We will remove the comment about the extension being appropriate when openly known.  Instead, we will be silent in the spec about how to handle openly known or not.  The expectation is that the medical system that records the gender identity will apply whatever security and privacy controls that are appropriate for the party that is receiving the data.   The concept of "openly known" is problematic from the start, as a gender identity may be openly known for a patient in the US, but if they travel to other countries, it may not be appropriate to share that GI information with users in that country.   This will be the updated Gender Identity text (comments about "openly known" are removed): Gender Identity  - a gender the patient has indicated they consider themselves to be. The gender identity can influence how the patient prefers to be addressed by care providers and other individuals. The standard  genderIdentity extension may be used to communicate this property. When determining how to address the patient, the pronouns  extension may also be applicable.