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WASHINGTON -- A keyword-based search in the electronic medical record (EMR) at an urban emergency department (ED) showed high rates of suicidal ideation among transgender and gender diverse (TGD) youth, according to a retrospective cross-sectional study.

In 81% of ED encounters at a single tertiary children's hospital, TGD youth screened positive on the Ask Suicide-Screening Questions (ASQ), reported Amanda Burnside, PhD, of the Ann and Robert H. Lurie Children's Hospital of Chicago and Northwestern University Feinberg School of Medicine, during the American Academy of Pediatrics annual meeting.

Most of the ED encounters (77.5%) were tied to mental health, and 10% of youth endorsed active suicidal ideation at the time of ED presentation. Compared with cisgender youth, TGD youth were more than five times as likely to screen positive for suicide risk, she said.

The "drive-home message here is this study emphasizes the importance of universal screening to identify gender diverse youth at risk," she added, "and we really need to develop robust strategies and systems to link them to mental health services."

Burnside elaborated on the spectrum of the care team involved in the screening process: "In our ED, the nurses actually administer the screening questions, the physician then comes in and does the follow-up screening, and then they'll page a mental health provider to follow up further."

Overall, suicide among TGD youth "represents a national crisis," Burnside said. Research involving this population has "historically been limited" by focusing on specialized clinic populations or gender-specific diagnostic codes in the EMR. The goal of this study was to "bridge that gap," she noted.

The study looked at ED encounters by youth who received suicide screening via the ASQ at the tertiary children's hospital from September 2019 through August 2022.

"Universal suicide risk screening for all youth 10 years and older, regardless of chief presenting complaint, was implemented about halfway through the study period," Burnside said. "Youth were excluded from screening if they were nonverbal or unable to complete questionnaires due to medical acuity upon presentation."

Nine keywords were used to identify TGD youth through a search in the EMR: they/them, preferred name, pronouns, male-to-female, female-to-male, nonbinary, agender, transgender, and gender dysphoria. If any of the nine keywords were present in the ED note, the surrounding text was extracted and manually reviewed by two members of the research team to determine TGD status.

In total, the ASQ was administered during 12,112 ED encounters, and one in four had a positive screen. Of these, there were 565 ED encounters by 399 unique TGD youth. Thirty-one percent of ED encounters by TGD youth contained just one keyword, and this was most likely to be "pronouns" or "they/them."

TGD youth ranged in age from 8 to 23 years; 43% were white, 35% were Latinx, 10% were Black, 4% were Asian, and 8% identified as other or two or more races. Additionally, 43% of TGD youth were publicly insured and 52% lived in a neighborhood with a "low" or "very low" Child Opportunity Index category.

Limitations to the study included the fact that 5% of the sample were gender diverse, representing a slightly lower figure than recent population-based estimates. It's also possible that relevant keywords existed in other sections of the EMR other than that for the ED, Burnside said, and misspellings or abbreviations related to keywords may not have been captured. In addition, the single-center study has not yet been externally validated in other healthcare systems.

"Overall, however, this study did demonstrate that keyword searching is a promising technique to identify and prioritize gender diversity in health services research," Burnside said.

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