Improving Nursing Care for the Transgender Community

As the transgender population grows and becomes more visible, it is vital nurses understand the issues this marginalized population faces in order to give sensitive and compassionate care.

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Improving Nursing Care for the Transgender Community

Nurses are to care for every patient in their charge, regardless of gender, race, ethnicity, sexual orientation, socioeconomic status, religion, and so on. Nurses give compassionate and competent care every minute of every day to patients they would not be friends with outside of the patient-caregiver context. Indeed, nurses care for people they may strongly disagree with in politics, religion, or just overall beliefs. But nurses do it because that is their job. It is, in fact, what they signed up for.

Marginalized communities have always had barriers to healthcare, and that is true for the LGBTQIA+ community. In particular, the transgender community faces unique struggles in accessing healthcare. The issues are distinct and go right to the core of who they are—their very identity. They deserve the same compassion and competence as every other person.

The Williams Institute of UCLA School of Law published a study in June 2022 that indicates the number of youth who identify as transgender has risen sharply in the last five years. With an estimated 1.6 million transgender people over the age of 13 in the US, healthcare providers need to understand what issues they face and how to care for this marginalized population. 

The Issues

Transgender people need the same basic and preventative healthcare as cisgender people. However, studies reveal that transgender people are less likely to seek care out of fear of discrimination. These fears are not unfounded. The LGBTQIA+ community has faced discrimination from everyone, from doctors and nurses to secretaries and insurance companies. Is it any wonder care is avoided or delayed?

Besides basic care, transgender people face many of the same issues as other minorities due to minority stress. These issues include:

  • Mental health problems such as depression and anxiety, often due to internalized stigma
  • Self-harm and suicidal ideation
  • Physical and sexual violence
  • Substance misuse
  • Sexually transmitted infections
  • Inadequate and/or misinformed care from healthcare providers
  • Increase tobacco use
  • Obesity 

Transgender people who wish to transition face another level of healthcare barriers and issues. The aim of this article is not to address these issues specifically but rather to bring to light the disparities for this population. However, it is beneficial to understand just how many considerations, health and otherwise, a person who wishes to transition may face. These include:

  • Legislation, including anti-trans legislation and variations from state to state
  • Coming out to family, friends, schoolmates, co-workers, boss, etc.
  • Parental consent
  • Possible job loss
  • Changing names and gender in legal documentation
  • Pronoun use
  • Presenting publicly, which may include changing clothing style and hairstyle or changing body contours to match gender identity (tucking, packing, binding)

The medical side of transitioning includes things like:

  • Hormone therapy; which can increase the risk of blood clots, strokes, heart disease, liver damage, and certain cancers
  • Top and/or bottom surgery
  • Speech therapy 
  • Hair removal
  • Tracheal shave
  • Lack of insurance coverage

Discrimination in Healthcare

Across the country, the healthcare needs of transgender people are misunderstood. Many consider changes "cosmetic.” Gender dysphoria, the distress felt when assigned gender at birth does not match gender identity, is not something that is the result of a choice. It is widely recognized by the medical community, including the American Medical Association, American Psychological Association, and the American Academy of Pediatrics, that gender-affirming treatments are critical, not cosmetic. 

A study published in the Journal of the American Medical Association shows that administering gender-affirming hormones significantly mitigates mental health issues such as depression and suicidal ideation. It saves lives. And yet many states are passing anti-trans bills that restrict access to things such as hormone therapy and puberty-blocking by barring insurance companies from covering these treatments ... or even defining them as child abuse. 

Nurses Can Provide a Safe Space for Transgender People

By recognizing the mountain of difficulties the transgender community faces, nurses are in a position to lend a safe place for them. Thankfully, more research has been done, and therefore resources are available to help guide care. The evidence is starting to surface. One does not need to become an expert in this, but it is worth seeking out these resources to better understand the issues transgender people face and how care can be provided for them in a sensitive, gender-affirming way. 

