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Assigned Sex, Gender Identity, and Death Reporting

By 15 Aug 2025October 6th, 2025No Comments

Authors: Sam Engrav MD & Meagan Chambers MD

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Background

Approximately 7.6% of adults in the United States identify as lesbian, gay, bisexual, transgender, queer, intersex, or asexual (LGBTQIA+), which accounts for 26.6 million people of the current US population. This number has been on the rise (with roughly 3.5% of Americans identifying as part of the LGBTQIA+ community in 2012, and 5.6% in 2020). Of this minority group of individuals, studies estimate that 0.49 to 1% of the total US population identify as gender diverse (an estimated 1.6 – 3.3 million Americans). 

A gender diverse individual is someone whose gender identity and/or expression does not conform to the sex they were assigned at birth, and/or either of the binary genders of man and woman. This includes, but is not limited to, individuals that identify as transgender, nonbinary, genderqueer/gender-nonconforming, genderfluid, agender, and two-spirit (an Indigenous/First Peoples person in North America who has both a feminine and masculine spirit). 

Gender diverse individuals are significantly more likely to have inadequately addressed mental and physical health concerns than their cisgender counterparts for numerous reasons including but not limited to: barriers in healthcare access, lack of healthcare knowledge of gender diverse individuals, distrust of the healthcare system, socioeconomic concerns, and political and legal barriers to accessing care. Additionally, older LGBTQIA+ individuals are roughly twice as likely to live alone than their counterparts highlighting a potential lack of support and increased risk for accidents, injuries, and in more severe cases, death. 

Accurate documentation of gender identity is essential. Most importantly, accurate documentation upholds respect and dignity for the decedent by ensuring the accurate capture and preservation of their identity. 

Additionally, accurate documentation serves critical functions for:

  • Families/next-of-kin
  • Support network coordination
  • Proper record keeping at the local, regional, state and national levels to drive effective public health management and policymaking. 

However, such record keeping can be difficult:

  • Family/next-of-kin may not be aware of a decedent’s gender diverse identity.
  •  A gender diverse individual may have different (and even conflicting) legal documents
  • Recommendations and policies regarding gender identity reporting in death investigation differ state by state, and are subject to change. 
    • When completing the autopsy, it is important to note what the given policies and recommendations in a jurisdiction dictate, however, it is imperative to document the observed and/or reported gender identity at time of death as best as possible.

Language and Terminology:

  • Assigned Sex at Birth (“Sex”)
    • The sex denoted on an individual’s birth certificate (often based on external genitalia) 
      • While sex has frequently been dictated by chromosomes (especially in the media), it is rare that chromosomal analysis is conducted to determine an individual’s sex
    • Male/Female/Intersex 
      • In regards to transgender/gender diverse individuals, you may see AMAB/AFAB – “Assigned male/female at birth” 
      • Intersex individuals are those with sex traits/reproductive anatomy that are, by medical definition, neither those associated with the traditional medical distinction of male nor female 
  • Administrative Sex (the sex designation on an individual’s driver’s license and/or other government-issued identification) 
    • M/F/X 
  • Gender Identity
    • A person’s internal sense of being man, woman, some combination of man and woman, or neither man nor woman (how a person “identifies”) 
      • This is separate from gender expression (how one presents their gender through appearance, dress, and behavior) and assigned sex at birth  
    • Cisgender: Denoting/relating to a person whose gender identity corresponds to their assigned sex at birth 
      • Ex. A cisgender woman is someone who identifies as a woman, and whose assigned sex at birth was female 
    • Transgender: Denoting/relating to a person whose gender identity differs to their assigned sex at birth 
      • May also be denoted/described by someone as “trans,” “transmasculine,” “transfeminine” 
        • A transgender man: assigned sex at birth was female,  identifies as a man
        • A transgender woman: assigned sex at birth was male, identifies as a woman 
    • Nonbinary: Denoting/relating to a person whose gender identity is outside or separate from the gender binary (man/woman) 
      • “Nonbinary” generally includes a wide range of identities (genderqueer, gender-nonconforming, genderfluid, agender, two-spirit, etc.) 
      • May also be denoted/described by someone as “enbee,” or “enby,” (documentation/social media) 
      • Some nonbinary individuals identify as transgender, some do not 
  • Gender affirming care: interventions that support an individual’s gender identity
    • Some examples include: 
      • Social/behavioral/psychological: Counseling, speech therapy, pronouns
      • Physical/medical: Appearance and dress (hair, makeup, clothing), breast binding/padding, genital tucking, surgery, hormone therapy
      • Legal: Changing one’s legal name, and gender/sex markers on legal documentation (passport, driver’s licence, etc.)

