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Q&A: Recording gender in medical records

Medicolegal expert Rachel Birch advised on having a better consultation with a transgender or transsexual patient

An increasingly common query on the MPS advice line relates to whether doctors should update and/or change medical records to reflect a patient’s new gender.

‘Transgender’ or ‘gender variant’ are terms given to individuals whose gender identity does not reflect their assigned biological sex. Prevalence of transgender people in the UK was found to be one in 5,000 in a study by the Gender Identity Research and Education Society (GIRES) in 2010.

While many doctors may not have extensive experience with transgender patients, it is an issue which must be treated with upmost care and sensitivity.

It is also important for doctors to understand that failure to address transgender issues appropriately can lead to criminal consequences.

The following questions cover common issues that affect consultations with transgender patients.

Q How can I sensitively raise the issue of gender transition or change with patients?

First, doctors should ensure they are approachable, unbiased and supportive, and have sufficient awareness of transgender issues. Some doctors may feel inexperienced or embarrassed and if this is the case, it may be beneficial for them to complete specific training and/or familiarise themselves with transgender guidance published by the Department of Health.1

While patients will usually raise the issue of gender transition themselves, doctors who consider that it could be an option for one of their patients should raise the issue sensitively. Asking the patient about their preferred name, gender and what term they prefer to use (for example, transgender or gender dysphoria) is likely to go a long way to reassuring them that they have professional support and understanding. It may then become appropriate to offer to refer them to a gender identity clinic.

Q At what point during a transition should I offer to change the gender of a patient’s record?

Under the Gender Recognition Act 2004, transgender people may have their preferred gender recognised by law if they have a Gender Recognition Certificate (GRC). To obtain a GRC, patients must have gender dysphoria, live for two years in their acquired gender and intend to live permanently as such.

Part of living in the acquired gender is likely to involve a change of gender pronoun, plus administrative gender and name changes. Patients going through this transition are entitled to request changes to their existing medical records or have an entirely new medical record created with a new NHS number – and should be supported in this. This request may come at any stage during the gender transition.

Patients may therefore notify practices of their intention to change their gender and those born in the UK do not need to produce any specific documentation. However, if they do produce documentation, it is likely to be a statutory declaration of name and gender change, which are signed on oath and witnessed by a solicitor.

Some patients with a GRC may also choose to have their medical records changed to reflect various details including their new name and gender, without requiring a new record and NHS number.

For requests from patients born outside of the UK, doctors should seek advice from MPS or their medical defence organisation.

Q What should I do if a patient asks me to delete the records from before the change of gender?

If a patient requests administrative changes to their medical records, this should be actioned from the date of the patient’s request. For example, if a patient requests their name and gender to be changed on their records, any reference to their previous name and gender should be removed and their new name and gender should be used going forward.

As doctors are required to keep accurate records, no clinical records created before the change of gender should be changed or deleted. However, patients may request to have factual errors in the records corrected and notes added to reflect their views.

Patients that request a new medical record may understandably be concerned about the confidentiality of their previous records under their old NHS number. Unless an alternative has been discussed and agreed with the patient, previous medical records should be filed with the CCG (or the BSC if in Wales). No reference to the old NHS number should be made on the new record.

Q What should I do if I cannot find a way to change the record (eg, if the IT system doesn’t offer that option)?

In England and Wales, if a patient has requested a new NHS number, doctors should write to the Personal Demographics Service (PDS) to request a new record. NHS Connecting for Health has published guidance to assist with this process.2 Practices which use the PDS’s National Health Applications and Infrastructure Services (NHAIS) interactive software should update the new details electronically, and once a new NHS number has been allocated, old patient records should be filed with the Clinical Commissioning Group (CCG) (or the Business Services Centre (BSC) in Wales) and the patient then re-registered with the new details. In some instances, a patient may request that their old records be filed at the practice. If this is the case, the old NHS number should not be recorded on any new records.

In Scotland, the process is slightly different. Doctors are required to input a patient’s new name and gender details into their practice management computer system. Practitioner services will then contact the patient to confirm that they wish to be issued with a new Community Health Index (CHI) and NHS number. Once agreed, the previous medical record will be transferred electronically to the new record.

If problems are experienced when attempting to change the gender of a patient on a practice’s internal system, doctors should contact their IT provider for further advice.

Q Are there any other changes I should make apart from to the patient record? (eg, informing other doctors)

It is important for doctors to clarify with patients how they would like details relating to their gender change and previous gender represented going forward. Many screening programmes are gender-specific and doctors should therefore discuss the risks and benefits of screening both in biological gender and acquired gender. If screening is requested, doctors should discuss and agree with the patient on an individual recall approach which preserves their dignity and privacy without disclosing their gender history. Documentation of the discussion should be accompanied with the date and the patient’s signature.

Doctors should not discuss a change in a patient’s gender with anyone else within the healthcare team unless they have the patient’s express consent.

Q Are there any approaches or terms that should not be used in consultation with transgender patients?

The General Medical Council (GMC) is very clear that doctors should treat patients fairly and with respect – whatever their lifestyle choices or beliefs – and must not allow their personal views on gender reassignment to affect a patient’s care. GPs should only use medically recognised terms when treating transgender patients and avoid using jargon to keep the consultation clear and polite.

Q What notes should I make on a patient’s sex if they are transitioning?

The GMC (in Good Medical Practice) advises that clinical records must be clear, accurate, legible and contemporaneous.

As doctors may be involved in arranging blood tests and prescribing hormonal medications prior to gender reassignment surgery, it is important to document all care and treatment provided. Whilst it is important to document relevant clinical information, the records should not contain any administrative reference to previous gender or name.

Reassurance should be given to patients that any medical records relating to gender transition are sensitive information and will be treated confidentially.

Q Why would doctors face criminal charges over mis-recording gender?

The Gender Recognition Act 2004 outlines the rights of patients who have legally changed their gender and presented a GRC.

It is an offence under Section 22 of the Act for doctors to disclose information relating to the patient’s former gender to any third party without the explicit consent from the patient. Consent should be obtained prior to sharing information with any other party (including to another person within the practice), even if considered necessary for the provision of care.

An exception might be if disclosure were justified in the public interest (for example, if the patient was displaying violent characteristics as a result of hormone changes).

However, doctors in this situation are advised to seek advice from MPS or their medical defence organisation first.

Rachel Birch is a medicolegal consultant at MPS.

The answer to, ‘What should I do if a patient asks me to delete the records from before the change of gender?’, was updated on 11 November.

References

1 Department of Health. Trans: a practical guide for the NHS. 2008; Gender Identity Research and Education Society (GIRES) for the Department of Health. Guidance for GPs, other clinicians and health professionals on the care of gender variant people. 2008; Department of Health. Gender dysphoria services. A guide for general practitioners and other healthcare staff. 2012. http://www.nhs.uk/Livewell/Transhealth/Documents/gender-dysphoria-guide-for-gps-and-other-health-care-staff.pdf

2 NHS Connecting for Health. PDS NHAIS Interaction Procedures Guide, Chapter 7.

3 NHS West London Medical Health. Your information leaflet.

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