Sexual and gender minorities (SGMs) face health inequities related to social and institutionalized prejudice [1-5]. Discrimination of SGMs should not happen in Canadian health care, where the ability of individuals to freely express their gender identity is a human right [4-6]. Yet, in its current state, each encounter with the health care system is fraught with the risks of emotional, psychological, and even physical harm to SGMs [1,3-5,7]. Recognition of the impact of outdated gender, sex, and sexual orientation (GSSO) information practices is growing [1-3,8,9], but information practices have changed little in recent decades [2], and are built on outdated, poorly defined, and highly constrained conceptualizations of sex, gender, and sexual orientation [1,2]. Current GSSO information practices are largely outdated and are not reflective of the progress that Canadian society has made in terms of being inclusive of SGMs and defending the human rights of SGMs [4,6].

The aim of this rapid review of grey literature was to elucidate GSSO information practices for SGMs from leading agencies for adaptation, adoption, and application to health care providers and organizations seeking to modernize outdated GSSO information practices that contribute to SGM health inequities. This research extends recent work done by our research team that explored peer-reviewed academic literature [1,2]. What is clear from our previous research is that throughout the Canadian eHealth landscape, GSSO data elements lack useful definitions; fundamentally conflate administrative, clinical, biological, and social concepts; and are structured around cisheteronormative binary constructs of sex and/or gender terms and codes [2-5] that are neither affirmative nor inclusive of SGMs and do not include Indigenous GSSO concepts [2].

GSSO information practices include the definition, collection, use, and sharing of GSSO information. The term definition refers to the meaning of the concepts used by humans to communicate and the corresponding concepts and codes used to represent this meaning in electronic health records (EHRs). Collection and use include clinical documentation, coding, and administrative input of health information into EHR systems to support direct clinical care and communication (primary uses) and organizational needs such as analytics and research (secondary uses). Sharing includes standardized protocols for the exchange of health information between health care providers and information systems for primary and secondary uses along a connected care continuum such as messaging standards. The term providers refers to regulated and unregulated health care staff and professionals (people employed to provide care). Unless specifically mentioned, we use the term EHRs in its broadest sense—health information systems that contain digital collections of a person’s health history and care records.

Our central question for this rapid review of grey literature was “What are modern and emerging GSSO information practices that reduce barriers to access and to delivery of safe and quality health care for SGMs?” The objectives of this review include the discovery, review, synthesis, and description of SGM equity-oriented GSSO information practices in EHRs from leading experts and organizations.

The rapid review method was chosen because rapid reviews have gained recognition in health care research as a suitable method for fast exploration of rapidly evolving topics [10] and because this work is a natural extension of and complement to our research team’s recent rapid exploration of peer-reviewed academic literature [1] and EHR systems in Canada [2]. This work expands the domain of inquiry to the body of grey literature that houses key institutional, professional, and technical knowledge of safe, quality, and inclusive health care for SGMs.

The search strategy (Multimedia Appendix 1) for this review was developed with the input of a subject matter university librarian and specifies the search terms, including Medical Subject Heading terms, repositories, inclusion and exclusion criteria, and the codebook (Multimedia Appendix 2) developed to guide our analysis. The initial phase of this work involved a search using MEDLINE for English language government reports and documents, white papers, theses, care guidelines, and literature published in a 6-year period between January 2015 and July 2020. The second phase involved a Google search. Search terms for the first two phases included “sex,” “gender,” “sexual orientation,” and “electronic health/medical records.” MEDLINE search results were screened by title, abstract, or description and full-text review for relevance to the topic; peer-reviewed journal papers were excluded. Results from the Google search were screened by hand by reviewing the name of the page and the title of the linked PDF file for relevance. Close screening and selection of GSSO information practice-related resources from the references of each of the included resources were also conducted. Finally, we canvassed an international working group of SGM health experts and organizations for grey literature resources. Duplicates were eliminated. ATLAS.ti was used to support coding and analysis. Researchers met weekly to compare data extraction, ensure consistency of coding, and resolve disagreements through consensus building. Themes were developed through an iterative process of writing and research team discussions. Figure 1 shows a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) [11] flow diagram of the article selection process.

The following 26 documents were identified for inclusion: one Canadian parliamentary standing committee on health report [3], two toolkits [4,5], one policy guide [12], seven quality practice documents [7-9,13-16], one presentation on GSSO information best practices [17], six government documents related to changing vital statistics information [18-23], six white papers or data collection standards papers [6,24-28], one doctoral thesis [29], and one statistical guidance paper [30]. Grey literature resources produced by the strategy are summarized in Multimedia Appendix 3.

