University scientists tell doctors to avoid 'traumatizing' and 'harmful' sex info in notes on trans patients

The study suggests trans people 'may be particularly vulnerable to the harms of medical documentation.'

Scholars at numerous universities published a list of recommendations for reviews of transgender electronic health records.

Earlier this year, scientists at numerous top universities published a study listing recommendations for how to make electronic health records less “traumatizing” for transgender patients. 

The studytitled “Experiences of Transgender People Reviewing Their Electronic Health Records, a Qualitative Study”—claims that transgender people “may be particularly vulnerable to the harms of medical documentation given the pervasiveness of stigma, blaming, discrimination, and microaggressions in their clinical encounters.”

Contributing scholars included Ash Alpert, a fellow in Hematology and Medical Oncology at the Wilmot Cancer Institute of the University of Rochester Medical CenterDr. Jamie Mehringer from the University of Rochester, and University of Michigan professor Jennifer Griggs

[RELATED: Michigan State research project partners with non-profit to fund legal name, gender marker changes]

The study found that using the unpreferred pronoun or gender marker reportedly caused trauma in transgender patients. It posits that certain medical customs like taking “one-liner” notes were dehumanizing. 

”Participants similarly described a preference for gender and sex-assigned-at-birth to be left out of one-sentence summaries,” the study states. 

The conclusion of the study claims that transgender people experience harm from “certain aspects” (such as the note-taking) of electronic health records, and therefore there is a need for recommendations for change. 

In the Recommendations for Documentation table, the study lists alterations that clinicians need to make for administering care to transgender people, which include “Avoid[ing] medically irrelevant mention of sex-assigned-at-birth” and “Document[ing] the patient’s stated gender. Avoid terms such as ‘male-to-female,’ ‘female-to-male,’ ‘FTM,’ or ‘MTF’ unless patient specifies identifying with one of these terms.”

[RELATED: Hormone therapy, top surgeries part of medical school’s ‘gender-affirming’ care]

Another recommendation states that clinicians need to refrain from including judgemental language in patient documentation. It lists words like “hostile” or “aggressive” as examples. 

Finally, the recommendations state that clinicians should discuss documentation with patients to ensure that language considered to be stigmatizing and judgemental is avoided as best as possible. 

Follow William Biagini on Instagram and Twitter