Gender identity

Gender identity is a way to describe a person’s innate sense of their own gender, whether male, female, or non-binary, which may not correspond to the sex registered at birth. Gender identity should not be confused with registered sex at birth, or with sexuality or who someone is attracted to.

Guidance on the differences between sex and gender have been published by the World Health Organisation and the Office of National Statistics:

• Definition of Gender - WHO
• What is the difference between sex and gender? - ONS

For many, but not all people, the sex they were registered at birth is the same as their current gender.

Anyone can change their legal gender, through the Gender Recognition Act, and ‘gender reassignment’ is a protected characteristic under the Equality Act (2010). 

Data collection about gender identity also covers if a patient’s gender identity is the same as their sex registered at birth and can also be referred to as ‘trans status’, ‘trans history’ or ‘trans identity’. Trans is an umbrella term used to refer  to people whose gender is different from the sex they were registered at birth. In the context of the Equality Act 2010, trans people are referred to as having undergone, currently undergoing, or proposing to undergo gender reassignment, a process for the purpose of reassigning the person’s sex by changing physiological or other attributes of sex. It is also important to distinguish between gender identity (which everyone has as per definitions above) and being trans (or having the protected characteristic of gender reassignment) which is a relationship to gender but is not a gender in itself.

To be protected from gender reassignment discrimination, an individual does not need to have undergone any specific treatment or surgery to change from their sex assigned at birth. This is because changing physiological or other gender attributes is a personal process rather than a medical one. A person can be at any stage in the transition process – from proposing to reassign their gender, to undergoing a process to reassign their gender, or having completed it. This can additionally include a change of name, pronouns and/or appearance.

Gathering information on gender identity and trans identity is important to allow us to better understand health inequalities. By collecting this data, services can provide more personalised care to patients, as well as better understand trans and non-binary people’s experiences, outcomes, and inequalities at a local system level. The opportunity to share information about patient’s gender identity in a welcoming environment can facilitate important conversations with clinicians who are in a position to be extremely helpful (Opens in PDF).

Staff and patients have to understand why this information is being collected, how it will be analysed and what the information will be used for.

It is important to find the right time to ask these questions, as patients may not feel comfortable disclosing at first but may feel comfortable enough to do so later on. It is also important to allow trans and non-binary identities to signal that trans and non-binary identities should be recognised and valued by services, to avoid cisnormativity and to promote LGBT+ inclusive practice. The consequences of not including and using options for trans and non-binary individuals to record and use their gender identity, could result in disengagement from care and feelings of stigmatisation.

A patient may ask why this data is being collected or choose not to share their gender identity and/or trans status. Staff should make it clear they are under no obligation to share anything they are uncomfortable with and reassure them that if they choose to share this information, it will be kept strictly confidential.

If a patient wishes to know why you are asking for this data, you can inform them that the service collects this information so that they can enhance services and to ensure that it continues to remain inclusive of people of all identities.

If a patient declines to respond to a gender identity data item as they do not agree with the question or how it is asked, then that is their choice and they can leave the field blank.

There is an increasing range of guidance and support to help people working in health services to consider how they can provide trans inclusive healthcare and how to appropriately ask for information on gender, including “Recommendations for Trans*- Inclusive Healthcare” from  Kings College London.

In MHSDS v5.0 and IAPT Data Set v2.1 (from April 2022), two new data items, which relate to gender identify and gender at birth (shown in in Table 3) together aim to better capture how patients would like their gender and sex to be recorded. They will also support services on how to better care for their patient.

These data items should be completed using information provided by the patient as part of registrations and/or care contacts. They should not be completed by linkage to the NHS Spine or assumed/inferred by the service. This is important because gender data recorded by other NHS services could relate to sex registered at birth or their gender identity, and also because it’s possible that a patient’s gender identity may have been recorded differently by services at an earlier time in their journey in understanding their identity.

In line with this, the gender identity selected by a patient within a service should never be overwritten by information recorded by other services or via the NHS Spine.

Further information on the gender data items present in MHSDS v5.0 and IAPT Data Set v2.1 is set out below:

Why prioritise the new data items Gender Identify and Gender Identity Same at Birth?

The NHS has a public sector duty to ensure equality for all our patients under the equality act, including sex and trans status. 

The move from requesting completion of the Person Stated Gender Code (version 4.1) to prioritising the Gender Identity Code and the Gender Identity Same at Birth Indicator Code (version 5) is to enable patients to more accurately and inclusively record their gender identity, sex and trans status, and thus more effectively gather information about how to treat someone. What is the benefit of these changes?

To:

• align with the changes made to the 2021 census.
• support Advancing Equalities Mental Health Strategy and understand inequalities and risk factors surrounding different population groups accessing mental health services
• close the gap in the evidence available on trans and non-binary patients' service access and care experience
• develop more inclusive and trauma-informed care services.
• remove the mixing of gender and sex registered at birth that exists in data held within person stated gender

The new data items GENDER IDENTITY CODE and GENDER IDENTITY SAME AT BIRTH INDICATOR allow patients and datasets to better distinguish gender and sex by recognising they are separate concepts.

What does the Person Stated Gender data item record?

The NHS data dictionary definition of person stated gender is “self-declared or inferred by observation for those unable to declare their PERSON STATED GENDER”.

