Accurate identification and use of sex assigned at birth (SAAB) and gender identity information are imperative for trans and gender-diverse (TGD) patient safety. Previous studies and literature reveal that miscommunication and/or misidentification of either SAAB or gender identity do occur,1–4 and this creates risk of patient harm and erroneous care.3,5

PA-PSRS Reports of Events Involving TGD Patients

We reviewed a sample of event reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) in which the patients involved were TGD and the event was described as involving inaccurate identification of or inattention to SAAB and/or gender identity information. The following are vignettes from a sample of the event reports:

A 24-year-old transgender male was prepped for elective head and neck surgery. The surgeon’s office was aware that the patient was a female at birth; however, this information was not conveyed through the scheduling document that was sent to the clinic. Furthermore, during the preoperative phone call and on the day of the procedure, the patient repeatedly stated that they were a male at birth. Shortly before taking the patient to the operating room, a staff member recognized the patient from a surgery at a different facility. This prompted further questioning of the patient, who then confirmed that their SAAB was actually female. Due to the patient’s age and reproductive potential, the staff requested permission to administer a pregnancy test prior to anesthesia.

A 27-year-old transgender female receiving hormone therapy was ordered the wrong testosterone test, which was based on SAAB. The laboratory tech then ran the wrong assay, instead of an assay aligned with the patient’s gender identity. Eventually, the issue was recognized, and the correct assay was run.

A 40-year-old transgender female was transferred from a hospital’s medical-surgical unit to a skilled nursing facility (SNF). The receiving facility stated that they were not informed of the patient’s transgender status by the hospital staff or through the referral. The SNF did not have a private room available for the patient. As a result, the patient chose to leave for their parent’s home rather than return to the hospital.

Clinical Implications

For TGD patients, inaccurate identification of or inattention to SAAB or gender identity information creates risk of harm associated with several clinical considerations, including the following:

  • Pregnancy: Patients with reproductive potential are recommended to receive preoperative pregnancy testing when the result may alter management of care.3,6,7

  • Hormone therapy: Gender-affirming hormone regimens affect hematocrit, hemoglobin, creatine, and lipid profiles and risk of venous thromboembolism; therefore, choice of hormone assay, dose adjustments of medications, and perioperative planning hinge on knowledge of treatment status and duration.3,5,6

  • Anatomical considerations: Undocumented prior surgeries, such as laryngoplasty, chondroplasty, phalloplasty, or vaginoplasty, can affect airway management, catheterization, or vascular access.3,6

  • Interactions and exposure to others: Unnecessary, unwanted, and/or insensitive interactions with staff or other patients could lead to TGD patients feeling unwelcome and reluctant to seek care.3,6,8 This may reduce a patient’s confidence in care and may hinder the patient’s sharing of pertinent information.

Strategies for Improvement

The following strategies are intended to increase the accurate identification and use of SAAB and gender identity information during the care of TGD patients:

  • Two-step method: Use separate fields for current gender identity and SAAB in patient questionnaires and electronic health records to improve clarity while supporting gender affirmation.3,6,9

  • Standardized screening: Embed SAAB, hormone use, and gender-affirming surgery questions in medical histories, with confidentiality assurances, to normalize disclosure and help prevent potential safety issues.3,9

  • Document review and reconciliation: Review and reconcile all primary documents in advance of a procedure to ensure that gender identity and SAAB are recorded and accurate. This is the responsibility of both the procedural provider and the facility where the procedure will be performed.10,11

  • Environmental and privacy practices: Make every reasonable effort to provide a private room when preferred by the patient.3,6,8 During physical examinations, provide a chaperone of the gender requested by the patient.6 Ensure that all patient care discussions occur in a private setting where no one outside the care team can overhear.6

  • Cultural competency training: Provide staff education in gender-affirming communication and care to foster trust and support transparent interactions with patients.8,12–14

  • Additional information: References 3, 6, 8, 9, 13, and 14 can be used to foster enhanced care of TGD patients.

Conclusion

Balancing patient safety with gender-affirming care requires capturing and using SAAB and gender identity in a respectful and systematic manner. Using consistent and comprehensive information-gathering practices, protecting privacy, and training staff to be respectful and informed can help prevent safety issues, improve care, and build patient trust.

Notes

This analysis was exempted from review by the Advarra Institutional Review Board.

Data used in this study cannot be made public due to their confidential nature, as outlined in the Medical Care Availability and Reduction of Error (MCARE) Act (Pennsylvania Act 13 of 2002).15

Artificial intelligence (Microsoft Copilot, version: 2.20260526.52.0) was used for drafting of text and to improve sentence clarity. The authors take full responsibility for the accuracy and integrity of the manuscript.

Disclosure

The author declares that they have no relevant or material financial interests.

About the Author

Matthew A. Taylor (MattTaylor@pa.gov) is a research scientist on the Data Science & Research team at the Patient Safety Authority, where he conducts research, uses data to identify patient safety concerns and trends, and develops solutions to prevent recurrence.