The primary threads that emerged from the review of grey literature included institutional policies, care practices, social attitudes, and GSSO information practices required to provide safe and quality health care for SGMs. These threads define SGM cultural competence; they naturally and logically constitute the narrative themes that emerged from the literature produced by the organizations addressing SGM barriers to health care through modern GSSO information practices. Cultural competence “…is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or amongst professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations” [31]. SGM-competent GSSO information practices are therefore modern GSSO information practices. Modern GSSO information practices emerge from and reinforce the delivery of culturally competent care for SGM. Themes that emerged included (1) essential competency through shared language, terms, and clear definitions of GSSO concepts; (2) the central importance of welcoming and inclusive care environments and inclusive practices for reducing barriers to accessing health care; (3) health care policy that supports competent SGM health care; and (4) modernized GSSO information practices and EHR design requirements that support SGM competence.

Gender, sex, and sexual orientation are very different and unambiguous concepts that relate to one another in complex ways for all people [1,4,6,9,16,29]. SGM-competent GSSO information practices are rooted in the language and terminology used to communicate with, for, and about SGMs in health care [4,9]. Standardized definitions and routine use of GSSO data in EHRs support SGM-competent practice by reducing ambiguity, normalizing diversity and inclusion, and affirming SGM human rights. In this section, we provide working definitions of core GSSO concepts.

Sex is a complex biological concept that includes anatomy, physiology, genes, and hormones [4,6,15,26]. Biological sex is based on the physical presence of sex organs (physical or phenotypic sex) [15], sex chromosomes (chromosomal or genotypic sex) [15], and hormone levels (hormonal sex) [6].

Gender is a complex human psychological and sociocultural concept that can impact sex characteristics [15,17,26]. Like sex, gender is often erroneously conceptualized and represented as a binary construct (i.e. man/woman), but there is considerably more variation than this in reality [4,6,17]. Gender concepts should not be conflated with sex concepts, but very frequently they are. Gender is both expressed and felt as a part of a person’s identity. As such, the concept of gender and gender-related labels are frequently inappropriately applied to patients by external agents and then used inappropriately in clinical practice.

Sexual orientation is a term that broadly describes how a person characterizes their emotional and sexual attraction to others [4,12,13,26] and is a complex facet of human sexuality.

Human sexuality is dynamic and multidimensional, and includes a constellation of interrelated concepts such as sexual identity, sexual attraction, and sexual behavior [8,26]. For some people, these concepts align with monogamous heterosexualism. For others, there are important differences. Sexual identity depicts how a person self identifies (eg, lesbian, gay, bisexual, pansexual, and asexual) [4,7,26], and includes both how a person views themselves and what groups they consider themselves to be part of. Sexual attraction describes what gender group or groups one is or is not attracted to [4,7,26]. Sexual behavior refers to the sex acts that one engages in and may be periodic (eg, 1 year) [4,7,26]. Sexual behaviors may occur within one’s sexual and/or romantic partners, but also may occur outside of relationships, in groups, or with oneself [26]. Sexual orientation does not strictly determine sexual behaviors [4], and assumptions about sexual behavior should not be made based on sexual orientation.

Health assessments should include information about sexual behaviors and context for all people, regardless of sexual orientation [8], because behavior and context are important factors in the characterization of risk and in the subsequent formulation of relevant preventative teaching and interventions.

The Indigenous concept of Two-Spirit pre-dates Western colonial frameworks for sexual and gender diversity [8]. Ongoing colonial forces include the structural imposition of belief systems that condemn sexual and gender diversity and enshrine cisheteronormative binary constructs. This fuels transphobia and homophobia, resulting in Indigenous SGMs sometimes being forced from their home communities [5]. The English language term Two-Spirit was adopted by Indigenous SGMs for Indigenous SGMs in 1990 at the third gathering of Gay and Lesbian First Nation People in Winnipeg, Manitoba, Canada; the term Two-Spirit can encompass gender, sex, culture, sexuality, and spiritual identities [3-5,15,32]. Not all Indigenous people who are SGMs are Two-Spirit [5]. Adopting a stance of cultural humility and including Indigenous GSSO concepts is essential for culturally safe and SGM-competent health care for Indigenous people [9]. Work in this space must center around, be led by, and involve earnest partnership with Indigenous Two-Spirit people and engage with ongoing processes of decolonization and anti-Indigenous racism.