Here are just a few resources and tools to help bone up on definitions, vocabulary, and knowledge so that care is administered in a sensitive way:

Like many things involving inequalities and basic human rights, the issues of healthcare for the transgender population are fraught with politics, personal beliefs, social norms, and cultural traditions. Solutions come over time, piece by piece, and often with setbacks. Complicated problems require a multifaceted approach and collaboration from a variety of stakeholders. But in the end, the transgender community, along with the entire LGBTQIA+ population, deserve to lead happy, healthy lives, feel safe in their communities, and be confident in their healthcare team to do what is best for them.

Definitions

  • Gender Identity - an internal identification of one's gender, not always visible to others
  • Gender Expression - includes mannerisms, styles, interests, and pronouns that reflect gender. This expression is steeped in cultural norms and heavily influenced by social constructs.
  • Nonbinary - an umbrella term that includes experiencing gender identity outside of a male-female binary
  • Genderqueer - falls outside the categories of man or woman
  • Cisgender - identifying with gender assigned at birth
  • Transgender - identifying with a gender other than that assigned at birth

References/Resources

Social Acceptance of LGBT People Ranked By State.pdf

Poverty Rates by Sexual Orientation and Gender Identity.pdf

Meeting the Health Care Needs of Transgender People

Gay & Lesbian Medical Association: Guidelines For care of Gay, Lesbian, Bisexual, and Transgender Patients

Gender Dysphobia

Terminology surrounding Gender Identity and Expression

Study estimates trans youth population has doubled in 5 years

Supporting Trans Youth

PROHIBITING GENDER-AFFIRMING MEDICAL CARE for Youth

Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care

Health concerns for transgender people

What do I need to know about trans health care?

Protect Trans Health: What Do We Want?

LGBTQ Health

National Center for Transgender Equality: Issues/Health & HIV

What do I need to know about transitioning?

Transition Roadmap

The Williams Institute: Infographics

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nikkulele77

About nikkulele77, BSN

Nicole Hill has 20+ years of experience in a variety of settings including hospitals, public health, community, schools, and camps. She now writes health content.

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Specializes in LTC & Rehab Supervision.

Love this article and topic!

Back at my old job in the doctor's office, I had a non-binary patient. They were so shocked (because they were a new patient) that I asked their preferred gender/etc, due to being unsure if it was in the computer correctly. I asked their preferred name as well.

They were so shocked and grateful I asked those questions, as no one has ever asked them before. I treated them just like any other patient.

I'm gay myself, and sometimes it lightens people's faces up when I tell them. I know that can be risky at times, but every time I've done it with patients, they've always been more involved and super grateful that I'm their nurse/student/etc.

It's the little things, you know? We gotta do good as a whole for our LGBTQIA+ community. 

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Specializes in ED, ICU, Public/Community Health.

I love that you are able to ask those questions and give a safe place! As an older nurse, I didn't even think to ask about gender  for many years - it wasn't taught to us. And then it was just really uncomfortable for a long time. But it's super important to be able to ask questions and have conversations surrounding these issues, even if it's unknown territory. Like you said, it's the little things that are important!

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Specializes in Freelance Health Care Writer|End-of-Life Educator.

Thank you for this informative article! As an older nurse, I’ve worked really hard to adjust my vocabulary in order to become more inclusive. Asking for their identified pronouns is but one of the ways I’ve pivoted so I can make folx more at ease when they are at their most vulnerable. Nurses can be judge-y…but we can do better. 

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Specializes in ED, ICU, Public/Community Health.

I know, right? It can be hard to adjust, but it's so important. I admire your efforts and hope that more nurses can follow. We don't need to wear the word "jaded" as a badge of honor!

 

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Specializes in Freelance Health Care Writer|End-of-Life Educator.

I like that perspective! Keep up the great writing!

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Specializes in ED, ICU, Public/Community Health.

Thank you!

 

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.

