According to results published in Sexually Transmitted Diseases, a 2-step gender identity question led to a 4.8-fold increase in ascertainment of transgender patients at a clinic for sexually transmitted infections (STIs) in Seattle, Washington. 

In May 2016, the clinic switched to a transgender inclusive and gender affirmative 2-step methodology of asking patients about gender identity and sex assigned at birth. Study investigators conducted a pre-analysis and a post-analysis comparing the proportion of patients who identified as transgender or gender nonconforming during the year before and the year following implementation of the new method.

Gender identity and medical history questions were delivered by means of a computer-assisted self-interview, and the 2-step method included the new gender response options of non-binary/genderqueer as well as a write-in option. Results showed the new question method resulted in a 4.8-fold increase in patients who identified as transgender or gender nonconforming; from 36 of 6635 (0.5%) before implementation to 172 of 7025 (2.4%) afterward (P< .001). The proportion of patients identified as transgender men increased more than that of transgender women, 0.2% to 0.5% (P =.002) and 0.4% to 0.6% (P =.096), respectively.

Of the patients identifying as transgender or gender nonconforming after implementation of the new choices, 51.7% identified as non-binary/genderqueer. The HIV/STI risk profile of non-binary patients was distinct from that of both transgender and cisgender men who have sex with men.

These results are only reflective of this single center and may not be generalizable to other transgender or gender-nonconforming communities, noted the study investigators. Small sample sizes also increased the difficulty of characterizing accurately the differences between the transgender or gender-nonconforming population and other patients. The study investigators also observed a low prevalence of self-reported HIV infection in transgender women at their clinic compared with the disproportionally high rates reported in the literature. This could reflect a true lower prevalence in their patient population or may be the result of other factors.

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The finding that HIV/STI risk profiles of non-binary patients were distinct suggests that distinguishing subpopulations within the transgender or gender-nonconforming population is important for risk stratification. Researchers also stated that “implementing a 2-step gender identity question in [a] STD clinic setting is feasible and leads to increased identification of [transgender or gender nonconforming] patients.” They concluded that improving ascertainment of gender minorities is critical to providing care, identifying risk factors, and meeting the sexual health care needs of these groups.


Tordoff DM, Morgan J, Dombrowski JC, Golden MR, Barbee LA. Increased ascertainment of transgender and non-binary patients using a two-step versus one-step gender identity intake question in a STD clinic setting [published online December 3, 2018]. Sex Transm Dis. doi: 10.1097/OLQ.0000000000000952