Editor’s Note: Dr. Kimberly Horstman is a pediatric hospitalist at John Muir Medical Center in Walnut Creek, CA and a Clinical Assistant Professor of Pediatrics at Stanford Children's Health. She is on the steering committee for the AAP Section on Hospital Medicine Sub-Committee qPHM supporting LGBTQ+ patients and providers (Twitter: @PHMLGBTQ). - Jessie Allan, MD, Assistant Editor, Digital Media, Hospital Pediatrics
Transgender or gender-diverse (TGD) youth face significantly higher rates of depression, self-harm, and suicidal ideation than their cisgender peers,1 and nearly 40% report avoiding necessary medical care because of fear of discrimination and disrespect regarding their gender identity.2 Of those who do seek care in the emergency department (ED), very few report being given the opportunity to have their affirmed name and pronouns documented in the electronic health record (EHR), which can easily lead to misgendering in the medical setting. Using the correct pronoun promotes well-being and improves mental health including decreased depressive symptoms, suicidal behavior, and suicidal ideation,3 and helps to create a gender-affirming healthcare environment.
In a research article published in Hospital Pediatrics titled, “Increasing Frequency of Affirmed Name and Pronoun Documentation in a Pediatric Emergency Department” (10.1542/hpeds.2022-006818), Dr. Gina Sequeira and colleagues shared the results of a quality improvement project conducted in the UPMC Children’s Hospital of Pittsburgh ED, with the goal to increase affirmed name and pronoun EHR documentation in children ages 5 and older.
At the start of the 2-year study period, the authors found multiple barriers to improving patient name and pronoun documentation:
- Staff uncertainty about how to ask patients about preferred pronouns
- Lack of EHR capability to document pronouns
- Provider difficulty in remembering to ask about names and pronouns
- Poor communication about preferred names and pronouns across the care team
They performed 3 Plan–Do–Study–Act (PDSA) cycles to implement change. The first focused on updating the language on the EHR rooming form to prompt nursing staff to ask about preferred names and pronouns during the rooming process, which then automatically displayed in the EHR banner bar and remained visible during subsequent ED encounters. In addition, multiple didactic education sessions were held for nursing staff, ED providers, and pediatric residents to update them about changes in the intake process and EHR documentation, and to discuss the health disparities faced by TGD youth. A 1-page toolkit was also introduced to help ED providers assess patients for additional gender-related support needs. Finally, a key element to improving documentation (which occurred independent of the PDSA cycles) arose from strong messaging from ED leadership to hospital staff about the importance of using correct names and pronouns after a negative patient experience. Pre-implementation data found that only 13.8% of youths ages 5 and older had affirmed names and pronouns documented in the EHR. By the end of the study, 47.8% had both name and pronoun documented.
The population of TGD is increasing.4 This study has shown that intentional discussions about and EHR documentation of affirmed name, pronoun and gender identity, as well staff education about the health disparities faced by TGD youth, create a more welcoming healthcare environment with resultant improvement in mental health. By creating an atmosphere of trust, providers may also have an increased opportunity to help TGD patients find additional gender-affirming resources. Ultimately, improving recognition of a patient’s preferred name and gender helps all members of the medical community develop holistic care plans that take into account every aspect of a patient’s lived experience, which in turn will contribute to improved mental and physical health outcomes for these patients.
- Connolly MD, Zervos MJ, Barone C, Johnson CC, Joseph CLM. The mental health of transgender youth: advances in understanding. J Adolesc Health. 2016; 59(5):489-495
- Sequeira GM, Boyer T, Coulter RWS, Miller E, Kahn NF, Ray KN. Healthcare experiences of gender diverse youth across clinical settings. J Pediatr. 2022; 240:251–255
- Russell ST, Pollitt AM, Li G, Grossman AH. Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. J Adolesc Health. 2018; 63(4):503–505
- Herman JL, Flores AR, O’Neill KK. How many adults and youth identify as transgender in the united states? Report, Williams Institute at the UCLA School of Law, June 2022