gender reassignment medical records

Gender Identity in Medical Records

• You may be asked for your gender, sex assigned at birth, and your pronouns, but there is no legislation requiring you to disclose them.
• There are a variety of steps you can take to change the gender identity on your medical records.

The more your healthcare providers knows about you, the more they can give you appropriate care. This also includes knowing and validating your gender identity , which is both the gender you identify with and how you express your gender.

Because we know many healthcare providers do not routinely discuss or collect information about their patients’ gender identity and sexual orientation, it is important to be your own advocate to ensure the information is correct in your medical records.

From a public health perspective, we also know gender and sexual orientation can put you at a higher risk of certain health issues, such as the risk of contracting HIV/AIDs and having breast cancer. Healthcare providers need all the facts to make informed and evidence-based recommendations for treatment and care.

Here we explain best practices for collecting gender identity information and how trans patients can be better included and provide ways you can go about changing your gender identity within your medical records.

Explaining the Importance of Collecting Gender Identity Information

If you are transgender, healthcare rules such as needing to have a form of identification that matches your legal name for hospital records can cause harm and frustration. Notably, the Center for American Progress found 66% of trans patients reported having difficulty obtaining documentation with their correct name and pronouns.

Validating someone’s identity is only the first step in providing good care to trans and nonbinary patients, with gender-affirming care also being incredibly important. A 2022 investigation published in JAMA Open Network found that after receiving gender-affirming care, such as hormones and puberty blockers, trans and nonbinary youths had a 60% lower chance of experiencing severe depression.

A report published in the Journal of the American Medical Informatics Association also emphasized the importance of not assuming the pronouns that people may have, and not limiting which pronouns a person can say that they have.

Options for Collecting Gender Identity in an Electronic Health Record

Researchers suggest a form includes the following gender identity options:

• She/her/hers
• They/them/their
• Use all pronouns
• Try to avoid pronouns
• Unsure of what my pronouns are
• Use other pronouns (Here you would give an option for people to fill in their pronouns).

Is My Healthcare Provider Allowed to Ask for My Gender Identity?

Your healthcare provider may ask you for your gender, sex assigned at birth, and your pronouns, but there is no legislation requiring you to disclose this information. (Considering the anti-transgender legislation many states have enacted or are considering, it is nevertheless understandable if you are uncomfortable answering).

Keep in mind knowing more about you can help your healthcare providers give you better care. For example, the U.S. Department of Veteran’s Affairs notes:

• The medical record system uses sex assigned at birth to determine your lab ranges, for example hormone levels and kidney function.
• Sex is used to automatically remind your provider what health screenings are due, such as prostate screening and pap smears.
• Sex along with height, weight, and age are used to determine doses for your medication(s).

A Message to Professionals Working with Youth Who are Transgender

If you work with youths who are transgender in states with anti-transgender legislation, here are some questions to investigate regarding the protection of personal health information:

• What are your hospital’s policies in dealing with anti-transgender legislation?
• Under what circumstances do you share youths’ information with governmental parties and/or the police?
• Do you and/or your hospital consider gender-affirming care for minors to be a form of abuse?
• What training do people in your hospital receive on being inclusive of transgender and nonbinary patients?

How to Change Your Gender in Your Medical Records

If you want to change your own gender identity on your medical records, there are a variety of steps that you can take, depending on your healthcare provider.

• Your healthcare provider may allow you to update your name, gender identity, and pronouns from your online portal. This could be easily done in the privacy of your home.
• You may have to contact your healthcare provider’s office to ask them to update your gender identity and any other related information via phone, a portal or in person.
• You may be asked to provide legal documentation that your name and pronouns are legally changed if you wish for your dead name to no longer be in your healthcare records. It’s understandable if this is frustrating for you, as updating documents can take a lot of time.

If you find that your current healthcare provider has too many hoops to change your gender identity in medical records, you could provide this feedback or look for a new provider that has a more inclusive practice.

Additional Information:

• AHIMA supports the AMA’s call for Inclusivity in EHRs for the Transgender Patient Population (AHIMA.org)
• Treating LGBT Status as a Patient Safety Issue (AHIMA.org)
• Improved Patient Engagement for LGBT Populations: Addressing Factors Related to Sexual Orientation/Gender Identity for Effective Health Information Management (AHIMA.org)
• Capturing Sexual Orientation/Gender Identity Data through HIT (Journal of AHIMA)
• In a win for trans veterans, VA adds gender identity to medical records (NBCnews.com)
• Electronic health records as an equity tool for LGBTQIA+ people (Nature)

The World Professional Association for Transgender Health (WPATH) is an international multidisciplinary professional association that publishes recognized standards for the care of transgender and gender-variant persons. Read WPATH's best practices specific to electronic health records (EHRs) .

Collecting Sexual Orientation and Gender Identity Information

Importance of the collection and use of these data.

Many health care providers do not routinely discuss sexual orientation or gender identity (SO/GI) with patients, and many health care facilities have not developed systems to collect structured SO/GI data from all patients. Without this information, lesbian, gay, bisexual, and transgender (LGBT) patients and their specific health care needs cannot be identified, the health disparities they experience cannot be addressed, and important health care services may not be delivered. Such services include appropriate preventive screenings, assessments of risk for sexually transmitted diseases and HIV, discussions about parenting, and effective interventions for behavioral health concerns that can be related to the experiences of anti-LGBT stigma. 1 An opportunity for transgender people to share information about their SO/GI in a welcoming and patient-centered environment  opens the door to a more trusting patient–provider relationship.

Collecting SO/GI data in electronic health records (EHRs) is essential to providing high-quality, patient-centered care. SO/GI data collection has been recommended by both the National Academy of Medicine 1,2 and the Joint Commission 3  as a way to learn about which populations are being served and to measure the quality of care provided to LGBT people. Some patients may question the relevance of being asked about their sex listed at birth or their sexual orientation. However, providers need this information to recommend appropriate preventive care. 3 In addition, SO/GI may be fluid across time and should be reassessed periodically so the most up-to-date information is available in the medical record.

Collecting SO/GI data is essential to providing high-quality, patient-centered care.

Leading experts in LGBT health, such as the organizations’ whose recommendations are discussed above, recommend the following questions. These questions are recommended based on testing with rural and urban health centers and other studies of SO/GI data collection, such as research conducted by the Center of Excellence for Transgender Health at the University of California, San Francisco. 1,2

Note that the gender identity questions have two parts: one on current gender identity and one on sex listed at birth. Together, these questions replace “Sex: male or female?” on patient information forms and in EHRs. Asking two questions offers a clearer, more clinically relevant representation of transgender patients. For example, asking whether someone is transgender will exclude some transgender people who do not identify as such (e.g., a person who was born male but whose gender identity is female may check “female” rather than “transgender” on a form). The gender identity question also includes options for people who have a non-binary gender identity (people who do not identify as male or female).

