Nursing's Transition: Creating Inclusive Healthcare Settings for Transgendered Patients
Transgender patients should be able to access healthcare without fear or ridicule. By advocating for the individual needs of our patients we can continue to strive for quality outcomes for everyone.
The waiting room is busy; she sits gently pulling at the edge of her new Summer dress. It seemed like such a smart buy earlier in the week but now leafing through the shiny guide she received at the new employee orientation she wonders if the bright blue flower pattern and sleeveless cut is a bit too flashy for the office. Next to her is the stack of paperwork which she has dutifully completed, such a joyful task. The clock ticks on, she chews nervously on her pencil. She thinks back to other appointments, ones similar to this, she breathes in and lets out a long sigh. Finally the door opens, the nurse steps out and calls loudly, "David, the doctor will see you now". She stands, a swirl of Azure wilted by a moment of ignorance.
The story of "David", although fictional, is based upon the realistic events of a Transwoman, assigned a male gender at birth, now identifying as a female. Transgender individuals often avoid seeking healthcare related to fear and the potential for discrimination. Nurses are often the first contact that patients make when receiving care so they play a crucial role in developing rapport with their patients and creating welcoming environments.
Transgender is the general term used when referring to people who identify with a different gender than what they were assigned at birth. It really is not possible to get an accurate count on the number of people in the world that are transgender since the statistics are sketchy due to under reporting. With the accomplishments of actress/producer/LGBTQ advocateLaverne Cox as well as the recent outing of Olympic athlete, formerly known as Bruce Jenner, transgender topics have become more acceptable in social media. However the potential for violence and discrimination are still major issues for most patients. It is for this reason that it is not uncommon for patients to limit interactions with providers based upon feelings of anxiety or negative past experiences.
Issues with insurance coverage for medically necessary gender-related care or inappropriate care, reprisal at work related to their gender identity/need for medical procedures, and general access to medical services needed within their communities are frequent worries for patients. Lack of continuity of care and noncompliance with treatment is cause for concern as it relates to such medical disorders such as diabetes, heart disease, substance abuse, HIV, and mental health conditions. In recent studies, transgender patients were found 9 times more likely to have attempted suicide than the average person. Social risks such homelessness and lack of support systems were known to be high stressors. Refusal of care by medical providers and discrimination were also key factors for suicide risk.
Transgender patients should be able to access healthcare without fear or ridicule. Barriers to care exist in all environments and need to be broken efficiently. It is extremely important to educate yourself and others within your workplace in an effort to create safe, inclusive, patient centered care facilities. Increased awareness of barriers that patients may have already encountered prior to our visit allows us to appreciate the potential for underlying apprehension and frustration they may be experiencing. Nursing staff may also have feelings of nervousness stemming from a lack of knowledge regarding Transgender patients. Our own approach and demeanor can allow us to better anticipate the needs of the patient to improve overall outcomes.
What can nurses do to reduce stigma and make their workplaces more sensitive to the LGBTQ/transgender community? Focus on making sure that you are properly educated and share your knowledge with your colleagues. Be sure to use transgender affirmative and inclusive language. Ask patients their preference for word choice, especially when using names, pronouns, and other words to describe their body. It is important to ensure that environments are welcoming to the LGBTQ/transgender community. This can be accomplished through the display of LGBTQ acceptance signage as well as educational materials in the waiting room. Lastly, never assume! Whether it is the gender of a person, sexual orientation, or the answer to another health related question, nurses cannot avoid asking the questions necessary to properly assess and care for patients even if they are embarrassing or difficult. Remembering to incorporate sensitivity from the beginning of our assessment all the way through care delivery is a must! Respecting the individual needs of our patients and advocating for quality care has always been the nurse's forte. Ensuring that we do all that we can for the transgender population to receive the healthcare services that they deserve should be no different.
Look at it this way: I'm a Pagan. My deity is the earth and anything that damages Her or Her creation is sinful to me, including the enormous use of single use, disposable plastics. If I therefore decided to refuse to bag my trash and dispose of it according to facility policy, I would be told in no uncertain terms to get over myself because infection control is more important than my religious objection to plastic in a landfill or promoting a petrochemical product.
And those who told me that would be absolutely right to do so.
Hi. I've been away at a wedding all weekend, and boy did this thread explode. As a mental health professional, I want to point out a couple of things. First, being transgender isn't a mental illness. It's not recognized as an illness by either APA (psychological or psychiatric). Also, the AMA has published a policy on the acceptance of transgender patients, students, and physicians (if anyone cares what the AMA thinks anymore). Links:
Wait, the APA doesn't recognize being transgender as a mental illness? Fact. Gender dysphoria is not intended to be diagnosed in everyone who is transgender according to Jack Drescher (APA DSM-5 subcommittee on sexual and gender identity disorders member), who said, "We know there is a whole community of people out there who are not seeking medical attention and live between the two binary categories. We wanted to send the message that the therapist's job isn't to pathologize." Thus, people who are living transgender without significant distress have no mental illness.
