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in recent years health care centers have started understanding the importance of incorporating sexual orientation and gender identity or shoji in their medical records traditionally ones assigned sex at birth is their biological sex which depends on their sex chromosomes if they have a white chromosome their biological sex is male if they have two x-chromosomes their biological sex is female however things aren't that simple for example a person could have a Y chromosome but they're missing specific genes that encode for specific male characteristics so even though their chromosomal email they appear as what is stereotypically described as female so you're thinking biological sex can be linked back to genes right well things get even more complicated than that some genes get expressed at high levels and others at low levels so a person may have genes that Express a high level of testosterone and little or no estrogen or progesterone or vice versa finally hormones like testosterone estrogen and progesterone bind to receptors and some people may have lots of receptors that can easily bind to hormones whereas others may have very few receptors in many cases these people are intersex individuals whose bodies do not fit into the standard definition of male or female the bottom line is that biology is messy and like most things biological sex exists on a spectrum now separate from the biological construct of sex is gender identity and gender expression gender identity is a person's own sense of their gender and gender expression is how they present themselves to the world many people identify as either man or woman but there are also various types of non-binary gender or gender identities that lie outside of the man-woman dichotomy for example someone could identify with multiple genders such as native or indigenous to spirits do furthermore some will identify with a gender that's neither man nor woman while others may have a more fluid gender identity some individuals identify themselves as transgender when their gender identity is discordant from the assigned at birth meanwhile there are people who don't feel any of these labels describe them or don't like the idea of identifying with a specific gender at all neither biological sex nor gender identity determines a person's sexual orientation this concerns what gender or genders an individual is sexually and/or romantically attracted to an individual can be heterosexual which means they're attracted to a different gender or they're attracted to the same gender and the preferred term is gay not homosexual an individual can also be bisexual meaning attracted to two or more genders or pansexual meaning that they are attracted to any gender some people identify as asexual where they may not experience sexual attraction to anyone finally terminology continues to change and evolve and the words that people use to describe their sexual orientation is ever-changing and evolving as well now depending on their gender identity any person can choose the pronouns that suit them the best commonly used pronouns include he/him/his or she/her/hers often a person can choose the pronouns they then theirs which are more gender neutral and you can use these pronouns when talking about someone whose gender you don't know for instance you might say this patient's name is Sam they have diabetes and they're here for a follow-up on their new medication not only is this considered grammatically correct but pronouns like they have been used to refer to singular personal pronouns for hundreds of years even by steamed authors like Shakespeare and Jane Austen when someone changes their gender expression they may choose to go buy a new first name and might even regard their previous first name as a dead name all right now many individuals have to face a daily struggle of being referred to by the wrong pronoun this is known as being misgendered imagine the following scenario a transgender young woman named Esther is in a waiting room and a clinician yells across the room mr. Albert Kim please follow me being referred to by the wrong gender or dead name or both can cause a deep sense of shame loss of self-esteem and leads to harassment and discrimination from others even from health care staff this is especially true if that information is declared publicly that young woman might not want to come back to the clinic and might even feel unsafe now that others are aware that she's transgender in fact based on the 2011 national transgender discrimination survey 28 percent of transgender patients postponed medical care due to discrimination 19 percent are refused medical care altogether and 28 percent experience verbal harassment by medical professionals that's why in a healthcare setting it's essential to collect shoji data or patients assigned sex at birth gender identity and their pronouns without making assumptions based on their name appearance or behavior also make sure that these are documented in the electronic health record or EHR for other health care workers now gathering shoji data and referring to a person as they wish can take an additional 30 seconds or so but this is time well spent simply saying I want to address you the way you want to be addressed can you tell me your name in pronouns can make them and their families feel more comfortable and trust that they're getting the best care possible it's important to note that shoji information can change over time so it shouldn't be considered fixed if you accidentally refer to a patient using the wrong pronoun or they're dead named it's important to apologize correct the mistake and go on using the right pronoun and their chosen name okay now in a healthcare setting sometimes administrators ask for a patient's assigned sex at birth for insurance or billing purposes and that is often confirmed with an identity document such as a driver's license administrators can also ask for their gender identity and pronouns however sexual orientation is considered private or sensitive information and can only be asked by the clinician responsible for the patient and only if it's relevant to the patient's care all right as a quick recap health care systems collect and report sexual orientation and gender identity data or shoji data from their patients sexual orientation refers to whom you are sexually and/or romantically attracted while gender identity is about how you identify yourself and sex is about biology it's also important to ask someone which pronouns to use when referring to them collecting this data is essential to show respect to patients and their families but also to understand the differences individuals with a particular sex and gender identity can have you