In addition to collecting SO/GI data, asking patients to include the name they want their providers to use as well as the correct pronouns to use is also recommended by leading experts in LGBT health (see below). This is important because many transgender patients have insurance records and identification documents that do not accurately reflect their current name and gender identity. Asking these questions and training the whole health care team to use an individual’s pronouns and name can greatly facilitate patient-centered communication.

Collecting SO/GI data is essential to providing high-quality, patient-centered care for transgender people. SO/GI data can be collected in several ways:

1. Information can be obtained through patient portals and transmitted to an individual’s EHR. 2. Questions can be included on registration forms for all patients as part of the demographic section along with information about race, ethnicity, and date of birth. 3. Providers and their care team can ask questions during the patient visit, for instance, as part of a social or sexual-history discussion.

To address the lack of SO/GI data in health systems, the Department of Health and Human Services’ (HHS’s) Healthy People 2020 external icon included an objective to “increase the number of states, territories, and the District of Columbia that include questions that identify sexual orientation and gender identity on state level surveys or data systems” to improve “the health, safety, and well-being of lesbian, gay, bisexual, and transgender (LGBT) individuals.” Increasing the number of population-based data systems that collect standardized data on (or for) lesbian, gay and bisexual populations and on (or for) transgender populations and expanding the availability of sexual orientation/gender identity (SO/GI) statistics have also been priorities for other federal agencies.

SO/GI information can be entered into the EHR by staff or directly by the patient through a patient portal from home or using electronic kiosks or tablets at various points during their visit (when available). Regardless of how the data are collected, it is helpful to ask SO/GI questions periodically because SO/GI can change over time. Some recommend integrating SO/GI questions with data that are checked regularly such as address and insurance changes, while others recommend updating these data every 6 months or once a year. It is important to include this in the clinical workflow. The figure below illustrates a sample process for gathering SO/GI data in clinical settings.

Sample Process for Collecting Data From Patients in Clinical Settings

The Health Resources & Services Administration (HRSA), an agency of HHS, is requiring all HRSA-funded health centers to collect and report SO/GI data to promote culturally sensitive care delivery and help reduce health disparities.

Although EHR forms and formats will vary, it is critical to collect standardized SO/GI data in all health records, including EHRs. Asking these questions and educating the whole care team on the value of collecting this information can improve patient-centered care. Providers who are informed of their patients’ SO/GI are better able to provide care that is relevant, specific, and compassionate . See below for more information, resources, and training opportunities:

• Patient-Centered Care for Transgender People: Recommended Practices for Health Care Settings
• Additional Resources
• National Academy of Medicine. The health of lesbian, gay, bisexual, and transgender (LGBT) people: building a foundation for better understanding. Washington, DC: National Academies Press; 2011. Available from: www.nap.edu/catalog.php?record_id=13128 external icon
• Deutsch M, Green J, Keatley J, et al.; the World Professional Association for Transgender Health EMR Working Group. Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group. J Am Med Inform Assoc. 2013;20(4):700-703. PubMed abstract external icon .
• Deutsch M, Buchholz D. Electronic health records and transgender patients—practical recommendations for the collection of gender identity data. J Gen Intern Med . 2015;30(6):843-847. PubMed abstract external icon .
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Sex, gender, and medical data: a way forward

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Sex, gender, and medical data

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Rapid Response:

Dear Editor

Thank you for publishing this article which raises important issues about data integrity and protection around the attribute “sex” in NHS data systems.

As the authors state that “Sex and gender are not synonymous.” Sex, relates to biology - male or female. This is a fact about a person which is observed at birth (in most cases without ambiguity or difficulty) and recorded, in a binary fashion into a baby’s NHS number and their medical record. This fact about a person that does not change. However these records are now corrupted.

Gender can mean a number of different things which are not consistent or synonymous with each other..

1. A synonym for sex

2. The broad patterns of behaviour and appearance of the two sexes

3. Appearance/perception i) The clothing and appearance norms associated with either sex ii) Being perceived as a particular sex iii) Wishing to be perceived as a particular sex iv) Making an effort through appearance to appear as a particular sex

4. Social roles i) The traditional social roles and expectations of behaviour of the sexes ii) Wishing to be treated as a particular sex iii) The extent to which someone conforms to traditional social roles

5. Self expression/identity i) A means of self- expression ii) An internal feeling of being a particular “‘gender’” (or both or neither)

6. Language i)The words used to refer people by sex (e.g. him/her, Mr, Ms) ii)The words a person uses to refer to themself iii)The words a person wishes other people to use to refer to them iv) The words other people spontaneously use to refer to someone

Basic principles of data management are that each field or attribute should be clearly defined and contain only that information. Healthcare providers and the NHS should hold accurate, reliable information about patient's sex as a basic minimum. At the moment they do not. There is no single data attribute that records that I am female (and not in fact a male person who identifies as female and has asked to have their record changed).

More than ten years ago the NHS recognised the need for clear systems for recording biological sex and making sure it was not conflated with social gender. They carefully set up a system of data and definitions which could deal with both.[1]

The data standard for the CUI written in 2009 explained:

“The term ‘Gender’ is now considered too ambiguous to be desirable or safe… ”

The data standard set out definitions for patient “sex” and “current gender” and warned:

“Users may confuse the terms current gender and sex, or assume that they are synonymous. Therefore, it is essential that all NHS applications display and explain current gender and sex terminology and values in a clear and consistent manner.”

The data standard set out in detail how to keep these two characteristics separate and unconfused, and how to design computer interfaces to ensure that sex data was captured (with social gender as an optional extra). It also set out potential consequences of not adhering to these standards including:

- The patient is given the wrong treatment as a result of a failure to identify the patient correctly. - The patient is given the wrong treatment as a result of a failure to match the patient correctly with their artefacts (samples, letters, specimens, X-rays, and so on). - The patient is given the wrong treatment as a result of a failure in communication between staff, or staff not performing or checking procedures correctly. - The patient is categorised with a value that cannot be utilised by any other systems. - The patient is categorised incorrectly from a legal perspective. - The patient is categorised incorrectly from their perspective.[2]

However despite establishing the basis for meeting these principles this system was not implemented. The current NHS data dictionary differentiates, "phenotypic sex" (as observed by a clinician) and "patient stated gender", but in practice “male” and “female” are recorded only against gender and the phenotypic sex field typically remains empty.

Policies to allow patients to change their registered "gender" are now embedded across the NHS.

The GMC tells doctors to change a patient’s sex/gender as recorded on medical records on request. This does not require any medical diagnosis, anatomical changes or a legal gender recognition certificate. [2]

Public Health England tells GP surgeries to change a patient’s’ recorded sex/gender on their medical record at any time, without requiring diagnosis or any form of gender reassignment treatment. They are given a new NHS number and previous medical information must be "gender neutralised" and transferred into a newly created medical record. They will be sent screening appointments (e.g. for cervical smear tests or prostate cancer screen) according to their new gender (i.e. invitations to attend the wrong screenings). [3]

Gender (self identified as male or female) is held by the Patient Demographic Service (PDS) for matching rather than clinical purposes. But it has recently been removed from the API because of sensitivity of people who identify as non binary and do not wish to be identified by their sex.[4]

This approach shows the way forward. Sex should not be confused with gender identity, or any other of the myriad definitions of gender. Accurate information on everybody's sex should be held in their NHS record but it should only be disclosed or displayed when it is needed and should not be used for matching purposes.

