Nursing's Transition: Creating Inclusive Healthcare Settings for Transgendered Patients

[Jessica Quigley]

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.

Jessica S. Quigley RN, DNP

[banterings]

Such a slippery slope argument. Comparing someone who transgender which affects self image, and not even about their sexuality at it's core, to someone who experiences a sexual reaction to... it's not the same thing.

Being transgender, at it's core, is not illegal. Trans people can be any sexuality in the book. Being transgender is about how they feel about themselves, not what they are sexually attracted to.

Pedophila on the other hand, is wholy about what they are sexually attracted to. There is a choice involved when it comes to acting on sexuality. They need help in so many ways. Not all pedophiles have acted on their attractions, and should be encouraged not to.

This article recently popped up in my facebook feed, and explains the difficulty for finding help. This 19-year-old pedophile has never gone near a child. And he needs you to hear his story. it's a horrible sorry, some of the parts of it made me very upset, but read it and then try to tell me that being transgender is at all like pedophilia.

jaycam,

I am going to get a lot of negative feedback on this, but please note, this is NOT my view on this topic, and I am sure that Dogen, BSN, RN can back me on this and probably express it more eloquently:

In a move toward destigmatizing pedophilia, the American Psychiatric Association (APA) in its updated Diagnostic and Statistical Manual of Mental Disorders (DSM), distinguishes between pedophiles who desire sex with children, and those who act on those desires.

The former group -- those who want to have sex with children but whose desires are not distressing or harmful to themselves or others -- is no longer classified as having a psychiatric condition in the updated DSM.

"The difference [from the last edition of the DSM] is, you're not automatically saying that as soon as someone has a marked, unusual erotic interest that they have a mental disorder," said Ray Blanchard, who cowrote the chapter on sexual disorders in the new DSM. (Source: The Huffington Post)

Note that in 2013, the allegedly scientific mental health manual, the DSM-V, declared briefly that pedophilia was a sexual orientation,” rather than a mental illness, before retracting the claim in response to public outrage. After a national backlash from social conservatives, the American Psychiatric Association (ASA) has dropped its designation of pedophilia as a sexual orientation.”

In May, the APA released the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In this document, the first new edition in 10 years, the APA described pedophilia as a sexual orientation.”

The classification went largely unnoticed until last month, when the NeonTommy blog of the Annenberg Digital News at the University of Southern California published a blog post critical of the terminology.

Social conservatives said calling pedophilia an orientation” was a step towards normalizing pedophiliac behavior.

But within days, the APA changed the classification, noting in a press release 'Sexual orientation' is not a term used in the diagnostic criteria for pedophilic disorder and its use in the DSM-5 text discussion is an error and should read ‘sexual interest.'”

The APA said the unwelcome attention from conservative Christians helped them turn out a more precise and accurate guide.

In using [the term] sexual orientation, APA did not intend for it to be construed in the legal sense – as in a protected status under title IV and other legislation, but we learned that some may construe it that way,” a spokesperson who asked to remain anonymous told LifeSiteNews.com. Therefore, we changed the word to ‘interest' so that it would be clear that APA is speaking in medical terms, and is not commenting on legal status.”

[jaycam, RN]

banterings,

I am not so sure where the line between interest and orientation is drawn but certainly think that it is a form of mental illness when someone in a position of power, such as that of an adult over a child, would take advantage of that power.

There are people out there who claim to be virtuous pedophiles who do not act on their urges, that much is probably as much as I know about it. For them, I hope that the whole stigma behind admitting one has the issue can be reduced so we can help them.

It's a very difficult topic that probably deserves it's own thread, rather than being discussed in full on this thread since it is not relevant to the issue of this thread, which is treating transgender patients with respect and dignity.

[Horseshoe, BSN, RN]

Also note that transgender individuals and homosexuals do not create victims by acting on their indentification/orientation.

[Conqueror+, BSN, RN]

Equating pedophilia with transgender or homosexuality? COME ON.

