Capturing Gender Identity through Documentation: A Program Evaluation of a Rural Mental Health Clinic

Capturing Gender Identity through Documentation: A Program Evaluation of a Rural Mental Health Clinic

Introduction & Background: Gender identity reflects a person’s internal experience of gender, which may or may not align with the sex assigned at birth. This identity may encompass male, female, a blend of both or neither making it a crucial aspect of the LGBTQIA+ community. Purpose: This program evaluation aimed to assess the documentation of gender identity among adolescents in a rural mental health clinic, focusing on compliance with the American Academy of Pediatrics (AAP) recommendations. Methods: Electronic Health Records were reviewed for the following documentation element of gender identity: male, female, not asked, not answered and gender non-conforming. Each element was logged independently in a secure electronic spreadsheet. The data was recorded numerically so that quantitative retrospective analysis could be performed. Results: Between 2020 to 2023, 151 children and adolescents (ages 4-18) were treated at the clinic. The four most common primary diagnosis were anxiety disorders (24.6%), adjustment disorders (18.9%), attention deficit hyperactivity disorder (17.9%) and depression (14%). The rate of documented gender identity improved significantly, increasing from 0% in 2020 to 95% in 2023. Implications: Relying solely on initial intake assessments may result in inadequate support and recognition for evolving adolescent gender identities. Accurate identification of clients’ gender identity is crucial for determining service needs. Improving standard of care for the LGBTQIA+ adolescents not only benefit immediate and long-term health outcomes but also strengthens relationships between adolescents, mental health providers, staff and families through improved communication, beginning with proper documentation.