The authors state that "sex and gender should not be used interchangeably". In fact data quality risks mean that "gender" should not be used as an attribute at all, because it is undefined and invites confusion.

Aspects of social gender such as titles, name used, and preferred pronouns can be recorded in other fields to facilitate social interaction. Transgender identity may be recorded.

Given that the law allows people to change their legal sex, a field may be needed where people's legal sex is recorded, without changing the record of their biological sex (since this, in fact, has not changed and it destroys day integrity for everyone if the field can contain either biological or legal sex).

If someone has a diagnosis or medical treatment such as hormones or surgery to change the appearance of their sex, this of course should be in their medical record.

Greater clarity about definitions, privacy, confidentiality and data protection would allow people to keep their sex private in situations where it is no one else's business but maintain the integrity of medical records. In NHS systems this would need to include a general system of not displaying the last digit of NHS numbers on screen.

Data protection principles apply to everybody and currently the NHS (along with the Passport Office and DVLA) are failing in these principles by requiring information about individual's sex, but then processing it in such as way (mixing it in a category with self declared gender) that the data is corrupted.

As the ONS case over the census highlighted by the authors shows, there will be legal challenges. The Digital Identities Trust Framework being developed by DCMS is also an opportunity to fix the problem of data corruption of the sex attribute. The NHS should establish a task force to understand the corruption of sex data across medical records and establish a plan to fix it.

[1] NHS. 2009. Sex and Current Gender Input and Display User Interface Design Guidance https://webarchive.nationalarchives.gov.uk/+/http:/www.isb.nhs.uk/use/ba... [2] https://www.gmc-uk.org/ethical-guidance/ethical-hub/trans-healthcare#con... [3] https://pcse.england.nhs.uk/help/registrations/adoption-and-gender-re-as... [4] https://sex-matters.org/posts/updates/nhs-lets-talk-about-sex/

Competing interests: No competing interests

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What Is Gender Confirmation Surgery?

Learn about transgender surgery: male-to-female, female-to-male.

Transgender individuals feel that the sex they were assigned at birth, such as male or female, does not match the gender with which they identify. For example, a baby assigned “male” at birth may grow up with a sense of feeling they are female.

As a result of feeling that they were born in the wrong gender, some transgender individuals experience psychological distress known as “ gender dysphoria ” and take various actions to better align their gender identification with their external appearance. For some individuals, the transition process from one gender to another may include medical treatments, such as hormone therapy and gender confirmation surgery.

What is hormone therapy?

Usually the first step in the gender transition process, hormone therapy is intended to suppress the assigned sex characteristics, promote the desired characteristics, or both. For example, men who identify as women may take anti-androgens to block production of the male hormone testosterone, as well as estrogen to appear more feminine. Similarly, women who identify as men may take testosterone to develop more masculine features, such as facial hair.

What is gender confirmation surgery?

If hormone therapy does not have the desired effectiveness, gender confirmation surgery may be an option. Also called gender reassignment surgery, the goal of this procedure is to create the outward physical appearance of the gender with which the person identifies. “Top surgery” refers to surgery above the waist, while “bottom surgery” refers to surgery below the waist.

Transgender surgery is major surgery and generally not considered reversible, so many healthcare providers require transgender individuals to complete several steps before they will proceed with surgery. These may include requiring a formal diagnosis of gender dysphoria and having counseling to determine their psychological readiness for surgery.

“Gender confirmation surgery involves both physical and psychological aspects,” says Manish Champaneria, MD , a plastic surgeon at Scripps Clinic. “Scripps follows the recommendations of the World Professional Association for Transgender Health (WPATH) regarding preparation for surgery, including having a referral from a mental health provider. Patients undergoing surgery are urged to live as the gender they identify as for at least 12 months before having the procedure.”

Gender confirmation surgery options

Scripps offers gender confirmation surgery procedures for both male-to-female (MTF) or transwomen patients, and female-to-male (FTM) or transmen patients.

Top surgery

Performed on the chest, top surgery is intended to create a more gender-confirming physique. Top surgery procedures include mastectomies for transmen and breast augmentation for transwomen. In most cases, top surgeries are completed in a single procedure.

MTF top surgery

MTF top surgery to augment the breasts may involve fat transfer or breast implants. In a fat transfer procedure, the surgeon removes fat from other parts of the body and injects it into the breasts. Fat transfer may be recommended for patients who wish to increase breast size without breast implants.

Patients who seek larger breasts may choose to have breast implants, which are surgically placed under the chest muscles to enhance breast size and shape. The surgeon and patient together determine the most appropriate size and type of implants.

FTM top surgery

In FTM top surgery, the surgeon removes breast tissue and manipulates the remaining tissue to create a more masculine appearance.

Facial feminization surgery

During MTF facial feminization surgery, the surgeon restructures masculine facial features to achieve a more feminine look. This involves reshaping bones and soft tissues and may be performed as a single procedure or in several stages.

Body contouring

Using various procedures, body contouring reshapes the body to create a more masculine or feminine physique. Specific procedures depend on the patient’s original body shape and desired outcomes. For example, fat transfer may be used to reduce curves in some areas and create them in others.

“We understand that gender confirmation surgery is a life-changing procedure that requires multidisciplinary medical expertise and experience, and we work very closely with our transgender patients every step of the way,” says Dr. Champaneria. “We urge anyone considering this surgery to start by talking with a trusted and physician who is experienced in transgender procedures.”

Related tags:

• Health and Wellness
• Women’s Health
• Men’s Health

Transgender Patients/Gender Reassignment

Gender Identity toolkit:  The toolkit has been produced in collaboration between the Institute of General Practice Management, Indigo Gender Service, Practice Index and Pride in Practice. It is designed to support the knowledge and confidence of general practice teams providing inclusive and equitable care to trans and non-binary patients. The barriers trans and non-binary patients face range from direct discrimination to supportive healthcare professionals lacking the knowledge or confidence to provide appropriate care. Concurrently, the number of openly trans and non-binary patients seeking gender-affirming care from their GP and other healthcare professionals is increasing. The Gender Identity Toolkit is a practicable resource to improve the availability of inclusive and equitable care for trans and non-binary patients at a crucial moment.

A patient may request to be known by a different gender with or without the legal recognition which will only follow after the issue of a full Gender Recognition Certificate by the Gender Recognition Panel under provisions contained in the Gender Recognition Act 2004 (1). In this case, the patient must by law be supplied with a new identity and the old identity revoked, including transferring all medical records.