If you read the PP that I quoted what I am saying is relevant. They stated that who sexually excites you is who you are and beyond your control. Pedophiles say the same thing. Another poster stated that pedophilia is a crime. SO WAS homosexuality/being TG and still is in some places. I didn't compare the two I stated that we all have lines regarding what is acceptable and your line being different than mine does not make you superior or a better nurse.

[Conqueror+, BSN, RN]

Also note that transgender individuals and homosexuals do not create victims by acting on their indentification/orientation.

Tell that to the husbands wives and children that have their lives/futures/marriages ruined because someone used them to hide who they really were to protect themselves until it was more convenient to come out. That is off topic so I won't post on that again.

[Rocknurse, MSN, APRN, NP]

Tell that to the husbands wives and children that have their lives/futures/marriages ruined because someone used them to hide who they really were to protect themselves until it was more convenient to come out. That is off topic so I won't post on that again.

Convenient? Wow...a new low.

[jaycam, RN]

Tell that to the husbands wives and children that have their lives/futures/marriages ruined because someone used them to hide who they really were to protect themselves until it was more convenient to come out. That is off topic so I won't post on that again.

Perhaps if we lived in a society that didn't stigmatize them, they wouldn't feel the need to hide or be in denial about who they are. Those families are just as much victims of our society as the person who was hiding was.

[Horseshoe, BSN, RN]

Tell that to the husbands wives and children that have their lives/futures/marriages ruined because someone used them to hide who they really were to protect themselves until it was more convenient to come out. That is off topic so I won't post on that again.

They are not victims of homosexuality, they are victims of divorce which ensues after someone finally decides to finally admit their truth. And still, this is totally different from pedophiles who actively victimize children. Not to mention the fact that far more families are hurt by divorce of heterosexuals than homosexuals who marry before they come out.

Additionally, there are plenty of homosexuals who never marry, carry on with their lives as they were born to live it, and victimize no one as a mere fact of their orientation. To equate them with pedophilia is patently unfair.

[banterings]

banterings,

I am not so sure where the line between interest and orientation is drawn but certainly think that it is a form of mental illness when someone in a position of power, such as that of an adult over a child, would take advantage of that power.

There are people out there who claim to be virtuous pedophiles who do not act on their urges, that much is probably as much as I know about it. For them, I hope that the whole stigma behind admitting one has the issue can be reduced so we can help them.

It's a very difficult topic that probably deserves it's own thread, rather than being discussed in full on this thread since it is not relevant to the issue of this thread, which is treating transgender patients with respect and dignity.

jaycam,

I agree with the issue of power, and that does not have to be just an adult over a child, it is anyone in a position of power over someone who is vulnerable. (That is the issue that I have with paternalism in healthcare,)

I was simply pointing out that your label of a "slippery slope" is indeed correct, and an issue that the APA is wrestling with.

I agree that being transgender is biologically based, but I really have no opinion on the issue of pedophilia as I do not know enough about the subject matter.

I have researched philias (fetishes) and posed the question if they are invented by technology. For example before the invention of nylon or the use of silk in clothing, AND certain clothing styles, did stocking/pantyhose fetishes exist?

There is another argument that philias (as opposed to non-philias) tend to be extremes of (tactile) sensations or of fertility. Of this it can be said the tactile sensation of stockings or them presenting the illusion of fair, unblemished, smooth (hairless) skin (the hallmarks of estrogen). Pedophilia has probably been around as long as man, so is it due to (tactile) sensations or extremes of fertility?

What makes homosexuality and transgenderism NOT philias is that they are NOT learned behaviors but biologically based resulting from the alchemy of testosterone and estrogen. The choice of preference of victims being male, female, or both may have some biological basis, but that does not account for the deviation in at philia traction based on age. One may try and argue that it is attraction based on the lack of (active) testosterone and estrogen.

