Rethinking Documentation with a Lens of Protection

As clinicians, it is important to take many considerations into how one completes documentation for all clients in a clinical setting. Clinicians who work with a marginalized population such as trans and non-binary people, should be aware of additional considerations in documentation that not only protect the confidentiality of their clients, but also increase their safety.

Currently there have been approximately 669 anti-trans bill introduced throughout the United States. Around 48 of these bills have been passed, and 36 bills have been pre-filled for 2025. These bills have already had an impact on the care that can be provided to trans and non-binary clients, and their safety.

As clinicians continue to provide mental health and gender affirming care to trans and non-binary people, there are steps one can take in documentation that maintain confidentiality, increase safety, ethically document sessions and maintain a clinical record, and allow clinicians to maintain their ethical duty to do no harm. In this hour, clinician will increase knowledge and cultural competency, have a greater understanding of the impacts of clinical documentation, and gain practical steps in documentation that maintains confidentiality and increase safety for trans and non-binary clients.