Legal recognition will only follow after the issue of a full Gender Recognition Certificate by a Gender Recognition Panel. The panel must be satisfied that the applicant:

• has, or has had, gender dysphoria
• lived in the acquired gender throughout the preceding two years.
• intends to continue to live in the acquired gender until death.

Medical Records Flowchart 

In this case, the patient must be supplied with a new identity and the old identity revoked, including transferring all medical records.

Generally, patients will have lived as the alternative administrative gender prior to clinical reassignment.

A patient may request to be known by a different administrative gender without a full Gender Recognition Certificate.

This may be as a result of a clinical intervention or simply a desire to be known by a different gender.

In such cases the patient must be cautioned about the consequences of changing administrative gender, for example, in connection with cancer screening programmes. Both types of request are currently treated identically.GPs are obliged to make arrangements for patients to continue to have appropriate screening tests without need to reference the previous gender to the agency providing the service.

What happens now?

When a patient requests a gender reassignment the patient's GP or ICB must write to the Personal Demographics Service (PDS) National Back Office which creates a new identity with a new NHS Number (the old one is withdrawn and not re-used) and requests the records (or envelope) held by the patient's GP. These records are then transferred to the new identity and sent back to the practice. Written records should then be altered to remove any reference to the previous name, gender and NHS number but no changes should be made to conceal or alter the patient’s clinical history. GP clinical computer systems providers can give advice on merging clinical records.

GPs and staff should be careful that, whatever the stage of gender transition, information should only be passed on when it is relevant to patient care. For example, with the use of IT systems to help produce referral letters, it is easy for irrelevant personal information to be included in, say, an ENT referral where there can be no clinical reason for mentioning it. Furthermore, the Gender Recognition Act provides transsexual people with special protection of their privacy and so it is an offence to disclose the transsexual history of a patient with a Gender Recognition Certificate without their explicit consent. It is recommended that a warning be placed on the record stating “Confidential Patient Data – take care on disclosure of information” and that this should not be immediately visible to the patient.

Future work

The Department for Constitutional Affairs (DCA), which has overall responsibility for the Gender Recognition Act, is working with NHS Connecting for Health to incorporate the new legislation into the NHS Care Records Service.

The advent of the NHS Care Records Service means that there is greater opportunity to extend the policy to the patient's entire clinical record, rather than that just held by their GP.

Please refer to Chapter 7 of the procedures guide for f urther guidance and information

(1) The panel will have been satisfied that the applicant: has gender dysphoria; has lived congruent to the acquired gender throughout the preceding two years (generally this is before surgical intervention and is often referred to as “real life experience.”) and intends to continue to live in the acquired gender until death.

PCSE gender re-assignment processes

BMA Guidance for Primary Care

The role of the GP in caring for gender-questioning and transgender patients - RCGP Position Statement

Transgender GP letter template for private or NHS GIC March 2021

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Changing a trans person's name and gender marker on NHS systems

Advice and Information - 28 July 2021

A trans person can change their name and gender marker at their GP practice just by requesting it. They do not need to have been to a Gender Identity Clinic, taken any hormones, undergone any surgery, or have a Gender Recognition Certificate.

The law in the UK regarding names is actually very unusual, stating that anyone can call themselves by any first name without any documentation at all – as long as they are known by it, it is a legal name! Despite this, Primary Care Support England (PCSE) recommend that healthcare services see a deed poll before changing a patient’s name on their medical record. For this reason, almost all GP practices will ask for a deed poll when amending patient’s names/details.

Patients can obtain a free Deed Poll online at freedeedpoll.org.uk

Changing a patient’s name will not change the gender marker on their medical records. If patients wish to change their gender marker, they must request this. The practice will have to notify PCSE and should make the patient aware of the possible time scales and implications of changing their gender marker (e.g. changes to recalls for cancer screening services).

According to PCSE, when a patient changes gender, they are given a new NHS number and must be registered as a new patient at your practice. All previous medical information relating to the patient needs to be transferred into a newly created medical record.

When the patient informs the practice that they wish to change gender, the practice must inform the patient that this will involve a new NHS number being issued for the them, which is not reversible. If the patient wanted to change their gender marker back to the gender they were assigned at birth, patients would receive a third NHS number. The practice should confirm this has been discussed with the patient when notifying PCSE.

The process (outlined by PCSE) for changing a patient’s gender marker is as follows:

• The practice notifies PCSE via the enquiries form that a patient wishes to change their gender. The practice should include the patient’s name and NHS number in the notification to PCSE, plus confirmation that they have discussed with the patient that this will involve the creation of a new NHS number
• PCSE sends the practice a deduction notification for the patient and emails the main contact for the practice (if available) the new details for the patient
• The practice accepts the deduction and registers the patient using the new details provided by PCSE. Important: Do not update the patient’s original record with their new NHS number. If this happens they will not be registered and will miss out on continuity of care
• PCSE sends a new patient medical record envelope with the patient’s updated details to the practice

The practice creates a new patient record using the new details, and transfers all previous medical information from the original medical record

Any information relating to the patient’s previous gender identity should not be included in the new record. Practices can use gender neutral language and anonymise patient details to retain important information. For example, using phrases such as ‘the patient had a smear on….’ rather than ‘she had a smear on…’. This is to protect confidential information and ensure the practice is in line with the Gender Recognition Act 2004 which makes disclosing an individual’s trans history unlawful in many instances

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Billing and Coding: Gender Reassignment Services for Gender Dysphoria

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Copyright © 2023 , the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

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CMS National Coverage Policy

Title XVIII of the Social Security Act (SSA) §1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim

Article Guidance

Gender Dysphoria (GD) is defined by the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition, DSM-5™ as a condition characterized by the "distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender" also known as “natal gender”, which is the individual’s sex determined at birth. Individuals with gender dysphoria experience confusion in their biological gender during their childhood, adolescence or adulthood. These individuals demonstrate clinically significant distress or impairment in social, occupational, or other important areas of functioning. GD is characterized by the desire to have the anatomy of the other sex, and the desire to be regarded by others as a member of the other sex. Individuals with GD may develop social isolation, emotional distress, poor self-image, depression and anxiety. The diagnosis of GD is not made if the individual has a congruent physical intersex condition such as congenital adrenal hyperplasia. Gender Reassignment Therapy GD cannot be treated by psychotherapy or through medical intervention alone. Integrated therapeutic approaches are used to treat GD, including psychological interventions and gender reassignment therapy. Gender reassignment therapy, either as male-to-female transsexuals (transwomen) or as female-to-male transsexuals (transmen), consists of medical and surgical treatment that changes primary or secondary sex characteristics. Initially, the individual may go through the real-life experience in the desired role, followed by cross-sex hormone therapy and gender reassignment surgery to change the genitalia and other sex characteristics. The difference between cross-sex hormone therapy and gender reassignment surgery is that the surgery is considered an irreversible physical intervention. Gender reassignment surgical procedures are not without risk for complications; therefore, individuals should undergo an extensive evaluation to explore psychological, family, and social issues prior to and post-surgery. Additionally, certain surgeries may improve gender- appropriate appearance but provide no significant improvement in physiological function. These surgeries are considered cosmetic and are non-covered. NON-SURGICAL TREATMENT Initiation of cross-sex hormone therapy may be provided after a psychosocial assessment has been conducted and informed consent has been obtained by a health professional. The criteria for cross sex hormone therapy are as follows:

• Persistent, well-documented gender dysphoria;
• Capacity to make a fully informed decision and to consent for treatment;
• Member must be at least 18 years of age;
• If significant medical or mental health concerns are present, they must be reasonably well controlled.

