. However, despite their similar theoretical underpinning, gender identity measures are rarely found to correlate with one another, and contrasting patterns and trajectories are often found for each construct (Egan & Perry, Developmental Psychology, 37, 2001, 451). Therefore, this systematic review aimed to present a review of the longitudinal research evidence surrounding gender identity development in the absence of formal intervention. Using a systematic search strategy, 21 studies were identified. Narrative synthesis was used to synthesize the data collected in these studies and trajectories were explored for (1) self-identification measures of gender identity, (2) clothing preferences, (3) peer preferences, and (4) object/activity preferences. Overall, the results of this systematic review are consistent with wider research suggesting that distinct developmental patterns can be observed when using different constructs and measures of gender identity.

Utilization of electronic health record sex and gender demographic fields: a metadata and mixed methods analysis

OBJECTIVES

Despite federally mandated collection of sex and gender demographics in the electronic health record (EHR), longitudinal assessments are lacking. We assessed sex and gender demographic field utilization using EHR metadata.

MATERIALS AND METHODS

Patients ≥18 years of age in the Mass General Brigham health system with a first Legal Sex entry (registration requirement) between January 8, 2018 and January 1, 2022 were included in this retrospective study. Metadata for all sex and gender fields (Legal Sex, Sex Assigned at Birth [SAAB], Gender Identity) were quantified by completion rates, user types, and longitudinal change. A nested qualitative study of providers from specialties with high and low field use identified themes related to utilization.

RESULTS

1 576 120 patients met inclusion criteria: 100% had a Legal Sex, 20% a Gender Identity, and 19% a SAAB; 321 185 patients had field changes other than initial Legal Sex entry. About 2% of patients had a subsequent Legal Sex change, and 25% of those had ≥2 changes; 20% of patients had ≥1 update to Gender Identity and 19% to SAAB. Excluding the first Legal Sex entry, administrators made most changes (67%) across all fields, followed by patients (25%), providers (7.2%), and automated Health Level-7 (HL7) interface messages (0.7%). Provider utilization varied by subspecialty; themes related to systems barriers and personal perceptions were identified.

DISCUSSION

Sex and gender demographic fields are primarily used by administrators and raise concern about data accuracy; provider use is heterogenous and lacking. Provider awareness of field availability and variable workflows may impede use.

CONCLUSION

EHR metadata highlights areas for improvement of sex and gender field utilization.

Analysis of Inclusive Gender, Sexuality and Sexual Orientation Data Elements in Academic Electronic Health Records

Findings from an analysis of three vended academic electronic health records used in health science education are presented in this article. The quality assurance project examined the lexical and semantic fit and content coverage of gender, sexuality, and sexual orientation data elements within the academic electronic health records. A semantic comparative content analysis using a cognitive walkthrough was conducted as a means of comparing the ideal set of gender, sexuality, and sexual orientation data elements with those found in the three vended academic electronic health records. The results indicated a need for alignment to the research literature, expert consensus, and technical standards similar to what is expected for electronic health records used in clinical practice because of a lack of ideal state data elements. The findings align with ongoing issues with bias and disparities seen in the care of the lesbian, gay, bisexual, and transgender population and a lack of diverse, inclusive media and teaching technologies in health science education. The quality project and findings can inform academic electronic health record vendors on how they can create more inclusive systems and bring awareness to healthcare educators about the potential for implicit and explicit bias in their teaching technologies.

Advancing healthcare equity through dissemination and implementation science

OBJECTIVE

To provide guiding principles and recommendations for how approaches from the field of dissemination and implementation (D&I) science can advance healthcare equity.

DATA SOURCES AND STUDY SETTING

This article, part of a special issue sponsored by the Agency for Healthcare Research and Quality (AHRQ), is based on an outline drafted to support proceedings of the 2022 AHRQ Health Equity Summit and further revised to reflect input from Summit attendees.

STUDY DESIGN

This is a narrative review of the current and potential applications of D&I approaches for understanding and advancing healthcare equity, followed by discussion and feedback with Summit attendees.

DATA COLLECTION/EXTRACTION METHODS

We identified major themes in narrative and systematic reviews related to D&I science, healthcare equity, and their intersections. Based on our expertise, and supported by synthesis of published studies, we propose recommendations for how D&I science is relevant for advancing healthcare equity. We used iterative discussions internally and at the Summit to refine preliminary findings and recommendations.

PRINCIPAL FINDINGS

We identified four guiding principles and three D&I science domains with strong promise for accelerating progress toward healthcare equity. We present eight recommendations and more than 60 opportunities for action by practitioners, healthcare leaders, policy makers, and researchers.