I don't diagnose your patients' thyroid disorders or rashes, please don't try and do the job of a PMHNP or psychiatrist as a way of discrediting the experience of a group of people. I don't have any problem with people having religious convictions, but don't pretend your position is based in science. It makes science look bad.
I was frantically trying to get to the end of all the posts so that I could weigh in on this as a former mental health professional. Glad you beat me to it!
I also have some hypothetical questions (hoping to generate some internal reflection) for all of those who feel that god only designed 2 genders, etc etc (insert religious issues here):
Ever treated a neonate or pediatric patient born with ambiguous genitalia? Waited with the agonized and devastated family for the chromosome analysis to come back, hoping that it would clear things up? What about those who, after having been born with ambiguous genitalia and/or are also intersexed, are raised as one gender, only to realize right around puberty (or earlier) that they actually identify with the opposite gender? Is this still a "choice" or "delusion"? What would you do then, and how would you address this patient, particularly if they were a minor? How do you know that the trans* adult patient in your care didn't fall under one of these scenarios? Does the driving force behind their orientation really matter?
I feel that more than an ethics class or one based on "compassionate care for all", a basic neurobiology class, more embryology content, and a class in human sexuality should be had by all.
You guys have great discussions... but if I may: these are patients who are transgendered, maybe transgendered patients, but not "a trans." That's like saying "if a Chinese walks in..."
I see ridicule from people here because a Christian has the audacity to hold to a book that has stood the test of time for thousands of years but then refer to the DSM-5 like it's infallible. It has 5 editions for a reason. Not long ago, the DSM said that homosexuality was a mental illness. That obviously changed. What happens if the DSM-6 comes out saying it's a mental illness again? Will you still agree with it?
I have to point out that people who aren't religious don't accept the Bible as evidence, so pointing out that it has "stood the test of time," doesn't mean much to me. I appreciate that you have strong convictions, but to me it's just a book. I like that the DSM changes, because that reflects the growth in our knowledge. If the DSM didn't change it would be like reading a biology textbook that described health and illness in relation to the four humors, or a medical text that suggested transfusing blood from pigs into people. I trust science because it doesn't claim to be infallible, and that being able to challenge, test, and prove ideas is its greatest strength.
Say what you will, but if you have to change your approach when you care for a trans gendered individual, you are a crap nurse.
Put me in the "crap nurse" column, then. I change my approach with every patient. I talk softer to frightened patients, I'm less formal with young patients, more formal (at least at first) with very old patients, I bring my energy down with aggressive or anxious patients, and I'm more stern with borderline patients. I adapt my approach because people need different things from me; my patients aren't all the same.
@Dogen: your point on using the term "trans" is taken. It's one on which we'll have to agree to disagree. It's the term used by my intersexed partner, myself and our "circle" when discussing the subject, so I'm most likely gonna stay with it. The problem with "telling it slant" is that language becomes incredibly cumbersome, like that tapeworm of an abbreviation, lgbti.
You guys have great discussions... but if I may: these are patients who are transgendered, maybe transgendered patients, but not "a trans." That's like saying "if a Chinese walks in..."
The term "transgender" is best used as an adjective, not a noun. For example, I am a transgender women. You should not refer to anyone as a "transgender" or "transgendered women" Because it's a adjective and not an noun, you don't add "ed" to it.
The term "transgender" is best used as an adjective, not a noun. For example, I am a transgender women. You should not refer to anyone as a "transgender" or "transgendered women" Because it's a adjective and not an noun, you don't add "ed" to it.
And text didn't used to be a verb.
Language evolves, but people are also basically lazy, so terminology gets simplified in common usage. Now that the term is being discussed more, you're going to have to accept the evolution.
Language evolves, but people are also basically lazy, so terminology gets simplified in common usage. Now that the term is being discussed more, you're going to have to accept the evolution.
Don't shoot the messenger. There are certain ways to refer to people who are transgender. While it might be mere semantics to you, some people can be offended. I'm just trying to inform people, should they ever encounter this in their practice.
I was frantically trying to get to the end of all the posts so that I could weigh in on this as a former mental health professional. Glad you beat me to it!