The presence of co-existing mental health concerns does not necessarily preclude access to cross-sex hormones. These concerns should be managed prior to or concurrent with treatment of gender dysphoria. Cross-sex hormonal interventions are not without risk for complications, including irreversible physical changes. Medical records should indicate that an extensive evaluation was completed to explore psychological, family and social issues prior to and post treatment. Providers should also document that all information has been provided and understood regarding all aspects associated with the use of cross-sex hormone therapy, including both benefits and risks. READINESS FOR THE TREATMENT OF GENDER DYSPHORIA Readiness criteria for gender reassignment surgery includes the individual demonstrating progress in consolidating gender identity, and demonstrating progress in dealing with work, family, and interpersonal issues resulting in an improved state of mental health. In order to check the eligibility and readiness criteria for gender reassignment surgery, it is important for the individual to discuss the matter with a professional provider who is well-versed in the relevant medical and psychological aspects of GD. The mental health and medical professional providers responsible for the individual's treatment should work together in making a decision about the use of cross-sex hormones during the months before the gender reassignment surgery. Transsexual individuals should regularly participate in psychotherapy in order to have smooth transitions and adjustments to the new social and physical outcomes. TRANS-SPECIFIC CANCER SCREENINGS Professional organizations such as the American Cancer Society, American College of Obstetricians and Gynecologists and the US Preventive Services Task Force provide recommended cancer screening guidelines to facilitate clinical decision-making by professional providers. Some cancer screening protocols are sex/gender specific based on assumptions about the genitalia for a particular gender. There is little data on cancer risk specifically in transsexual individuals. There is difficulty in recommending sex/gender specific screenings (e.g., breast, cervix, ovaries, penis, prostate, testicles and uterus) for transsexual individuals because of their physiologic changes. For example, transmen who have not undergone a mastectomy have the same risks for breast cancer as natal women. In transwomen, the prostate typically is not removed as part of genital surgery, so individuals who do not take feminizing hormones may be at the same risk for prostate cancer as natal men. Therefore, cancer screenings (e.g., mammograms, prostate screenings) may be indicated based on the individual's original gender. Gender specific screenings may be medically necessary for transgender persons appropriate to their anatomy. Examples include:

• Breast cancer screening may be medically necessary for transmen who have not undergone a mastectomy.
• Prostate cancer screening may be medically necessary for transwomen who have retained their prostate.

Claims for gender reassignment surgery will be reviewed on a case-by-case basis. Surgical treatment of gender reassignment surgery for gender dysphoria may be eligible when medical necessity and documentation requirements outlined within this article are met. Surgical treatment for gender dysphoria may be considered medically necessary when ALL of the following criteria are met:

• The individual is at least 18 years of age.
• A gender reassignment treatment plan is created specific to an individual beneficiary
• The individual has a documented Diagnostic and Statistical Manual of Mental Disorders -Fifth Edition, DSM-5 ™ diagnosis of GD:

 A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two of the following:

• A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics.
• A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender.
• A strong desire for the primary and/or secondary sex characteristics of the other gender.
• A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
• A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).
• A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).

 B. The condition is associated with clinically significant distress or impairment in social, occupational or other important areas of functioning.

• That any co-morbid psychiatric or other medical conditions are stable and that the individual is prepared to undergo surgery.
• That the patient has had persistent and chronic gender dysphoria.
• That the patient has completed twelve months of continuous, full-time, real-life experience (i.e., the act of fully adopting a new or evolving gender role or gender presentation in everyday life) in the desired gender.
• The individual, if required by the mental health professional provider, has regularly participated in psychotherapy throughout the real-life experience at a frequency determined jointly by the individual and the mental health professional provider.
• Unless medically contraindicated (or the individual is otherwise unable to take cross-sex hormones), there is documentation that the individual has participated in twelve consecutive months of cross-sex hormone therapy of the desired gender continuously and responsibly (e.g., screenings and follow-ups with the professional provider).
• The individual has knowledge of all practical aspects (e.g., required lengths of hospitalizations, likely complications, and post-surgical rehabilitation) of the gender reassignment surgery.

 SURGICAL TREATMENTS FOR GENDER REASSIGNMENT When all of the above criteria are met for gender reassignment surgery, the following genital surgeries may be considered for transwomen (male to female):

• Orchiectomy - removal of testicles
• Penectomy - removal of penis
• Vaginoplasty - creation of vagina
• Clitoroplasty - creation of clitoris
• Labiaplasty - creation of labia
• Mammaplasty - breast augmentation
• Prostatectomy -removal of prostate
• Urethroplasty - creation of urethra

When all of the above criteria are met for gender reassignment surgery, the following genital/breast surgeries may be considered for transmen (female to male):

• Breast reconstruction (e.g., mastectomy) - removal of breast
• Hysterectomy - removal of uterus
• Salpingo-oophorectomy - removal of fallopian tubes and ovaries
• Vaginectomy - removal of vagina
• Vulvectomy - removal of vulva
• Metoidioplasty - creation of micro-penis, using clitoris
• Phalloplasty - creation of penis, with or without urethra
• Urethroplasty - creation of urethra within the penis
• Scrotoplasty - creation of scrotum
• Testicular prostheses - implantation of artificial testes

Services or procedures may not be covered when the criteria and documentation requirements outlined within this article are not met.

The determination of whether to cover gender reassignment surgery and related care for a particular individual is based on whether the item or service is reasonable and necessary to treat the beneficiary’s medical condition after considering the individual’s specific circumstances. These decisions are made after the individual has obtained the medical service and a claim has been submitted by the Medicare provider.   The individual's medical record must be submitted along with the claim and support the services billed. These medical records may include but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports. When reporting procedure code 55970 (Intersex surgery; male to female), the following staged procedures to remove portions of the male genitalia and form female external genitals are included:

• The penis is dissected, and portions are removed with care to preserve vital nerves and vessels in order to fashion a clitoris-like structure.
• The urethral opening is moved to a position similar to that of a female.
• A vagina is made by dissecting and opening the perineum. This opening is lined using pedicle or split- thickness grafts.
• Labia are created out of skin from the scrotum and adjacent tissue.
• A stent or obturator is usually left in place in the newly created vagina for three weeks or longer.

