Fenway Institute and Center for American Progress: Asking Patients Questions about Sexual Orientation and Gender Identity in Clinical Settings

This report summarizes the findings of research conducted by the Fenway Institute and Center for American Progress on asking patients in clinical settings questions about their sexual orientation and gender identity. The research was conducted at four community health centers as part of the Community Health Applied Research Network (CHARN) funded by the Health Resources and Services Administration (HRSA) to support patient-centered outcomes research to improve the care and treatment of individuals in a network of community health centers. The participating community health centers were Beaufort Jasper Hampton Comprehensive Health Services in rural South Carolina; Chase Brexton Health Center in Baltimore, Maryland; Fenway Health in Boston, Massachusetts; and Howard Brown Health Center in Chicago, Illinois. The findings from this study are based on survey responses from 251 patients at these four community health centers who were 18 years and older, and completed their own patient registration forms in English.

While research on how to ask about sexual orientation and gender identity in clinical settings is still in a nascent phase, public health and demographic surveys have been gathering these data for many years. These surveys include the National Survey of Family Growth, the General Social Survey, the National Survey of Sexual Health and Behavior, versions of the Behavioral Risk Factor Surveillance System survey administered by several states, and the California Health Interview Survey.

Meanwhile, a 2011 Institute of Medicine report on lesbian, gay, bisexual, and transgender health commissioned by the National Institutes of Health recommended the collection of sexual orientation and gender identity data in electronic health records. The Joint Commission’s 2011 report, Advancing Effective Communication, Cultural Competence, and Patient- and Family- Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide, also encouraged the collection of patient data on sexual orientation and gender identity.

The brief survey asked respondents the following questions about sexual orientation and gender identity:

Do you think of yourself as:
[ ] Lesbian, gay or homosexual
[ ] Straight or heterosexual
[ ] Bisexual
[ ] Something else
[ ] Don’t know

What is your current gender identity? (Check all that apply)
[ ] Male
[ ] Female
[ ] Female-to-Male (FTM)/Transgender Male/Trans Man
[ ] Male-to-Female (MTF)/Transgender Female/Trans Woman
[ ] Genderqueer, neither exclusively male nor female
[ ] Additional Gender Category/(or Other), please specify
[ ] Decline to Answer, please explain why

What sex were you assigned at birth on your original birth certificate? (Check one)
[ ] Male
[ ] Female
[ ] Decline to Answer, please explain why

Additional questions were asked about understanding the questions and the response options, and willingness to answer such questions in a clinical setting. The response rate to the surveys was high, with only two or three potential participants refusing to complete the surveys at each site, citing lack of interest or time limitations. Most respondents from the Beaufort Health Center network in rural South Carolina (82%) said they were straight or heterosexual, as did 45% of respondents at Chase Brexton in Baltimore, 34% of respondents at Fenway Health in Boston, and 36% of respondents at Howard Brown in Chicago. Altogether, more respondents from the four health centers reported being heterosexual (47%) than any other orientation. Twenty-nine percent from the four locations said they were gay, lesbian, or homosexual. Twelve percent identified as male-to-female, or transgender female, and 6% identified as female-to-male, or transgender male. The sample was racially diverse: 51% White, 32% Black, and 6% multiracial or other. Nine percent were Hispanic.

Nearly three in four respondents from the four community health centers said that asking about sexual orientation on registration forms is important (73% versus 25%). An even greater majority said that asking about gender identity is important (82% versus 18%).

Ninety-five percent of lesbian, gay, and bisexual respondents said that they strongly agreed or somewhat agreed that they “understood what the [sexual orientation] question was asking about me.” Most heterosexual respondents also said they understood the sexual orientation question (81% strongly or somewhat agreed that they “understood what the [sexual orientation] question was asking about me”. Most heterosexuals and lesbian, gay, and bisexual respondents in all age groups said they would answer the sexual orientation question.

Only 1% declined to answer the current gen- der identity question, while another 1% chose “other”; the other 98% chose from among the gender identity options. Three percent declined to answer the question, “What sex were you assigned on your original birth certificate?”, while 97% did answer this question.

Seventy-nine percent of all respondents strongly agreed that they understood all the choices in the gender identity question. Eighty-five percent strongly agreed that they would answer the birth sex question, and 78% strongly agreed that they would answer the current gender identity question. Eighty- seven percent of transgender men and 71% of transgender women agreed or strongly agreed that the questions allowed them to accurately document their gender identity.

This evaluation of questions about sexual orientation and gender identity among a diverse group of patients at four CHCs shows widespread understanding of these questions and willingness to answer them, both among lesbian, gay, bisexual, and transgender respondents and among heterosexual and non-transgender respondents. The sexual orientation question tested in these four settings could, if widely used, be acceptable to patients across the country — lesbian, gay, bisexual, and straight — and provide important information on patients that can help us better understand health disparities affecting lesbians, gay men, and bisexuals. The two-step gender identity question (current gender identity and birth sex) was also widely understood by all patients surveyed. Strongly majorities believed that it was important for providers to know about their patients’ gender identity and would be willing to answer the question.

However, further research, including focus groups, would be helpful regarding concerns among transgender respondents with regard to answering the sex assigned at birth question. Eighty-five percent of transgender male respondents and 69% of transgender female respondents agreed or strongly agreed that they would answer the sex assigned at birth question. Yet 17% of transgender female respondents and 7% of transgender male respondents disagreed or strongly disagreed that they would answer the birth sex question, warranting additional understanding and responsiveness to this level of disagreement.

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