Quick Tips at Time of Autopsy

The autopsy of a gender diverse individual should follow standard autopsy practice of an institution – the following is recommended to be used to identify impacts of gender affirming care and to understand some of the gross and histologic changes that may be present as a result of gender affirming care. The autopsy examination of a gender diverse person should have minimal impact on the work flow or reporting for the pathologist. 

Medical Record review / Clinical History 

Careful review of the medical chart/electronic health record can indicate markers that a decedent is gender diverse. Many records now have areas that allow providers (or an individual) to either document or self-identify preferred name, pronouns, gender, sexual orientation, etc. 

Other potential markers of gender diverse status in the chart include: 

  • Notes/record of intersex anatomy
  • Organ inventories – records of what sex organs a patient may have, often used to help guide appropriate screenings
  • Documented gender affirming care
    • Hormone therapy (estrogens, antiandrogens, testosterone)
    • Surgical interventions 
      • Chest: Masculinizing chest surgery, augmentation mammoplasty
      • External genitalia: Feminizing vaginoplasty, metoidioplasty, masculinizing phalloplasty
      • Internal genitalia: hysterectomy, oophorectomy, orchiectomy, vaginectomy
      • Face: Facial feminization procedures, laser hair removal

Review of the medical chart prior to autopsy can aid in understanding gross and histologic changes in sex organs as a result of gender affirming care, and may help explain some aberrations in lab values. (Ex. Transgender women can see decreases in AST, ALT, and ALP after initiating hormone therapy). 

Knowing that a comprehensive review of a decedent’s medical record, social history, etc. may not be initially available to a provider, the final report may require adaptation or amendment as information becomes available.

Ancillary Testing

  • When reviewing the medical record, lab values and reference ranges should be appropriately correlated if a decedent has been on stable hormone therapy as part of their gender affirming care:
    • Reference interval for affirmed gender should be used when evaluating: 
      • Hemoglobin
      • Hematocrit
      • Iron studies
      • Electrolytes
      • Lipid testing
      • Liver function
      • Creatinine
      • eGFR
      • Estradiol
      • Total testosterone
    • The reference interval for sex assigned at birth should be used when evaluating: 
      • High-sensitivity troponin
      • Prostate-specific antigen (PSA) – unless the prostate has been removed
    • Other tests (as of this time): no known modification for analysis is needed

Quick Tips at Time of Evaluation, Documentation, and Reporting

  • Gender affirming care can include a variety of interventions and be at various stages – anatomical language is helpful to describe these changes
  • The majority of an autopsy report can be completed without any changes to recognize an individual’s gender diverse status

External examination

  • There may be evidence of gender affirming care surgeries: 
    • Scars from breast tissue removal,  evidence of breast augmentation and/or vaginoplasty, phalloplasty, etc. 
    • Of note, surgeries and the presence or absence of surgical scars are not necessarily specific to gender diverse populations and should be corroborated with other clinical history. 
      • Mastectomy – Gender affirming vs breast cancer associated. 
        • Avoid making comments on the purpose or intent of a scar. Simply stating, “Well healed scars are present on the chest and the breasts appear absent” is sufficient. 
  • Some hormonal gender affirming care can result in changes in fat and muscle distribution, and nonsurgical changes in the penis/clitoris
    • These findings should be correlated with an individual’s medical history – as these interventions are not all specific to gender diverse individuals 
  • When describing anatomy (external), use anatomical language. “Phenotypic” should be used to describe external traits.
    • Ex. A transgender man (assigned female at birth) that has not undergone any surgery:
      • EXTERNAL: “The external genitalia are those of a phenotypic adult female.”