I have a question based on an experience from a few years ago on my medical surgical floor. We had a young adult patient admitted who identified as female, but still had the outward appearance consistent with being a male, including facial hair in a goatee type style. This person was initially admitted to a double room with a male patient, and I understand that was not consistent with their rights. They requested a room change and were moved to a private room, but then brought a complaint against our staff because we did not place them in a room with a female roommate. At the time, the only other open double was with an elderly woman and the bed was nearer to the door. I was charge at the time and the supervisor and I felt that the older woman might not be comfortable crossing to the bathroom with a roommate that she would visually identify as male. And we as staff could not explain to her that the patient identified as a female. How could we best balance the rights of both patients? We did not mean to insult this person in any way by giving them a private room, most people would prefer that, but it didn't work out as we had intended. 

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Specializes in ED, ICU, Public/Community Health.

That is a really good question in a challenging situation. Honestly, I feel like I would have done the exact same thing. The private room seems to be the most appropriate option. Patients don't always get a choice when it comes to room placement and bed control can get complex with many moving parts and considerations, including safety for everyone involved. Most patients don't understand that and complaints crop up. In this case, I wonder if the initial placement in the room with a male companion was hurtful enough that it bled over into when she was placed in the private room? Like it was more of an isolation thing than a privacy thing? That's just one thought. And I'm definitely not the expert.

Here's a link I found that addresses when patients object to transgender roommates, which isn't the case here, but it goes into hospital policy concerning transgender patients.

Transgender Roommates

It is good that you and your staff recognized the importance of privacy and HIPAA laws in regards to gender identification.

If anyone else would like to chime in with thoughts or suggestions, feel free!

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Specializes in Med-Surg.

I've seen on this board people call transgendered women "men wearing a dress wanting to use female bathrooms".    My thought was "this is a nurse saying this". 

I think we have a long way to go.  Thanks for your article.

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In my hospital we recently had a situation arise with a non binary person. 

From most physical attributes, this person would fall into the female side but presented more as masculine.  We were unsure of the internal organs, mainly if this person had a uterus or not as they were presenting wilth right side lower abdominal pain and symptoms associated with possible ectopic pregnancy or ovarian mass. The person had a high body index so diagnosis with a manual examination wasn't conclusive. 

Long story short, we had a barrier to diagnosis. We couldn't do standard imaging because we were hesitant to ask about LMP for fear of offending this person and could not risk a healthy pregnancy with xray. Time was important for risk of ovarian rupture or ruptured fallopian tube. 

In the end we asked if they were born with a uterus, they said yes and we went on for treatment of an ectopic pregnancy.  The person did not seem happy about being asked if they had a uterus. There was some concern about possible gender discrimination complaint. 

How do we as Healthcare professionals provide gender sensitive care and ask pertinent questions that would otherwise be standard? How do we create dialog with the LGBTQ community to not be offended when asked these questions so important to health and sometimes their life? 

It's to be expected to see more of these patients and I was wondering if anyone had any ideas on how they have approached this important topic in their practice? 

On a higher note I think there should be some legislation that protects HCP from claims of discrimination or complaint from asking pertinent health questions in relation to sexual anatomy. I would hate to see a case where someone was harmed or lost their life because HCP were deterred from asking for fear of offending someone. 

On 11/3/2022 at 4:04 PM, JBMmom said:

I have a question based on an experience from a few years ago on my medical surgical floor. We had a young adult patient admitted who identified as female, but still had the outward appearance consistent with being a male, including facial hair in a goatee type style. This person was initially admitted to a double room with a male patient, and I understand that was not consistent with their rights. They requested a room change and were moved to a private room, but then brought a complaint against our staff because we did not place them in a room with a female roommate. At the time, the only other open double was with an elderly woman and the bed was nearer to the door. I was charge at the time and the supervisor and I felt that the older woman might not be comfortable crossing to the bathroom with a roommate that she would visually identify as male. And we as staff could not explain to her that the patient identified as a female. How could we best balance the rights of both patients? We did not mean to insult this person in any way by giving them a private room, most people would prefer that, but it didn't work out as we had intended. 

Yes. These are important considerations. I had one I just posted above. 

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Specializes in Ob.

Love this ! 

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