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This chapter is unlike the other chapters in this book as it is comprised only of cases. The cases highlight and explore common scenarios encountered in the clinical care of transgender and gender diverse (TGD) populations. These cases can be used as self-study, in small groups for discussion, or in larger groups as prework to discussion. The goal of this chapter is to consider a variety of clinical scenarios of providing gender-affirming care and how a health care professional should respond to them.


Alex is 25 years old, new to the city, and presents to your clinic to establish care. Registration paperwork lists Alex’s sex as female. Past medical history reveals mild asthma, and Alex’s only medication is a rescue inhaler. Alex does not smoke, drink alcohol, or use any drugs. Alex has no family history of early coronary artery disease, blood clots, or cancer. You ask what Alex’s pronouns are, and Alex tells you “they/them/their.” You ask how they identify their gender, and they say “genderqueer.” Alex explains that they are interested in starting testosterone to affirm their gender and want to know more about the changes it can lead to.

Discussion Questions

  1. You and your office staff assumed that Alex identifies as a woman because of the information in the electronic health record (EHR). If a mistake was made with pronouns as Alex checked in at the front desk, how could you address this within the visit? What changes could be made in the EHR to prevent another mistake when Alex returns to the clinic?

    It is awkward for both clinicians and patients when an incorrect assumption is made during a visit, especially when it concerns something as important as one’s gender identity or pronouns. If a mistake is made, the best approach is for the clinician to recognize the error, apologize to the patient, and then move forward in a respectful manner. Documenting the patient’s name and pronouns in the EHR prevents such mistakes. Doing so ensures that all patients are accorded respect and dignity throughout their contact with the health care system. Each EHR has different ways that this information can be collected.1 If recording this information is not yet possible in the existing system, the health care team for the day should be notified about the patient’s name and pronouns.

    Gender identity and pronouns should be collected as part of registration paperwork completed by patients new to the practice. This process, however, may miss existing patients. Since 2016, health centers have been required to collect sexual orientation/gender identity (SOGI) data.1 If the SOGI information gathered is incorporated into the patient’s EHR “banner” where it is readily visible each time the EHR is opened, all members of the health care team will be continually reminded to use the patient’s correct identifiers.

    Additionally, clinicians can collect ...

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