When reporting CPT ® code 55980 (Intersex surgery; female to male), the following staged procedures to form a penis and scrotum using pedicle flap grafts and free skin grafts are included:

• Portions of the clitoris are used, as well as the adjacent skin.
• Prostheses are often placed in the penis to create a sexually functional organ.
• Prosthetic testicles are implanted in the scrotum.
• The vagina is closed or removed.

Response To Comments

Coding information, bill type codes, revenue codes, cpt/hcpcs codes.

Transwoman procedures (male to female) *NOTE: For Part A services only, the provider should bill the appropriate procedure code(s) for inpatient services. The following CPT ® codes will be considered when applicable criteria have been met:

Transman procedures (female to male) *NOTE: For Part A services only, the provider should bill the appropriate procedure code(s) for inpatient services. The following CPT ® codes will be considered when applicable criteria have been met:

All unlisted procedure codes will suspend for medical review. The following CPT ® codes are considered cosmetic. When billed with any Covered ICD-10 Codes listed below, the service will not be covered (list may not be all-inclusive):

CPT/HCPCS Modifiers

Icd-10-cm codes that support medical necessity.

The following diagnosis codes are considered covered when applicable criteria have been met:

ICD-10-CM Codes that DO NOT Support Medical Necessity

All other diagnosis codes will be denied as non-covered.

ICD-10-PCS Codes

Additional icd-10 information.

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Other Coding Information

Coding table information, revision history information, associated documents.

• Gender Reassignment
• Gender Dysphoria

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Page Help for Article - Billing and Coding: Gender Reassignment Services for Gender Dysphoria (A53793)

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When should a transsexual person’s medical records be amended to reflect their acquired gender? (that is, the gender in which the person wishes to be recognised, which is not the gender that they were recognised in at birth).

Under the Gender Recognition Act 2004 (‘GRA’), a transsexual person who is at least 18 years old can apply for legal recognition of their acquired gender through issue of a Gender Recognition Certificate (GRC). Once a person is granted a GRC, they will from that date – but not retrospectively – be entitled to be recognised as being of their acquired gender as opposed to the gender that was registered on their birth record.

However, GMC, NHS and BMA guidance states that requests to amend medical records should be granted, regardless of whether or not a Gender Recognition Certificate or updated birth certificate has been obtained. This reflects the spirit of the GRA which requires, amongst other things, that a person has lived in their acquired gender for the preceding two years in order to be eligible to apply for a GRC (note different rules apply to a person who wishes to apply for a GRC on the basis of having changed gender under the laws of a non-UK country).

Please see relevant extracts of the guidance below.

GMC, Ethical Guidance: Trans healthcare ( https://www.gmc-uk.org/ethical-guidance/ethical-hub/trans-healthcare#confidentiality-and-equality ):

“ Medical records: changing name, title, sex, NHS number

Name and title   Both electronic and paper medical records should clearly indicate your patient’s preferred name and title.

  Sex      A patient’s request to change the sex indicated on their medical records should be respected; they do not have to have been granted a Gender Recognition Certificate or have acquired an updated birth certificate for this to be changed.

  NHS number       If your patient is to be issued with a new NHS number which has no reference to their sex at birth, you should explain to them that they will not automatically be contacted regarding current or future screening programmes associated with their sex at birth, and discuss the implications of this. Decisions about screening should be made with patients in the same way as any other decisions about their health. ”

Department of Health, Gender dysphoria services: a guide for General Practitioners and other healthcare staff (attached):

“ The GP is also responsible for making appropriate changes to patient record systems to reflect the patient’s desired future gender role and to ensure that such changes facilitate screening for physiologically appropriate risks. For Male-to-Female patients, this includes a theoretical risk of breast and prostate cancer, but not cervical cancer. For Female-to-Male patients, the GP should arrange for a suitably dignified gynaecological examination according to the patient’s genital physiology. All such arrangements should take into consideration the need to ensure that patients’ gender histories are not disclosed (directly or indirectly) to third parties, in part because such disclosure can represent a criminal offence. Diligently kept and universally consistent records should minimise the risk of disclosure, but also of inadvertently addressing or referring to the patient inappropriately. The best general rule is to discuss matters in advance with the individual patient and obtain their informed consent for each process. ”

BMA guidance: Focus-on-gender-incongruence-in-primary-care

“ Changing medical records and disclosures of information

The Gender Recognition Act 2004 provides safeguards for the privacy of individuals with gender incongruence and restricts the disclosure of certain information. The Act makes it an offence to disclose ‘protected information’ (i.e. a person’s gender history after that person has changed gender under the Act) when that information is acquired in an official capacity.

  This means that the ‘protected information’ can only be disclosed when:

• it is to another health professional; and
• it is for a medical purpose; and
• there is a reasonable belief that the patient has consented to the disclosure.

PDS NHAIS guidance states that patients who are undergoing the transition process are also entitled to the same special protection against disclosure of their gender history.

  Sometimes GPs are asked by patients with gender incongruence to change their name and gender on the practice medical record, and patients do have this right to change their personal details direct with the practice. Patients also have the right to change the name and gender on their official NHS registration documents without obtaining a Gender Recognition Certificate.

The PDS NHAIS guidance sets out in more detail all the steps involved in changing the patient’s name and gender on the patient record. ”

GP practices should note the following:

• It is a criminal offence for a person who has, in an official capacity (including, for example, a doctor), acquired information relating to a person who has made an application under the GRA, to disclose the information to any other person without the person’s consent (or in other limited circumstances) (GRA).
• It is unlawful to discriminate against a person on the grounds of gender reassignment, which is a protected characteristic (Equality Act 2010)

Please also find an online article on Pulse which is written by MPS helpful. R ecording gender in medical-records

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Youth transgender care policies should be driven by science

U.s. states should follow europe’s example when deciding on medical care for minors experiencing gender dysphoria, by joshua cohen.

This article originally appeared on Undark.

I n the U.S., 23 states have passed legislation to ban medicalized care for minors with gender dysphoria, or the experience of distress that can occur when a person’s gender identity does not match the sex they were assigned at birth. On the other hand, 12 state legislatures have introduced laws to protect access to youth transgender care. Such care can include puberty blockers, which are medications that suppress the body's production of sex hormones, and cross-sex hormones like testosterone or estrogen that alter secondary sex characteristics. It also may include sexual reassignment surgery in rare instances.

U.S. policies on both ends of the spectrum are not science-driven but rather emanate from polar-opposite ideologies. Unlike in Europe, there doesn’t appear to be room for a non-ideological process for determining what the best care is that weighs the emerging clinical evidence and adjusts policies accordingly.