It has been suggested that men attracted to "cougars" (women in their 40's and 50's) may be biologically (hormonally) based in the decreased estrogen allows for the masculinization of a (pre)menopausal woman's features. If it can be proven (big IF here) that pedophilia is some how linked to a biological attraction (i really do not know a good word to use here) to humans lacking the pubertal effects of testosterone and estrogen, then it MAY not be a (although it would still be disgusting).

The real take-away here is that homosexuality and transgenderism are NOT learned behaviors, preferences, etc. because they are biologically based on the alchemy of testosterone and estrogen.

I have given a simplified explanation here, volumes can be written on any subject matter I have touched on.

[pmabraham, BSN, RN]

Good day:

What I find interesting is our government did a recent census of the LGBT community, and found ~ 1.8% of all Americans declare themselves to be a part of this community. While all individuals need to be treated with respect, it's interesting to me that certain parties continue to push the issue as if the 1.8% number was closer to 10%.

Thank you.

[Conqueror+, BSN, RN]

They are not victims of homosexuality, they are victims of divorce which ensues after someone finally decides to finally admit their truth. And still, this is totally different from pedophiles who actively victimize children. Not to mention the fact that far more families are hurt by divorce of heterosexuals than homosexuals who marry before they come out.

Additionally, there are plenty of homosexuals who never marry, carry on with their lives as they were born to live it, and victimize no one as a mere fact of their orientation. To equate them with pedophilia is patently unfair.

You are talking numbers NOW but in your PP you stated that there are NO victims. I didn't say they were victims of homosexuality but a homosexual does create victims when their "truth" finally takes priority in their lives and they destroy the family that they have been a part of for __ years. I'm sure you'll state how the wives/children are all fine with dad leaving to be with Ted and the wife is happy that he is happy. I have seen the devastation that comes when a married man starts sleeping with men and those wives/children are victims of HIS lies and deceit. Society did not make promises to them or take vows HE did. Finding out that your 15 year marriage was a lie born out of selfishness is no joke and it DOES victimize. How about embracing your truth without mass casualties.

And I did not say homosexuality/TG and pedophilia are the same. I said the two communities use the same arguments and in time will have the same level of acceptance. How can you say one group who claims "born this way" has more rights than another? Sounds like discrimination based on one groups perception of right and wrong.

[Miss Rayanne]

You are talking numbers NOW but in your PP you stated that there are NO victims. I didn't say they were victims of homosexuality but a homosexual does create victims when their "truth" finally takes priority in their lives and they destroy the family that they have been a part of for __ years. I'm sure you'll state how the wives/children are all fine with dad leaving to be with Ted and the wife is happy that he is happy. I have seen the devastation that comes when a married man starts sleeping with men and those wives/children are victims of HIS lies and deceit. Society did not make promises to them or take vows HE did. Finding out that your 15 year marriage was a lie born out of selfishness is no joke and it DOES victimize. How about embracing your truth without mass casualties.

And I did not say homosexuality/TG and pedophilia are the same. I said the two communities use the same arguments and in time will have the same level of acceptance. How can you say one group who claims "born this way" has more rights than another? Sounds like discrimination based on one groups perception of right and wrong.

Wow, you are completely off base. Do you really think our society will ever embrace pedophilia? While, I do believe pedophiles are "born this way" they don't deserve any of the same rights that LGBT people have. The major difference is, when I am with someone of the same sex, they are a consensual adult. A pedophile can't do that because children can't give their consent to sexual acts. That's the difference. I can't believe that I have to explain that to someone in the 21st century.

I will agree that when someone comes out of the closet when they have a wife/husband, it is tragic. However, I don't think anyone should stay in a marriage when they don't love or are not attracted to their partner. Like another poster said, this is often because of the stigma some people place on being gay or transgender (like some of the posters in this thread). If we lived in a world where people did not have to hide the fact that they are LGBT and can embrace their sexuality from an earlier age, then these kind of stories would be rare.