CONCLUSIONS

Promising areas for D&I science to impact healthcare equity include the following: attention to equity in the development and delivery of evidence-based interventions; the science of adaptation; de-implementation of low-value care; monitoring equity markers; organizational policies for healthcare equity; improving the economic evaluation of implementation; policy and dissemination research; and capacity building.

Conducting inclusive research in genetics for transgender, gender-diverse, and sex-diverse individuals: Case analyses and recommendations from a clinical genomics study

A person's phenotypic sex (i.e., endogenous expression of primary, secondary, and endocrinological sex characteristics) can impact crucial aspects of genetic assessment and resulting clinical care recommendations. In studies with genetics components, it is critical to collect phenotypic sex, information about current organ/tissue inventory and hormonal milieu, and gender identity. If researchers do not carefully construct data models, transgender, gender diverse, and sex diverse (TGSD) individuals may be given inappropriate care recommendations and/or be subjected to misgendering, inflicting medical and psychosocial harms. The recognized need for an inclusive care experience should not be limited to clinical practice but should extend to the research setting, where researchers must build an inclusive experience for TGSD participants. Here, we review three TGSD participants in the Family History and Cancer Risk Study (FOREST) to critically evaluate sex- and gender-related survey measures and associated data models in a study seeking to identify patients at risk for hereditary cancer syndromes. Furthermore, we leverage these participants' responses to sex- and gender identity-related questions in FOREST to inform needed changes to the FOREST data model and to make recommendations for TGSD-inclusive genetics research design, data models, and processes.

What's Next for Modernizing Gender, Sex, and Sexual Orientation Terminology in Digital Health Systems? Viewpoint on Research and Implementation Priorities

In 2021, Canada Health Infoway and the University of Victoria's Gender, Sex, and Sexual Orientation Research Team hosted a series of discussions to successfully and safely modernize gender, sex, and sexual orientation information practices within digital health systems. Five main topic areas were covered: (1) terminology standards; (2) digital health and electronic health record functions; (3) policy and practice implications; (4) primary care settings; and (5) acute and tertiary care settings. In this viewpoint paper, we provide priorities for future research and implementation projects and recommendations that emerged from these discussions.

Words matter: The language of difference in human genetics

Diversity, equity, and inclusion efforts in academia are leading publishers and journals to re-examine their use of terminology for commonly used scientific variables. This reassessment of language is particularly important for human genetics, which is focused on identifying and explaining differences between individuals and populations. Recent guidance on the use of terms and symbols in clinical practice, research, and publications is beginning to acknowledge the ways that language and concepts of difference can be not only inaccurate but also harmful. To stop perpetuating historical wrongs, those of us who conduct and publish genetic research and provide genetic health care must understand the context of the terms we use and why some usages should be discontinued. In this article, we summarize critiques of terminology describing disability, sex, gender, race, ethnicity, and ancestry in research publications, laboratory reports, diagnostic codes, and pedigrees. We also highlight recommendations for alternative language that aims to make genetics more inclusive, rigorous, and ethically sound. Even though norms of acceptable language use are ever changing, it is the responsibility of genetics professionals to uncover biases ingrained in professional practice and training and to continually reassess the words we use to describe human difference because they cause harm to patients.

Will clinical standards not be part of the choir? Harmonization between the HL7 gender harmony project model and the NASEM measuring sex, gender identity, and sexual orientation report in the United States

OBJECTIVES

To propose an approach for semantic and functional data harmonization related to sex and gender constructs in electronic health records (EHRs) and other clinical systems for implementors, as outlined in the National Academies of Sciences, Engineering, and Medicine (NASEM) report Measuring Sex, Gender Identity, and Sexual Orientation and the Health Level 7 (HL7) Gender Harmony Project (GHP) product brief "Gender Harmony-Modeling Sex and Gender Representation, Release 1."

MATERIALS AND METHODS

Authors from both publications contributed to a plan for data harmonization based upon fundamental principles in informatics, including privacy, openness, access, legitimate infringement, least intrusive alternatives, and accountability.

RESULTS

We propose construct entities and value sets that best align with both publications to allow the implementation of EHR data elements on gender identity, recorded sex or gender, and sex for clinical use in the United States. We include usability- and interoperability-focused reasoning for each of these decisions, as well as suggestions for cross-tabulation for populations.

DISCUSSION AND CONCLUSION

Both publications agree on core approaches to conceptualization and measurement of sex- and gender-related constructs. However, some clarifications could improve our ability to assess gender modality, alignment (or lack thereof) between gender identity and assigned gender at birth, and address both individual-level and population-level health inequities. By bridging the GHP and NASEM recommendations, we provide a path forward for implementation of sex- and gender-related EHR elements. Suggestions for implementation of gender identity, recorded sex or gender, and sex for clinical use are provided, along with semantic and functional justifications.