In addition to a shared understanding of language and terminology, enabling safe, quality, and inclusive care for all people requires welcoming care environments [4,5,7]. EHRs that support expanded GSSO concepts, and psychologically safe and meaningful care interactions between patients and health care staff are essential structures that drive and support modern practices [7]. Modern GSSO information practices are free of assumption and stereotype, and meaningfully address psychological safety of care environments, administrative interactions, care interactions, and other barriers to access. Administrative databases, anatomic inventories, and special considerations for the challenges faced by transgender, Indigenous, older, and newcomer SGM people are core foci for health equity.

Health care ought to be affirming and welcoming; a place where patients can feel accepted, safe, and cared for [4,5]. All health care staff are ambassadors of the health care system and should therefore receive SGM-competency training [15]. Affirming health care environments address a key barrier to access for SGMs (pervasive cisheteronormativity) [4,5]. Symbols of diversity and inclusion, such as rainbow flags, affirming images, posters that signal respect and inclusion, and nongendered bathrooms [4,5,8,12,13,15,16,29], send the message that health care is safe and welcoming of diversity. The use of culturally competent language and terms [9,13,15]; careful respect of patient privacy and confidentiality [4,8,30]; and avoidance of assumptions about patient names, pronouns, honorifics, gender identity, sex at birth, and sexuality are essential because assumptions can lead to negative experiences for both patients and staff [16]. Every interaction with health care should not be discounted in terms of its overall importance to ensuring equity. Competencies of services and providers within them are assessed by each patient at each interaction, and decisions about accessing health care or recommending care to others are made. As a logical consequence of experiencing stigma and discrimination, SGMs may not feel comfortable disclosing details about their sexual orientation, sexual behaviors, or gender identity [4,12,29]. Patients should not be made to feel forced to disclose GSSO information.

SGM-competent practices avoid assumptions, misgendering, outing, and deadnaming, protect patient privacy and confidentiality [4], and ensure that current GSSO information is collected and documented into EHR systems to maximize the safety and quality of primary and secondary uses [17]. Modern GSSO information practices are expanded to be inclusive and support affirming care by ensuring that name, gender identity, and pronouns used are meaningfully integrated into technical, social, and organizational layers of health care systems [24]. Routine collection of GSSO information is important for measuring, monitoring, and improving population health [8].

Patient registration involves gathering key administrative and demographic information from patients and entering that information into an electronic or paper patient record. Registration should be done in a private nonintrusive manner for all people [7,15,16], and in addition to being staff facilitated, it can be done through transcription of a paper form [7], direct patient entry self-interviews via a patient portal [7,16], a self-serve kiosk [16], or a mobile device [7]. When summoning patients to a registration desk is necessary, calling them by their last name without the use of gendered honorifics, pronouns, or legal names is a useful practice for avoiding negative experiences until preferred names, pronouns, and honorifics are confirmed by the patients and their consent to share that information with the care team is obtained. Patients may be more comfortable sharing GSSO information using self-interviews [12]. The dynamic nature of gender identity should be considered in patient intake and registration workflows, and GSSO information should be confirmed regularly [4,7,8,16]. Consistent and appropriate gender identification and use of appropriate names and correct pronouns for patients are simple yet important actions for providing affirming health care [4,5,8,13] at and beyond registration, and they demonstrate organizational and professional commitment to an inclusive and affirmative health care culture.

Governments are beginning to modernize vital statistics to be more SGM inclusive. At the federal level in Canada, citizens who do not identify with binary sex or gender designations can have an “X” printed on their passport, travel document, citizenship certificate, or permanent resident card [4,19,20]. Provinces, including Ontario, British Columbia, and Manitoba, are also aligning their systems to enable more diverse gender or sex designations on government-issued IDs through a similar mechanism [21-23].

Government-issued IDs are considered trusted sources for identifying patients for health care purposes [15]; however, there is a high degree of conflation of the two concepts within jurisdictional information systems [2] and subsequent variation in how administrative sex and gender data are labeled and presented on IDs from jurisdiction to jurisdiction. Administrative sex and/or gender on government IDs may not match with the gender identity (or felt gender), gender expression (or lived gender), or sex assigned at birth; administrative gender may even be labeled as sex on government IDs [22]. Use of administrative sex or gender for clinical care can lead to substantial confusion in information systems and clinical care and can increase the risk to patient safety.

