Pronouns in the Electronic Medical Record: A Potential Pitfall

More than 1.4 million Americans identify as transgender or nonbinary.1 With a reported threefold increase in gender-affirming surgical procedures between 2016 and 2019, patients seeking gender-affirming surgical procedures are on the rise.2 However, in addition to previous challenges transgender patients encountered in accessing essential healthcare services recent legislation in several states threatens to worsen patient trust of the healthcare system.3,4To this end, the need for an inclusive environment, made plain to patients seeking care becomes all the more important. One seemingly subtle yet critical aspect of providing care to transgender patients is the appropriate use of pronouns while refraining from misgendering—using pronouns or terms that do not align with an individual’s gender identity. In accordance with the World Professional Association for Transgender Health’s (WPATH; East Dundee, Illinois,) Standards of Care, gender-affirming healthcare encompasses a spectrum of behaviors, including the correct usage of gender identity, patient names, and obtaining informed consent.5,6 This holds particular significance in the perioperative setting, where patients may experience heightened anxiety before procedures, and negative interactions can significantly influence their future healthcare-seeking behaviors.7 Perioperative misgendering experiences in patients undergoing gender-affirming surgery highlight the urgent need for a gender-inclusive healthcare environment.8To investigate the prevalence of misgendering in the perioperative setting, we conducted retrospective chart reviews of the electronic health record system and report the incidence of misgendering at one large, urban, academic medical center in the Northeast offering gender-affirming surgery to national and international patients.The study protocol was approved by the Boston University School of Medicine Institutional Review Board (IRB; Boston, Massachusetts). The requirement for written informed consent was waived by the IRB given the retrospective nature of the study. We conducted chart reviews of facial feminization procedures performed on transgender patients from 2016 to 2020 at our institution. Inclusion criteria encompassed transgender patients with diagnoses of gender dysphoria and gender-dissociative identity disorder, as indicated by International Classification of Diseases, Tenth Revision (ICD-10) codes, and age greater than 18 yr. Our institution offers a variety of facial feminization procedures such as forehead contouring, tracheal shave, and rhinoplasty and the option to combine these procedures. Notably, all procedures were performed by a single surgeon. Misgendering was defined as any instance of incorrect pronoun usage in perioperative documentation, reflecting a discrepancy between the patient’s correct self-identified gender identity and the pronouns used in charts by nursing, anesthesiology, or surgical teams. As this was a cohort of male-to-female (or MTF) transgender patients obtaining facial feminization procedures, the research team worked under the assumption that any charts with the masculine (he/him) pronouns usage for the patient’s surgical visit would be incorrect and hence labeled “misgendering.” The authors acknowledge that not all patients may identify as transgender women; some may identify as nonbinary, women, etc.Among the 282 unique patient charts identified in our cohort of 296 facial feminization procedures, 120 incidents of misgendering were documented, resulting in an overall misgendering rate of 42.6% (120 of 282). Anesthesiology staff accounted for the highest frequency of misgendering at 65.8% (79 of 120), followed by nursing at 26.7% (32 of 120), ancillary perioperative staff at 4.2% (5 of 120), and surgical teams at 3.3% (4 of 120) (see fig. 1).Our study’s findings underscore a notably elevated rate of misgendering by anesthesia staff within this electronic health record system. The total incidence of misgendered charts for facial feminization procedures between 2016 and 2020 for self-identified transgender women was 42.6% with anesthesia providers displaying the highest misgendering rate at 65.8% (79 of 120 misgendered charts).On closer examination, it was determined that the template used by anesthesiology providers at our institution for preoperative assessment auto populated pronouns from the binary demographic gender within the electronic health record system to create a narrative note, and no actual pronouns were being entered by anesthesiology staff. For example, checking “No” for shortness of breath would create a line within the record that would read “He has no shortness of breath.” While the electronic health record system had listed entries for preferred pronouns for the patients, the template auto populated from binary demographic data and placed these incorrect pronouns in the medical record. Accurate pronouns would depend on proper updates to the demographic gender of the patient in transition.While the presence of this exclusionary technological characteristic accounted for a significant portion of misgendered charts in our electronic health record system during this retrospective analysis, it is important to acknowledge that misgendering incidents also occurred in the perioperative setting due to direct one-on-one interactions between providers and patients, as reported by a patient advocacy report filed during the same time frame as the study period. While Federal regulations under United States (45 CFR 164.524) required that healthcare organizations grant patients access to their medical information, new federal rules—passed under the 21st Century Cures Act—mandate that health care organizations must give patients unfettered access to their full health records in digital format.9 Patients now have access to their full clinical documentation via patient health portals in near real-time. Following the identification of misgendering issues highlighted in this study, we amended the electronic health record documentation structure to incorporate gender neutral language and circumvent the autogenerated pronouns that were identified as a result of our analysis.For specialties within the hospital that utilize templates to generate notes, this study highlights the importance of scrutinizing electronic health record system software to build patient trust, and demonstrates the need to adopt gender neutral language in the medical record system.The authors declare no competing interests.