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

Gender identity documentation is an important component of gender-affirming care, particularly for LGBTQIA+ adolescents who may be hesitant to disclose their gender identities due to fear of rejection or discrimination. Without family support, these adolescents face higher rates of suicide, depression, and anxiety. Despite both clinical relevance and the importance of providing inclusive health care services, currently, there is no national standard for collecting gender identity information within clinical settings.

This program evaluation assessed gender identity documentation practices for adolescents in a rural mental health clinic and examined compliance with the American Academy of Pediatrics (AAP) recommendations for inclusive care.

A retrospective chart review of 151 patients aged 4-18 was conducted from 2020-2023 to evaluate baseline and longitudinal documentation of gender identity and pronouns.

Gender identity documentation improved from 0% in 2020 to 95% in 2023. Pronoun documentation remained inconsistent, and identity was assessed only at intake, limiting the ability to support adolescents with gender identities evolving over time. A case example of a transgender adolescent illustrated how gaps in documentation can contribute to distress and unmet mental health needs.

Systematic gender identity documentation is feasible in a rural outpatient clinic and provides a replicable model for inclusive practice. These findings can guide public health nurses in reducing disparities, influencing policy, and supporting multi-step efforts to improve care of gender-diverse youth.