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Documenting Current Gender Identity and Assigned Sex at Birth

Current Gender Identity, Assigned Sex at Birth, and Administrative Gender

Documentation of both current gender identity and assigned sex at birth is critical for delivering appropriate care to transgender patients. We strongly caution that current gender identity data must be the information that populates the “gender” field on patient identification materials, such as hospital wristbands, and should be used for purposes such as making room assignments.

Some transgender people may not identify as transgender, but only as male or female. In these cases, assigned sex at birth can indicate that the individual is transgender, which allows providers to offer the full range of care – such as anatomically appropriate preventive screenings – that meets the individual’s needs. Data on sex assigned at birth are also useful for the development of algorithms for clinical decision support.

In addition to current gender identity and sex assigned at birth, it is critical to ask patients their preferred name and gender pronoun. This information should be used consistently by clinical staff in all conversations with or about the patient. Use of a name or pronoun that does not match that person’s current gender identity is stigmatizing and creates a hostile environment that can cause the patient to not return for health care in the future, or even to file a formal complaint of discrimination. Preferred pronouns are she/her/her for transgender women and he/him/his for transgender men. Some patients, especially younger patients, may identify outside of the gender binary and not identify strictly as male or female. These patients may prefer gender neutral pronouns that can include they/them/their or other, new pronouns such as ze/zir/zir.  It’s important to ask the patient what pronoun the patient wants to use and use it consistently.

It is important to note that the HL7 codes for “administrative gender” are separate and distinct from current gender identity and assigned sex at birth. Administrative gender data should only be used as necessary, such as for insurance billing purposes (though this use is rapidly becoming obsolete as rules regarding insurance coverage for transgender individuals change), and should not be used for identifying, housing, or communicating with patients.As an example, consider a transgender woman (assigned male sex at birth, current gender identity is female).

The relevant data in the record would be:

  • Current gender identity: SNOMED code “identifies as female gender” or “transgender woman”
  • Assigned sex at birth: SNOMED code “male”
  • “Sex”/Administrative gender: preferentially HL7 code “female”

Regardless of the data in the administrative gender field, this individual should be referred to as “she” and “her” throughout her time in the clinical setting. Similarly, identification such as a wristband should indicate this individual’s sex as “female,” and in sex-segregated circumstances like room assignments, she should be housed according to her female gender identity.


Questions or Suggestions? Let us know at [email protected].

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