An increasing number of transgender people, Snowdon continued, want to self-indentify as such despite the fear and anxiety they may have about doing so. They do, however, want people to know how to communicate with them respectfully, appropriately, and accurately. They want the entire health care system—the labs running clinical assays, the pharmacies filling prescriptions, and their physicians—aware of their sex at birth because transgender people know that information is important for them to receive the best care. Having said that, the most recent HEI survey found that only three clinics—two that specifically serve an LGBT population, the other serving a general population—offer a drop-down option for transgender status on their EHR. However, 78 facilities reported that they are actively considering a drop-down option on transgender status. The one general health facility that has a drop-down option has retained “male” and “female” as the options in the existing gender field, in order to match legal identification and insurance information, but also indicates “transgender MTF [male to female]” or “transgender FTM [female to male]” in a prominent drop-down list that a patient can access at their choosing. Snowdon noted that the facility made this modification to the standard EHR without involving the vendor.
In contrast to the situation with transgender people, who increasingly want to self-identify, lesbian, gay, and bisexual people seem more reluctant to self-identify in the context of an EHR, Snowdon said. Providing information in an EHR allows providers to know more about their patients, but many lesbian, gay, and bisexual people do not necessarily want their providers to know about their sexual orientation. EHRs are also envisioned to allow information to be shared more widely, and, in Snowdon’s opinion, many lesbian, gay, and bisexual patients do not want that information shared widely, if at all. While EHRs can be used to empower patients, many patients feel that being confronted with routine sexual orientation questions is disempowering.
Summarizing what she and her colleagues have learned over the years, Snowdon said that lesbian, gay, and bisexual patients have many concerns regarding volunteering information about sexual orientation in the health care setting. They are unsure whether to respond in terms of attraction, behavior, or identity. In her opinion, women in particular are unsure about whether the question refers to today, the past, or the future because they tend to view themselves as more sexually fluid. Reflecting this challenge, medical students are now taught that sexual orientation occurs on a spectrum that is not necessarily fixed over a lifetime. They are also taught to not ask about sexual orientation, but rather to ask their patients about actual behavior.