A two-step approach that includes sex assigned at birth and gender identity is considered the best practice for collecting gender and sex information by leading organizations [6-8,13,15,24] because it eliminates conflation between administrative and clinical sex and/or gender concepts and reduces conflation-related risks. However, health organizations must respect the patient’s choice to not provide this information, and staff are strongly cautioned to avoid making assumptions about patient identity or applying labels to patients that patients themselves may not identify with (ie, transgender) based on this information. Administrative sex and/or gender should not be labeled or documented as anything but administrative sex and/or gender to avoid conflation with clinical concepts. Nonbinary people may not wish to have gender markers on their documents [21]. Personal health numbers can, and should, be used for positive identification in the case of mismatches in administrative sex and/or gender information.

Thorough assessment and documentation of medical and surgical history in postregistration encounters can help ensure that opportunities for appropriate screening are not missed [4,13]. Preferred names and pronouns should be collected in the first visit [8]. Staff can positively identify their own names and pronouns when first meeting with a patient to build trust and a sense of safety [4,16]. Providers should ask about sexual orientation, sexual behavior, and gender identity using open-ended questions [8,12], and should confirm names and pronouns used with the patient so that they can correct any incorrect GSSO information that has been erroneously documented in the patient chart and minimize the possibility of it being used in subsequent clinical encounters. If affirming approaches are unsuccessful, GSSO information may be collected as part of a more formal and more focused sexual health assessment [12]. Clinicians who ensure that documentation is complete, accurate, and up to date with current GSSO information reduce the chances for negative experiences for both patients and providers in subsequent care interactions [24].

GSSO information should be collected without the presence of parents for youth aged 13 years or above, but parents should be involved in the conversation for children aged 12 years or below [7].

Gaps in preventative screening for SGMs exist because outdated GSSO information practices and binary administrative sex and/or gender data constructs interfere with appropriate matching of SGM patients’ preventive screening and health care needs [4]. Anatomic inventories enable transparent and assumption-free therapeutic relationships between patients and providers. Safe therapeutic relationships lead to increased opportunities for prudent screening and prevention [1,2,4,5,9].

In 2017, the Canadian Human Rights Act was amended to include gender identity and gender expression as prohibited grounds for discrimination [4,6]. All Canadians have the fundamental right to identify and express gender in a manner that is consistent with their identity [4]. The requirement for mandatory ongoing training for all staff in health care (physicians, nurses, social workers, clerks, administrative staff, and others) is aligned with the objective of improving knowledge and changing attitudes toward SGMs in support of these rights [3,4,27,29]. Health care policies and procedures should be evaluated for diversity, equity, and inclusion.

Health care providers have the responsibility to ensure respectful, compassionate, and equitable interactions with patients [16]. Since cultural competency requires changes in the attitudes and beliefs of the people who provide health care, both clinical and nonclinical staff require regular SGM-competency training [13,15] and evaluation. Educating staff about modern GSSO information practices is an essential step toward SGM-competent care [4,14,17]. SGM competency training reduces the knowledge gap and increases opportunities for psychologically safe therapeutic conversations between patients and providers. In turn, this can improve access to care [27] by reducing the barrier of stigma and the burden of education that many SGMs feel [3-5,29]. It is not uncommon for SGMs, especially transgender people, to have to educate their providers about their own care [29]. Providers should be receptive to this as a form of patient self-advocacy and engage in their own professional development [14]. Learning about the factors that impact SGM health may mean having to reflect on personal bias [4] and obtaining a nuanced understanding of GSSO.

Staff should be trained in small groups to support psychological safety. Health information technology staff should begin training early [8] because inclusive data structures support affirmative competent clinical practice and organizational culture [7]. Staff from EHR vendors and insurance companies also need to be educated on the health needs of SGMs [7]. Enthusiastic champions should be used to lead culture change in these organizations [8]. Digital solutions for training can be offered and completed remotely and are one option for addressing disparities in urban-rural service offerings [5,8].

EHRs facilitate instantaneous communication of accurate and inaccurate information among the care team. Policies and procedures for correcting inaccurate GSSO information at registration are required to avoid downstream confusion of terms [15] and risks to patient safety. Inclusion of expanded unambiguous GSSO concepts in EHRs provides appropriate space for GSSO information and is necessary to eliminate health data invisibility and to support SGM-competent care [7]. Where discrepancies exist between labels, codes, and data elements, labels and data dictionaries should be corrected quickly to avoid harm to patients resulting from their use in clinical care.