Maybe they had a bad day: how LGBTQ and BIPOC patients react to bias in healthcare and struggle to speak out

OBJECTIVE

People who experience marginalization, including Black, Indigenous, People of Color (BIPOC) and Lesbian, Gay, Bisexual, Transgender, Queer, Plus (ie, all other marginalized genders and sexual orientations) people (LGBTQ+) experience discrimination during healthcare interactions, which negatively impacts patient-provider communication and care. Yet, scarce research examines the lived experience of unfair treatment among patients from marginalized groups to guide patient-centered tools that improve healthcare equity.

MATERIALS AND METHODS

We interviewed 25 BIPOC and/or LGBTQ+ people about their experiences of unfair treatment and discrimination when visiting healthcare providers. Through thematic analysis, we describe participants' immediate reactions and longer-term consequences of those experiences.

RESULTS

We identified 4 ways that participants reacted to discrimination in the moment: Fighting, Fleeing, Excusing, and Working Around Bias. Long-term consequences reflect 6 ways they coped: Delaying or Avoiding Care, Changing Healthcare Providers, Self-prescribing, Covering Behaviors, Experiencing Health Complications, and Mistrusting Healthcare Institutions.

DISCUSSION

By describing how patients react to experiences of unfair treatment and discrimination, our findings enhance the understanding of health disparities as patients cope and struggle to speak out.To combat these problems, we identify 3 future directions for informatics interventions that improve provider behavior, support patient advocacy, and address power dynamics in healthcare.

CONCLUSIONS

BIPOC and LGBTQ+ patients' perspectives on navigating unfair treatment and discrimination in healthcare offers critical insight into their experiences and long-term consequences of those experiences. Understanding the circumstances and consequences of unfair treatment, discrimination, and the impact of bias through this patient-centered lens is crucial to inform informatics technologies that promote health equity.

Digital health systems-let's talk about sex (and gender)

Historically, within digital health information systems, sex and gender have been conflated as a single concept and often have been limited to a binary answer. This has led to inappropriate care, erosion of client trust and avoidance of the healthcare system. Health leaders can improve care for all clients with technical and clinical information practice initiatives. While procurement processes could require digital health systems that utilize modern Gender, Sex, and Sexual Orientation (GSSO) terminology, for most health leaders, technical initiatives will focus on modernizing existing systems to the maximum extent possible. Terminology updates may not be immediately visible to clients, but providing the correct information to clinicians will support respectful client encounters. Simultaneously, clinical information practice initiatives can directly affect clinical encounters. Change management strategies need to include all levels of employees and redesign tools and workflows to support modernized information handling practices.

Pediatric sexual orientation and gender identity data collection in the electronic health record

The systematic documentation of sexual orientation and gender identity data in electronic health records can improve patient-centered care and help to identify and address health disparities affecting sexual and gender minority populations. Although there are existing guidelines for sexual orientation and gender identity data among adult patients, there are not yet standard recommendations for pediatric patients. In this article, we discuss methods that pediatric primary care organizations can use to collect and document sexual orientation and gender identity information with children and adolescents in electronic health records. These recommendations take into consideration children's developmental stages, the role of caregivers, and the need to protect the privacy of this information. We also focus on the current limitations of electronic health records in capturing the nuances of sexual and gender minority identities and make suggestions for addressing these limitations.

Transgender Individuals and Digital Health

PURPOSE OF REVIEW

The goal of this review is to assess the use of digital technologies to promote the health and well-being of transgender and gender diverse (TGD) people.

RECENT FINDINGS

TGD individuals experience numerous health disparities, including low uptake of HIV prevention strategies, such as pre-exposure prophylaxis, increased HIV incidence, and suboptimal HIV-related outcomes. These health disparities are the result of widespread intersectional stigma on the basis of gender identity, gender expression, socioeconomic class, race, and ethnicity, which negatively impact access to general medical and transgender-specific health care. TGD individuals often delay or avoid essential medical services due to fear of discrimination. Clinicians frequently lack training, competence, and skills in transgender medicine, further exacerbating the health disparities faced by TGD people. Digital technologies have been used to improve research and clinical care for TGD populations through various modalities; telemedicine, telehealth and mHealth. Digital health technologies, including HIT-enabled clinical decision support, telehealth, telemedicine, and mHealth, offer innovative ways to improve health care access, improve quality of care, and reduce health disparities for TGD populations, including and beyond HIV outcomes, through enhanced care delivery, clinician education, and enhancing social support networks.