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Objective: Disclosure of sexual orientation and gender identity correlates with better outcomes, yet data may not be available in structured fields in electronic health record data. To gain greater insight into the care of sexual and gender-diverse patients in the Veterans Health Administration (VHA), we examined the documentation patterns of sexual orientation and gender identity through extraction and analyses of data contained in unstructured electronic health record clinical notes. Methods: Salient terms were identified through authoritative vocabularies, the research team’s expertise, and frequencies, and the use of consistency in VHA clinical notes. Term frequencies were extracted from VHA clinical notes recorded from 2000 to 2018. Temporal analyses assessed usage changes in normalized frequencies as compared with nonclinical use, relative growth rates, and geographic variations. Results: Over time most terms increased in use, similar to Google ngram data, especially after the repeal of the “Don’t Ask Don’t Tell” military policy in 2010. For most terms, the usage adoption consistency also increased by the study’s end. Aggregated use of all terms increased throughout the United States. Conclusion: Term usage trends may provide a view of evolving care in a temporal continuum of changing policy. These findings may be useful for policies and interventions geared toward sexual and gender-diverse individuals. Despite the lack of structured data, the documentation of sexual orientation and gender identity terms is increasing in clinical notes.

Transgender people experience harassment, denial of services, and physical assault during healthcare visits. Electronic health record (EHR) structure and language can exacerbate the harm they experience by using transphobic terminology, emphasizing binary genders, and pathologizing transness. Here, we investigate the ways in which SNOMED CT and ICD-10-CM record gender-related terminology and explore their shortcomings as they contribute to this EHR-mediated violence. We discuss how this “standardized” gender-related medical terminology pathologizes transness, fails to accommodate nonbinary patients, and uses derogatory and outmoded language. We conclude that there is no easy fix to the transphobia beleaguering healthcare, provide options to reduce harm to patients, and ultimately call for a critical examination of medicine’s role in transphobia. We aim to demonstrate the ways in which the [mis]use and [mis]understanding of gender-specific terminology in healthcare settings has harmed and continues to harm trans people by grounding our discussion in our personal experiences.

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