Clear organizational support and guidance for GSSO laboratory information practices is required to ensure patient safety [15] because laboratory results frequently inform clinical interventions such as the appropriate dosage of medications. Changes to administrative gender codes by jurisdictions may impact downstream laboratory and EHR systems [15]; implementation requires planning, particularly as it relates to the gender or sex value “X” [4,8]. Incongruencies in sex, gender, and name listed on samples should be confirmed, rather than discarded [16]. Clear labeling on screening samples is required to ensure that samples are processed correctly, despite the possibility of gender marker incongruence between EHRs and laboratory information systems [13,16]. Sex assigned at birth, legal sex, and gender identity data elements provide necessary information for interpretation [15], and incongruence between gender elements and sex at birth can guide safe laboratory interpretation and reporting practices [16] provided that staff have the required competency. Making both male and female reference ranges available to clinicians can improve safety for SGMs [8]. Hormone levels for nonbinary people may intentionally be in between typical male and female levels [13].

Policies governing privacy and confidentiality are a cornerstone of SGM-competent health care. It is quite logical that SGM patients may be reluctant to share information about themselves, particularly in the context of open waiting rooms or areas where privacy cannot be assured [12] given the risk of stigma-related trauma. Privacy is very important to SGMs, especially transgender people [30] and people who have experienced harm via public acts of being misgendered, outed, or deadnamed in previous health care experiences. Organizations that collect GSSO information must ensure that the privacy and confidentiality of patients is maintained [4,7]. Technical safeguards must be in place to ensure privacy and confidentiality of the EHRs and data within them [12], and patients can be informed about these safeguards. SGM-competent health care, with modern GSSO information practices, addresses risks related to breaches in privacy and confidentiality for SGM patients [4].

Informed consent is an important patient right and, where applicable, should include reproductive and fertility considerations [13] for the wide range of gender-affirming hormonal therapies and surgical procedures that are available [4]. Transgender people, for example, have the same range of reproductive desires as nontransgender people; reproductive goals for gender-affirming procedures should be considered before they are undertaken. Gonadectomies, for instance, will have clear impacts on fertility that should be discussed [13].

Costs for medically necessary procedures are a barrier to health care and should not be borne by patients alone. Reimbursement policies should recognize the unique health needs of SGMs [3,7], and insurance companies should support gender-affirming surgeries that are deemed medically necessary [3]. Binary administrative sex and/or gender structures that govern coverage eligibility for certain procedures are commonly cited as problematic barriers to access and to health equity for transgender people [29].

Conversion therapy is a broad term that encompasses health care practices intended to change an individual’s sexual orientation or gender identity. Conversion therapy is considered to have negative effects on the mental health of SGM patients, and there have been calls to ban such practices in progressive jurisdictions [3].

EHRs support clinical practice and are an extension of clinical culture. Adoption of modern GSSO information practices in EHRs addresses the invisibility of SGMs on user interfaces, in data repositories, in health terminology, in classification and coding schemes, and in messaging and exchange standards. EHRs designed to support modern GSSO information practices improve outcomes by supporting SGM-competent health care.

Data invisibility and institutional erasure of SGMs are increasingly recognized as structural problems contributing to poor outcomes for SGMs [3,6,7,16]. The passive erasure of gender and sexual diversity in EHR code systems has led to inaccurate documentation, unsafe care, invisibility of SGMs in health data [16], and inaccurate information for health care providers, health information professionals, and researchers [7,33]. Addressing the erasure of SGMs in the data means developing and implementing unambiguous data standards as well as methods for analytics and statistics that are inclusive of SGMs. Policies and practices that support routine collection of expanded GSSO information are essential.

EHRs must include expanded GSSO concepts [7,16,17] or else they risk acting as barriers to quality care [29]. The use of expanded GSSO data elements (beyond the binary) enables culturally competent and clinically safe care and provides a richness of discrete variables for clinical care and analytic uses that does not currently exist in most EHRs [1,6,15-17,29]. Routine standardized collection of GSSO information that includes expanded GSSO concepts is recommended by health care quality organizations as best practice and as a foundational step to understanding and addressing inequities for SGMs [7,14].

Use of other as a sex or gender code is a common and outdated information practice in EHRs [2] and statistical surveys [18,26]. It is often done with the intent of capturing sex and gender data that are not binary male/female or man/woman, but has the effect of normalizing binary elements and obfuscating the range of possible nonbinary elements. This practice creates ambiguity in code sets and data sets and can be stigmatizing for SGMs, particularly in the context of patient-user interfaces where a person may be forced to “other” themself via a health care artefact. Please specify is one option [18] that can provide space for entering correct information where correct options do not exist. However, a full complement of discrete expanded GSSO terms is preferable because discrete elements can support logic-based rules, decisions, algorithms, and artificial intelligence.

