In the questions to balloters are asked to comment on the recommendation for:
Patient sex mapped to Patient.gender (not birth sex)
It is not clear where the guide makes this recommendation. Nonetheless this guidance should not be encouraged because patient.gender is not a semantically stable data element and it cannot be reliably utilized for any clinical uses.

This guide should adopt the recommendations of the gender harmony Sept 2022 ballot and pre-adopt the changes needed to support use of a verifiable representation of clinical sex. If gender is what is actually needed, then again, the guide should align with gender harmony on exchanging gender identity. If gender or clinical sex (SFCU) information is not useful or needed, explicitly state exchange should not include it