Internal examination 

  • Of note, at the time of the autopsy and collection of tissue for preservation 
    • There is no specific testing that should be carried out in regard to a decedent’s gender diverse status
    • There is not specific changes to collection procedures for stock jar, toxicologic, or histologic tissue samples (see histology section below for further details)
  • Use organ inventories (if in the chart) and descriptive anatomical terminology to help corroborate what reproductive organs may or may not be present. 
  • Avoid using gendered language such as “female reproductive organs”, instead using “uterus, cervix, and ovaries”.
  • Like the external description, when describing internal anatomy use anatomical language. “Phenotypic” should be used to describe external traits.
    • Ex. A transgender man (assigned female at birth) that has not undergone any surgery:
      • INTERNAL / GENITOURINARY: Can be described as having a uterus and ovaries (instead of “normal female internal genitalia”)
      • OR – “The uterus, fallopian tubes, and ovaries are unremarkable and there is no evidence of pregnancy.”

Histologic examination

  • Various observations on histologic evaluation may be noted in gender diverse individuals, most often associated with individuals that have had stable and consistent hormone therapy as part of their gender affirming care
    • Histologic examination of tissue from individuals assigned female at birth that had androgen exposure can show:
      • Increased fibrous tissue and lobular atrophy of breast tissue
      • Sparsity of endometrial glands with stromal changes of the uterus
      • Cervical transitional cell metaplasia
      • Cystic follicles of the ovaries with increased follicular density
    • Histologic examination of tissue from individuals assigned male at birth that had estrogen exposure and antiandrogen therapy can show:
      • Development of acini and lobules in breast tissue
      • Testicular atrophy with increased basement membrane thickness, and spermatic maturation arrest 
      • Squamous metaplasia changes of the prostate and urethra
  • It should be noted that gender affirming therapy shall not be considered binary in regard to “result”, and thus, histologic changes occur in a spectrum

Write-Up and Reporting 

  • The death certificate should be completed based on state laws.
  • While the legal name of a decedent is included in an autopsy report for administrative and legal reasons, the decedent’s chosen name and pronouns should be used in the report whenever possible
    • When in doubt, it is best to use the name/pronouns that an individual identified with at the time of death. If this is unknown, gender neutral language, such as they/them, can be used.
    • For example, “The decedent was reported to have a significant medical history. They were located unresponsive in a secured residence.”
      • This type of language can easily be applied to any and all autopsy reports. 
    • If in doubt, the decedent’s legal name and chosen name can also be listed in the report 
      • Ex. Legal name: “…” Chosen name “…” (See suggested passages below for ways to reconcile potential differences between a decedent’s legal and chosen name)

The following recommendations are from Juniper Fedor (MS, PA (ASCP)CM), Alison Krywannczyk (MD), and Anthony Redgrave (EdD) from “Gender Identity in Forensic Death Investigation.”

  • Suggested Passage for the Narrative: “… reported the death of [LEGAL NAME], who identified as [nonbinary] and was assigned [male] at birth. The decedent used the name [CHOSEN NAME] and the pronouns [they/them], which will be utilized in reference to the decedent throughout the remainder of this report.”
  • Suggested Passage for the Autopsy Report: “The body is that of an adult assigned [female] at birth, who identifies as a [transgender man] and [has] undergone gender affirming care, [to include a double mastectomy and hormone replacement therapy].”
  • Suggested Description of External Genitalia and Reproductive Organs:
    • “The external genitalia are those of a phenotypic [female/male].”
    • “The external genitalia consist of a normally developed [vulva/penis and testes].”
    • “The external genitalia consist of a [penis with the absence of testes in the scrotum].”
    • “The reproductive organs consist of a [penis, uterus, and gonadal structures].”
  • Suggested Examples of Terminology for Sex/Gender Labeling on Report Headers
    • “Sex: Transgender Woman, Assigned Male at Birth”
    • “Sex: Intersex, Assigned Female at Birth”
    • “Gender: Transgender Woman”
    • “Gender: Nonbinary”

Recommended References

Additional References

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