I also have some hypothetical questions (hoping to generate some internal reflection) for all of those who feel that god only designed 2 genders, etc etc (insert religious issues here):
Ever treated a neonate or pediatric patient born with ambiguous genitalia? Waited with the agonized and devastated family for the chromosome analysis to come back, hoping that it would clear things up? What about those who, after having been born with ambiguous genitalia and/or are also intersexed, are raised as one gender, only to realize right around puberty (or earlier) that they actually identify with the opposite gender? Is this still a "choice" or "delusion"? What would you do then, and how would you address this patient, particularly if they were a minor? How do you know that the trans* adult patient in your care didn't fall under one of these scenarios? Does the driving force behind their orientation really matter?
I feel that more than an ethics class or one based on "compassionate care for all", a basic neurobiology class, more embryology content, and a class in human sexuality should be had by all.
Carry on.
Again, a beautiful book of fiction on exactly this topic: Middlesex, by Jefferey Eugenides.
I have been thinking about reading it again since this discussion began.
This is also the same as referring to an adult patient as "Eddy" (without his permission) instead of Mr. Jones. What if patients called providers "girl" or "boy"???
After all you were born that gender but you choose to be a nurse.
@Dogen: your point on using the term "trans" is taken. It's one on which we'll have to agree to disagree. It's the term used by my intersexed partner, myself and our "circle" when discussing the subject, so I'm most likely gonna stay with it. The problem with "telling it slant" is that language becomes incredibly cumbersome, like that tapeworm of an abbreviation, lgbti.
But I do take your point.
This is, honestly, the most difficult thing about these conversations. The language is fluid, everyone has their preferred terms, and different communities of relatively similar groups of people will want to be called different things. I'm far, far from an expert, and am happy to defer to those with more experience. It's a lot easier to have these conversations with an individual patient because I can say, "Tell me what makes you most comfortable." I had a patient who referred to herself as a "bull d**e" (rhymes with Mike), which is something I probably would have jumped on if said by someone here (or anywhere). When in doubt, though, I always go "people first," which is a result of my generation seeming to be very aware of our language.
The term "transgender" is best used as an adjective, not a noun. For example, I am a transgender women. You should not refer to anyone as a "transgender" or "transgendered women" Because it's a adjective and not an noun, you don't add "ed" to it.
I'm happy to drop the "ed," and I never mind the correction, so thanks. :) As I said above, the terminology is the most difficult part of these conversations, because no one seems to agree on what's right. Your rule seems generally applicable enough, though, that I can make that switch... at least until someone else corrects me.
This is, honestly, the most difficult thing about these conversations. The language is fluid, everyone has their preferred terms, and different communities of relatively similar groups of people will want to be called different things. I'm far, far from an expert, and am happy to defer to those with more experience. It's a lot easier to have these conversations with an individual patient because I can say, "Tell me what makes you most comfortable." I had a patient who referred to herself as a "bull d**e" (rhymes with Mike), which is something I probably would have jumped on if said by someone here (or anywhere). When in doubt, though, I always go "people first," which is a result of my generation seeming to be very aware of our language.
Dogen, you are correct that the individual approach is best. I have a couple friends that are MTF transexuals who live as women, but refer to themselves as "trannies" (slang for transexual). They prefer the pronouns "she."
This reminds me of the debate that was had some years ago where some rappers had referred to themselves by the "N-word." One school of thought on the "N-word" issue was that it was offensive and promoted a stereotype, the other (and a valid position as well) was that they had taken the power away from the word.
There is no substitute for good etiquette, and in a healthcare setting use the formal (female in the case of MTF). I believe that there is a certain balance that needs to be achieved out of human dignity and necessity.
The WHO and UN have addressed barriers that LGBTI individuals face (especially in healthcare) as human rights violations. The ACA addresses these issues as well. So why is so difficult (for some) to treat a fellow human being with dignity and respect? I am a practicing Catholic and I do not believe that being LGBTI is wrong, after all that is how God made that person.
The religious argument is the same as it has been used from the time that man has realized there is a God, from the inquisition to ISIS; just one group of humans justifying domination and imposition of their will on another group of humans.
I think what we all need to remember is to be respectful and polite to ALL patients.
Being a nurse isn't about US, its about the PATIENT.
Therefore, our religious beliefs should not interfere with the care of our patients. That said, if you have strong objections to caring for a transgendered patient, then please be objective enough to realize this and ask for a different assignment.
In all fairness, where do we get to the part where you get ostracized, tarred, feathered, written up, and possibly fired for even uttering such a thing? Let's be realistic with our solutions.
heron, ASN, RN
4,641 Posts
Look at it this way: I'm a Pagan. My deity is the earth and anything that damages Her or Her creation is sinful to me, including the enormous use of single use, disposable plastics. If I therefore decided to refuse to bag my trash and dispose of it according to facility policy, I would be told in no uncertain terms to get over myself because infection control is more important than my religious objection to plastic in a landfill or promoting a petrochemical product.
And those who told me that would be absolutely right to do so.