because of personal experience to divulge this information. Ehrenfeld said that his team certainly observed a generation gap in the willingness to self-identify on intake forms. Gonzalez said that Fenway Health’s approach to this problem has been to retain the ability to ask about sexual orientation and gender identity in the clinical setting rather than during registration because it is easier to put people at ease and educate them about why this information is important. Snowdon noted that this is not just a problem at the older end of the spectrum—a large longitudinal study of youth conducted by the Human Rights Campaign found a similar reluctance among youth between 16 and 24 years of age. Harvey Makadon noted, though, that in his experience, older LGBT people feel more comfortable when they talk to their physicians about their sexual orientation or gender identity because it makes them feel that their health care professional is listening to them.

George Brown of the Department of Veterans Affairs asked how intersex people are supposed to identify themselves when the sex-at-birth question offers just male or female options. Snowdon replied that these choices are dictated by insurance company systems that only accept male or female. In that respect, that field only reflects the legal identification or insurance record of the patient. Intersex status is collected in the gender identity drop-down list.

Barbara Warren, director for LGBT Health Services at Continuum Health Partners in New York, relayed her experiences in working with the New York State Office of Mental Health to add questions on sexual orientation and gender identity to the standard patient admissions form. The challenges she faced in adequately training personnel was reflected in the low rate of practices in New York State including those questions and the resulting small amount of data that was obtained. She added that they were still working to improve the training component. Weinick responded to this comment by discussing the need to approach repetitive training creatively. She used sexual harassment training as an example of training that uses role playing and vignettes to reinforce the training components.

The issue for some LGBT patients, explained Snowdon, is that just being asked these questions will make them very anxious and may make them less likely to seek care. She asked if there was an equivalent of that in race and ethnicity. Rebecca Fox, of Wellspring Advisors, pointed out that collecting ethnicity data in a community clinic in Arizona, and asking about a patient’s Latino background, may make some patients very anxious. It could lead them to not seek care because they are afraid of being asked what about their racial and ethnic background and that may bring up fears around immigration status. Weinick agreed that while bias against race and ethnicity differs somewhat from bias against sexual orientation

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