SGM health information facilitates improved knowledge about their health and liberates evidence that can be applied for quality improvement [7,26]. Gender-based analysis is important for statistical comparisons [30]. National [3] and international [30] efforts to address data invisibility for SGMs are now underway by national statistics organizations [6,26]. Due to the small proportion of people with diverse gender identities, special statistical considerations are required to prevent breaches of confidentiality on result maps and to ensure inclusiveness in mathematical and statistical modeling [2,30]. In order to harmonize and strengthen the measurement of health inequalities in Canada, the Canadian Institute for Health Information has proposed Canadian equity stratifiers (standard data elements) that support quality health information for improving outcomes [6].

Administrative or legal GSSO concepts are found in jurisdictional repositories and are used by governments for administrative reasons as minimum data elements collected and used for vital statistics, by insurance agencies for billing, and by health care organizations for patient registration [1,2,15,19-21,23,28]. Administrative GSSO concepts include legal name, administrative gender, administrative sex, and sex assigned at birth, amongst others. Many jurisdictional repositories represent sex and gender concepts as a single data element using a male/female binary supplemented by a category of other, unknown, or undifferentiated [1,2]. The integration of administrative and health care information systems must be done carefully such that administrative and clinical GSSO data elements are appropriately sequestered. Clinical data elements must be clearly labeled and easily differentiated from administrative sex and/or gender data elements in order to support safe and SGM-competent clinical care.

Health equity is the absence of unfair differences in access to quality health care or health outcomes [6,16], and is supported by modern GSSO information practices that aim to reduce barriers to access and provision of safe and quality health care to SGMs. Equitable access to quality health care is a right for all Canadians and should be a right for all people including SGMs.

Binary representation of sex and gender in EHRs obfuscates natural and cultural diversity and, in the context of health care, places SGM patients at risk of clinical harm because it leads to clinical assumptions. Outdated GSSO information practices render SGMs invisible in therapeutic interactions, data sets, and bias analytics, and ensures that researchers have little quality SGM data with which to improve health care for SGMs.

Knowledge and use of inclusive and gender-affirming language in clinical interactions in the context of welcoming care environments with SGM-competent staff and EHRs that include and display unambiguous GSSO information are all key elements of modern GSSO information practices. Modern GSSO practices are assumption free, unambiguous, and antistigma, and are necessary to support the psychological safety of SGM patients in health care spaces. Modern GSSO information practices support quality therapeutic relationships that, in turn, enable thorough and appropriate screening, care, and referral of SGM patients.

Health care system performance may continue to improve as new and innovative technologies are implemented, but if GSSO information practices are not modernized, the health inequities of SGMs are likely to persist or worsen [6]. Further research is needed to improve primary care for transgender people [29], to development specific laboratory guidelines and reference ranges for the gender diverse community [15], and to improve the accuracy of hormone therapy [16]. SGM-inclusive analytics and outcome measures need to be developed, and future research projects should consider using an intersectional lens to gain further insight into structural factors such as institutionalized prejudice faced by SGMs. Anatomic inventories are a core tool that should be evaluated as the best practice for modern GSSO information practices in health care for all people. Both private and public sector health technology regulations ought to include specifications for interoperable SGM-competent system design, including the use of expanded GSSO concepts and definitions in EHRs.

Health equity for SGMs requires systemic change. Agencies and agents in health care need to be equipped with the knowledge and tools needed to cultivate modern attitudes, policies, and practices that enable health equity for SGMs. Adopting small but important changes in the language and terminology used in technical and social health care systems is essential for institutionalizing SGM competency. Modern GSSO information practices depend on and reinforce SGM competency in health care.

The primary limitations of this review include language and timeframe. Only English-language documents published in the past 6 years and indexed within a single database (MEDLINE) were included. The authors are not bilingual. Publication year range was limited for expediency and for recency. Relevant documents from outside of the time frame or published in other languages or databases may have been missed. All included articles were from Western countries and cultures, limiting generalizability to other settings and creating a bias for Western ideals and strategies. Efforts to mitigate these limitations included seeking resources from an international group of experts and stakeholders that represented non-Western countries and non–English-speaking persons.