As reported in Axios , state efforts to restrict various forms of transgender medicine are being fueled by religious groups that aim to shape policy based on their strongly held beliefs around the immutability of gender and family.  Faith-based objections to transgender care come from a worldview in which God created humans as male or female. Here, the role of parents’ rights features prominently, as well as a conviction that adolescents are insufficiently mature to decide on trans alterations to their bodies. Moreover, lawmakers point out that some young people later regret having had irreversible body-altering treatment.

To take a more rational approach, the U.S. ought to adopt the European perspective and look to the forerunners in gender care — the Dutch.

The bans on care can be driven by extreme religious views. In one example, The Associated Press reported last year that Oklahoma state Sen. David Bullard introduced what he called the “Millstone Act” — a bill that would make the act of providing gender transition procedures to anyone under the age of 26 a felony — by citing a Bible passage that suggests those who cause children to sin should be drowned. The age limit was later lowered to 18.

Proponents, however, see the idea behind gender-affirming care as offering medical treatment so that a person can live as the gender with which they identify. A frequently heard argument is that children who can’t access care are at significantly higher risk of worse mental health outcomes. There is evidence that gender-affirming care for youth yields short-term improvements in terms of less depression and suicidality. However, a review of the literature shows it suffers from a lack of methodological rigor by not adequately controlling for the presence of other psychological conditions, substance use, and factors that enhance or reduce suicide risk. This greatly enhances the possibility of misinterpreting the data, leading researchers to cite significant differences between groups being compared when in fact there are no differences.

U.S. policies on both ends of the spectrum are not science-driven but rather emanate from polar-opposite ideologies.

A critique in The Economist assessed apparent political motivations underlying the presumed consensus among U.S. health care providers, including groups like the American Academy of Pediatrics, or AAP, that gender-affirming care is invariably beneficial and should be made as accessible as possible. But an empirical basis for relatively easy access is lacking. In 2020, the British National Institute for Health and Clinical Excellence published two systematic reviews — one on puberty blockers, the other on cross-sex hormones — which indicated no clear clinical benefit of such treatments regarding gender-dysphoria symptoms. The review found that analyses regarding the impact of puberty blockers were “either of questionable clinical value, or the studies themselves are not reliable.” On cross-sex hormones, the institute identified short-term benefits but said these “must be weighed against the largely unknown long-term safety profile of these treatments.”

Furthermore, based on a four-year review led by Hilary Cass, the National Health Service in England declared in March that puberty blockers will not be available to children and young people, unless they’re enrolled in clinical research trials. In April, the final report was released which reinforced the NHS policy change.

To take a more rational approach, the U.S. ought to adopt the European perspective and look to the forerunners in gender care — the Dutch. Caution is at the heart of the Dutch model of care for those presenting with gender dysphoria. Over a period spanning two decades, gender specialists in the Netherlands methodically compiled a comprehensive set of guidelines for providing trans care for minors, known as the Dutch protocol . The protocol outlines prerequisites  for care, which include documented onset of gender dysphoria during early childhood, an increase of the experience of gender incongruence after puberty, the absence of other significant psychiatric illnesses, and a demonstrated knowledge and understanding of the consequences of medical transition.

After a youth enters a clinic, they undergo a diagnostic phase that lasts at least six months, during which time there’s an intensive work-up involving detailed questionnaires and dialogue between the young person and a mental health support team. After that, youths who want to pursue a medical transition are prescribed puberty blockers, and it may be a couple more years before they become eligible for cross-sex hormones.

Treatment with puberty blockers typically begin around age 12. Irreversible and partially irreversible interventions, which include cross-sex hormones and surgery, cannot be given until the person reaches 16 and 18, respectively. Patients who go through with the transitioning process are provided with psychotherapy throughout.

To take a more rational approach, the U.S. ought to adopt the European perspective and look to the forerunners in gender care.

This watchful waiting approach to helping gender-diverse children is rejected by the AAP, psychologist James M. Cantor wrote in an analysis of the AAP’s policy. U.S. clinicians have criticized the Dutch process for being too slow and erecting unnecessary obstacles on the path of gender transition. They tend to favor quicker access to puberty blockers, cross-sex hormones, and even surgeries for young people. Although sex reassignment surgeries are relatively rare in the U.S., recent research using data from 2016 to 2020 show that 3,678 (7.7 percent) of them were in the 12 to 18 age group. In Europe, such surgeries for youth are mostly inaccessible .

And a growing number of European countries are  reevaluating  their approach to pharmaceutical care for gender-incongruent minors, indicating the need for even more caution than the Dutch Protocol provides. Medical experts point to the dearth of rigorous high-quality evidence to support the use of drugs. They base their assessments on a series of  systematic evidence reviews  conducted by public health authorities in Finland, Sweden, and England to determine the risks and benefits of puberty blockers and cross-sex hormones. The data collected and analyzed in the reviews suggest a risk-benefit ratio that is characterized as unknown , unfavorable, or insufficient on a scientific basis .

A landmark study published this year examined deaths from all causes and from suicide in Finnish adolescents and young adults who were seen at specialized gender identity clinics between 1996 and 2019. It found that pharmaceutical intervention or surgery was not linked to a reduction in suicide when researchers took psychiatric treatment history into account.

Study findings have informed changes in policy regarding treatment of gender incongruence in minors. Besides England, most health authorities are not instituting bans on treatment. However, currently in European countries that have traditionally been leaders in youth gender medicine — such as Sweden , Denmark , France and Finland , — patients under 18 typically only receive puberty blockers and cross-sex hormones if they meet strict eligibility requirements. Health authorities suggest that key questions remain unanswered, including the long-term effects of puberty blockers and hormones on bones, brain, sexual function, and fertility. In the meantime, clinicians are prioritizing approaches which seek to address possible psychological conditions that might accompany gender dysphoria and explore the psychological and other possible determinants of trans identity.

Despite these findings and the changing viewpoints in Europe, there’s intransigence on the part of AAP and other U.S. medical professional societies to alter course. Although after years of balking, AAP finally called for a review of the medical research, it continues to advocate for its position. In what amounts to a politically charged statement, the an editorial in the AAP journal Pediatrics stated that withholding gender-affirming care is “harmful to children and amounts to state-sanctioned medical neglect and emotional abuse.”

Europe’s approach of not banning but instead restricting medicalized transgender care for minors stands in stark contrast to the U.S. Changes in policies are dictated by emerging clinical evidence, not gender-identity politics or theological ideology.

Joshua Cohen is an independent healthcare analyst and freelance writer based in Boston.

This article was originally published on Undark . Read the original article .

about youth mental health

• We need to reframe how we think about juvenile sex offenders
• Social media is a lifeline for mental health, not a curse, according to CDC's own data
• We've gotten the "teenage mental health crisis" dangerously wrong

Joshua Cohen is a writer who lives in Pennsylvania.

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As SC legislature winds down, bill banning transgender youth medical care returns to House

South Carolina’s state Senate voted to approve a House bill outlawing gender-affirming medical care for transgender youth. Now, it heads back to the House after the Senate designated amendments to the bill.

