The CLD for the Gender Identity value set used in the Gender Identity Extension (http://hl7.org/fhir/StructureDefinition/individual-genderIdentity) includes the core SCT concepts via an include of a VSAC value set. Unfortunately VSAC always identifies SCT concepts using the US Edition version and these need to be drawn from SCT International. Use of VSAC was to simply cross-paradigm use but this turns out to be not as helpful as thought. When a US realm guide, such as US Core or C-CDA need to use these, they can just replicate the core (no Nulls) concepts in VSAC or even in THO when necessary.

Recommendation:

Change the Compose to specifically include the three SNOMED CT concepts and NOT include the VSAC value set. The compose will be (this has a syntax error):

{
  "compose" : {
    "include" : [{
      "system" : "http://snomed.info/sct",
      "concept" : [

{         "code" : "446141000124107",         "display" : "Identifies as female gender (finding)"       }

,
     

{         "code" : "446151000124109",         "display" : "Identifies as male gender (finding)"       }

,
      

{         "code" : "33791000087105",         "display" : "Identifies as nonbinary gender (finding)"       }

]
    {
      "system" : "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
      "concept" : [

{         "code" : "UNK",         "display" : "Unknown"       }

],
    }
  }
}