It is sometimes incorrectly assumed that in practice the PERSON STATED GENDER CODE is capturing the sex assigned at birth of patients.

This data captures the gender someone states to an NHS service and so does not capture sex assigned at birth. However, for many people these two things will be the same. Patients can also request the gender recorded for them in NHS systems to be changed to reflect their gender identity - Process for registering a patient gender re-assignment (england.nhs.uk).

It is therefore important for patient safety and care to ask gender inclusive questions of patients regardless of what gender has been recorded for the patient.

How and why are the new gender data items included in the Data Quality Maturity Index (DQMI) score?

Currently only Person Stated Gender is included in the performance scoring for the DQMI.

The Gender Identity code and Gender Same at Birth Indicator code have been included as experimental data items in the DQMI. This means they do not have an impact on the DQMI score. 

As the priority is to record the Gender Identity code, it is important that providers are not penalised for recording that data rather than Person Stated Gender. The methodology for the DQMI is therefore being updated so that where data is submitted in the Gender Identity field, it is used to determine the scoring for Gender Identity data instead of Person Stated Gender. 

When this change is implemented, the DQMI score will only be impacted negatively for the Gender Identity code if providers submit:

• Invalid codes
• “X (not known)” code 

Person Stated Gender will be used for DQMI scoring where no data is recorded against the Gender Identity code, in which case that would have no impact on the DQMI score.

This approach to scoring gender data will be implemented from February’s 2023 data reporting.

How are the new gender data items used in mental health metrics, including perinatal mental health service access?

Gender based metrics, such as the perinatal mental health services access metric, are currently only based on contacts with patients recorded as “Female”. 

To identify female patients, the analysis now prioritises using any valid codes recorded against the Gender Identity code. This means that if providers are not collecting accurate data against this data item and simply put “Z” (not stated) or “X” (not known) against all records, then it will lower the access count for that provider.

If the provider does not have accurate gender identity codes collection for patients, the solution is simply to leave the Gender Identity code empty until meaningful data is collected against it.

The perinatal team plan to implement changes to that approach in 2023/24 to also include patients identified through the two new gender data items as trans men or non-binary.

Why is it not possible to record a specific gender at birth for non-binary patients?

The new data items to record GENDER IDENTITY CODE and GENDER IDENTITY SAME AT BIRTH INDICATOR enable more inclusive recording of gender identity while also more clearly identifying gender at birth for cisgender and transgender patients.

However, it is not possible to identify gender at birth for patients whose gender identity is non-binary. That is because the gender at birth data item only records Y/N whether current gender is the same as at birth.

The consultation process through which the new gender data items developed established that non-binary individuals actively do not wish to be considered within the binary protected characteristic sex and may decide not to answer any questions that cover this area. It was through engagement that it was established that non-binary people were likely to reject a direct sex question and including one could mean that cohort disengaging and rejecting to answer any of the questions on gender.

For more information on how to ensure your services are providing inclusive healthcare for non-binary people, please visit the LGBT Foundation website.

Organisations will not be in breach of the Gender Recognition Act 2004 by asking for and, where the patient consents, sharing and recording the trans status of patients with a Gender Recognition Certificate (in line with other medical data). Organisations will also not be in breach for reporting this to the MHSDS via the gender at birth data item.

It is not an offence under this act to disclose protected information relating to a person with a Gender Recognition Certificate if that person has agreed to the disclosure of the information.

Delivering clinically safe care to patients where sex-based characteristics are relevant

All services should be asking all patients inclusive questions to identify relevant care information. It is not safe to make assumptions about an individual using the Person Stated Gender code. 

The MHSDS data items are not meant to replace clinical information about the patient’s anatomy, hormone levels, medical and/or surgical treatment to alter the body. This information should be documented properly in the clinical notes, not relied upon from this data field. The fields are for data monitoring, not clinical information.

To understand the sex assigned at birth for non-binary people, this should be done through the patient’s assessment process, as with any person with a male/female gender recorded, not based from the Gender Identity or Gender Same at Birth data items.

This briefing on monitoring Trans Status provides further information on why is important to capture this information from patients. In addition, there are videos available on the Trans Health Inequality YouTube channel that support healthcare professionals understanding of the needs of trans patients not only as an equality issue, but also as a patient safety issue.

Good practice examples of gender inclusive service support are set out in the same sex accommodation guidance published in 2019.

The British Medical Association (BMA) has also published guidance on Inclusive care of trans and non-binary patients to support services.

What about services that rely on sex assigned at birth information? 

Some services do in part use the Person Stated Gender item to identify patients in scope of their services, such as cervical and prostate screening services. 

Sex based services already need to take additional steps to use the person stated gender data items to identify trans men and women that should be referred to those services. The screening programmes that are linked through primary care settings, such as their GP clinic, use the gender code recorded in the GP system to pull people onto screening lists. 

The National LGBT Advisor team is working with screening programmes to enable manual removal/addition to screening lists, which will be assisted by better inclusive questions. The Person Stated Gender is already not adequate to be used in isolation for this purpose. Therefore, services must have inclusive processes and conversations with their patients for important healthcare issues like screening.

The two new gender identity codes, and the more inclusive conversations with patients that clinicians aim to promote, will therefore improve services’ ability to identify people that need screening and other support.

Table 3 identifies the data items required to record and flow this data to the MHSDS and IAPT Data Set.