After a lengthy debate last week, state senators voted 28-8 to forward the bill to the House in the last days before the legislative session ends on May 9.

The bill would eliminate the use of puberty-blocking drugs, hormone therapy, and gender reassignment surgery for those under 18. It would allow puberty-blocking drugs for minors diagnosed with conditions like precocious puberty or endometriosis who use puberty blockers as treatment.

It would also ban the South Carolina Medicaid Program from providing coverage for minors and adults.

One of the largest changes from the Senate’s amendments was a provision requiring public school principals and vice principals to inform parents if a child reported identifying as a different gender from their assigned sex or using different pronouns.

More: UMC Thursday updates: United Methodists strike down 52-year-old statement on homosexuality and Christianity

Opponents of this bill argued this would be a forced outing and could cause problems for a child at home. Sen. Tameika Devine (D-19), for example, had an issue with the bill that it only addressed public schools and not private schools. She also argued that the bill revokes medical freedom.

“This bill isn’t showing love, it’s not showing compassion. It is actually malicious and is showing that we are not caring for all citizens,” Devine said.

Supporters of the bill argued that the goal of the bill was to protect children. Those against the bill argue that the bill would harm transgender children.

“The main reason for this bill is to protect minors from making life-changing decisions that can have harmful and irreversible effects,” Sen. Richard Cash, a Republican representing Anderson County, said last week.

But, a study from the New England Journal of Medicine shows transgender and non-binary youth who use hormones and puberty blockers show lowered signs of depression and anxiety.

If passed by the House, South Carolina would join 25 states to outlaw medical care for transgender youth, according to the Human Rights Campaign.

Savannah Moss covers Greenville County politics and growth/development. Reach her at [email protected] or follow her on X @Savmoss.

Texas district judge blocks Ken Paxton's demands for PFLAG gender-affirming care records

A Travis County state District Court on Monday blocked Texas Attorney General Ken Paxton from demanding information from a nationwide LGBTQ+ organization about its support for families seeking gender-affirming medical care for transgender youths, finding that there is "a substantial likelihood" that the nonprofit's case against the state "will prevail after a trial on the merits."

The LGBTQ+ organization, PFLAG National, sued the attorney general's office Feb. 29 after receiving what it called an "outrageous and unconstitutional demand" for records. The civil investigative demand that Paxton sent to PFLAG seeks information about alleged "misrepresentations regarding Gender Transitioning and Reassignment Treatments" as well as relating to the nonprofit's statements in Loe v. Texas and PFLAG v. Abbott, two cases in which the group is suing the state on behalf of families that have sought or provided gender-affirming care to their children.

In Loe v. Texas, the Texas Supreme Court in January heard oral arguments on whether parents in the state have the right to let their children receive gender-affirming medical care after the Legislature last year passed Senate Bill 14, a law that went into effect in September and prohibits doctors in Texas from providing certain gender-affirming medical treatments — including puberty blockers, hormone therapy and certain surgeries — to minors experiencing gender dysphoria, a condition in which a person’s gender identity doesn’t match their sex at birth.

After a Monday morning hearing, District Court Judge Amy Clark Meachum, a Democrat, issued the temporary injunction against Paxton's "unlawful" demands for information and documents, writing that the attorney general's office exceeded its authority.

The injunction replaces a temporary restraining order that Judge Maria Cantú Hexsel of the 53rd District Court issued March 1, which would have expired Friday, and will remain active until the case is resolved. A trial is set for 9 a.m. June 10.

In addition to allowing PFLAG to keep its information private, the judge's order bars Paxton from retaliating against the organization.

“PFLAG National has consistently protected Texas families with transgender youth in the face of the State’s persecution,” Chloe Kempf, an attorney for the ACLU of Texas, said in a statement. “This court ruling is a critical step in allowing PFLAG National and its members to join together and advocate for each other, free from the threat of the attorney general’s retaliation and intimidation."

In its original petition, lawyers for the group wrote that it appeared Paxton's office was "seeking to determine which Texas families are seeking to access gender-affirming care for their transgender adolescents" in multiple civil investigative demands, which could reveal the families' identities.

In Monday's injunction order as in the March 1 temporary restraining order , the court wrote that the requests for information and documents are "unlawful" and that PFLAG and its members — the parents and families of transgender youths — would suffer "immediate and irreparable injury" if the attorney general were allowed to obtain information ahead of a trial.

The order states that Paxton's office's requests would have inhibited families' exercise of free speech and harmed their ability to "avail themselves of the courts when their constitutional rights are threatened." The order also says the demands would have led to "gross invasions of both PFLAG's and its members' privacy in an attempt to bypass discovery stays entered in both Loe v. Texas and PFLAG v. Abbott."

Paxton's office did not respond to an American-Statesman request for comment Monday.

In a statement Feb. 29 about the lawsuit, Paxton said he is going after PFLAG for hiding what he called "incriminating documents" that he thinks will answer the question of whether "medical providers are committing insurance fraud in order to circumvent" SB 14.

“Texas passed SB 14 to protect children from damaging, unproven medical interventions with catastrophic lifelong consequences for their health,” Paxton said in the statement. “Any organization seeking to violate this law, commit fraud, or weaponize science and medicine against children will be held accountable.”

More: Is Texas' ban on gender-affirming care for minors constitutional? Supreme Court hears case

The state has argued that gender-affirming care treatments are ineffective and potentially dangerous in the long term for minors, largely tossing aside discrimination concerns and the effects on parents' rights to seek medical treatment for their children.

Major medical associations, including the American Academy of Pediatrics, the American Medical Association, and the American Psychiatric Association, support the provision of developmentally-appropriate and individualized gender-affirming medical care for transgender youth, saying it can be lifesaving and medically necessary. 

Paxton's requests to PFLAG also come after several efforts by the attorney general's office to obtain medical records of Texas residents who might have received gender-affirming care at out-of-state hospitals in  Seattle  and Georgia. Seattle Children's Hospital  sued the attorney general's office  over Paxton's requests in December.

In requesting records dating back to 2022, Paxton's office cites a state provision that forbids companies from making "misrepresentations regarding Gender Transitioning Treatments and Procedures and Texas law" in advertisements sent to Texas residents.

Several motions in PFLAG's case against the attorney general are still pending, including a motion from Paxton that the court "modify and clarify" the initial restraining order and another plea that the office filed Friday.

In a statement Monday afternoon, Brian K. Bond, CEO of PFLAG National, celebrated the court's decision.

“PFLAG families in Texas gained further protection today when the court reaffirmed that the Attorney General can’t two-step around the law,” Bond wrote. “PFLAG National will continue to fight to protect our families, because trans youth and their loved ones deserve better, and loving your LGBTQ+ kid is always the right thing to do.”

Statesman staff writer Hogan Gore contributed to this report.

This article originally appeared on Austin American-Statesman: Texas district judge blocks Ken Paxton's demands for PFLAG gender-affirming care records