Standard Practices

Ideal documentation includes charting through body maps and narrative. Gender neutral body maps are recommended but may not be within your control if you work for a large hospital or health care facility. If you are using gendered body maps, consider developing a protocol for charting transgender patients' injuries. If it is necessary to use a gendered body map that does not match the patient's gender identity, reassure the patient by saying something like, "I know you are [patient's stated gender], but this body chart will allow me to more accurately document your injuries."

The complexity of transgender bodies, coupled with the need for accurate forensic recording, may require writing a more lengthy narrative to explain how information was charted. If illnesses and injuries are not related to transgender-specific anatomy, medication, or surgery, do not reference that the patient is transgender. If illnesses or injuries are related to transgender-specific anatomy, medication, or surgery, constructing an objective narration is critical to the patient's privacy, continued medical care, and forensic evidence collection/recording.

When documenting medical injuries, accurately and consistently reflect the person's chosen name, gender identity, and pronoun choice. When there are conflicting identity documents, or there is a difference between a person's identity documents and their presentation, it is most respectful to state the person's legal name and gender marker and note that the rest of the report will be under the preferred name or gender.

Individual fire departments or first responder agencies may require staff to file reports using a patient's legal name or require the use of gendered body maps. In these cases, accurately describing an individual's appearance and stated name and pronoun choice can help validate the reality of the patient's daily life.

When documenting the assault in records, accurately and consistently reflect the person's chosen name, gender identity, and pronoun choice. When there are conflicting identity documents, or there is a difference between a person's identity documents and presentation, it is most respectful to state the person's legal name and gender marker and note that the rest of the report will be under the preferred name or gender. Individual jurisdictions may require officers to file reports using a victim's legal name. In these cases, accurately describing an individual's appearance and stated name and pronoun choice can help validate the reality of the victim's daily life.

• A National Protocol for Sexual Assault Medical Forensic Examinations: Adults/Adolescents, Second Edition

Due to a general lack of knowledge among health care providers and the public about how to support transgender victims, you may need to offer other professionals recommendations on how to respectfully and accurately document case details.