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Letter to the Editor

Letter to the Editor

Smith, Asa B. BSN, RN

Author Information
doi: 10.1097/ANS.0000000000000165
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This letter is in response to the July-September 2016 article “Nurses' Knowledge About Transgender Patient Care: A Qualitative Study.” I found the article to be a valuable and engrossing piece of literature with a vital message for improving nursing practice. However, I have concerns regarding the epistemological framework that was used to determine the causes of a nurse's lack of knowledge when caring for transgender patients. In the article, there was extensive discussion about the effect of insufficient education, institutional-enforced gender binaries, and external social stigma on the health disparities seen in this population. While these are all important points, I noticed a paucity of discussion surrounding internal stigma as a causal factor of the documented discomfort, confusion, and absence of understanding seen in the nursing workforce. This is an important issue to discuss as it could adjust implications for future practice and education to improve care for this patient population.1

This issue at the core is both a philosophical and ethical one because it highlights an assumption that nurses do not exhibit stigma or bias when caring for patients. In the health care setting, it has been documented that both nursing students and registered nurses can exhibit negative attitudes toward transgender patients.2,3 From an epistemological standpoint, the results gained from this study did not consider all angles and focused primarily on insufficient education and external stigma as the primary causal factors. There was inadequate discussion in this article about the effect of internal bias and discrimination on the current health disparities seen in this particular population. Given that some nurses did display such attitudes in the study this article was based on, a nurse's assumptions about gender binaries may not necessarily be caused by a lack of knowledge or experience.4 It could also arise from preconceived stigma and resistance to adapt an egalitarian world view to gender identities.2,3 Ultimately, this creates a disconnect because not all causes of the reported lack of nursing knowledge have been explored.2

As a result, it raises concerns about the completeness of the claims and recommendations presented.

One applicable example that highlights this issue is the landmark “Fundamental Ways of Knowing” article written by Barbara A. Carper in 1978. Carper5 claimed that knowledge and beliefs in health care practice stem from multiple factors, including empirical, personal, ethical, and aesthetic factors. According to Carper,5 self-understanding and empathy are key determinants of knowing from a personal perspective. Therefore, stigma creates a barrier to learning because it reduces empathy and negatively impacts how a nurse understands patient needs and perspectives. In addition to typology that illustrates the many influences on health care practice, there are theories that highlight the issue of caregiver stigma in minority groups. One pertinent example is syndemic theory, developed by Singer and Clair6 in 2003. Syndemic theory relates to the interaction of social conditions with disease. It is described by Singer and Clair as “...interacting deleterious conditions among populations produced by the structural violence of social inequality.”6(p434) Research with transgender patients in a syndemic framework has found multiple psychosocial factors that contribute to the documented health disparities within this population, including HIV infection and high-risk sexual behavior.7 In addition, there is a higher prevalence of mental health disorders combined with syndemic indexes of social marginalization within transgender patients, such as a history of incarceration and/or sex work.7 Given the combination of these multiple factors, it makes stigma within the nursing workforce a more probable phenomenon.6–8 This stigma has indeed manifested in the previously mentioned studies2,3 and should be considered and addressed among the nursing profession. Otherwise, education may only be minimally effective at reducing bias and improving health care quality for transgender patients.1,3

In summary, I would be interested in hearing about an appraisal of the impact of internal stigma on the lack of knowledge surrounding the needs of transgender patients. It would be interesting to hear some clarification on how stigma education and awareness raising could improve the interventions that are provided to both student and practicing nurses. It would be also be intriguing to apply Carper's5 Fundamental Ways of Knowing and to examine how empirical and personal influences play a role in understanding this phenomenon. Ultimately, recognizing and applying the optimum measures to reduce the discrimination and health disparities through education, sanctions, and policy development are needed to develop appropriate care for this vulnerable patient population.1,4

—Asa B. Smith, BSN, RN
Doctoral Student
University of Michigan
School of Nursing
Ann Arbor
[email protected]


1. Eliason MJ, Dibble S, DeJoseph J. Nursing's silence on lesbian, gay, bisexual, and transgender issues: the need for emancipatory efforts. ANS Adv Nurs Sci. 2010;33(3):206–218.
2. Lim FA, Hsu R. Nursing students' attitudes toward lesbian, gay, bisexual, and transgender persons: an integrative review. Nurse Educ Perspect. 2016;37(3):144–152.
3. Dorsen C. An integrative review of nurse attitudes towards lesbian, gay, bisexual, and transgender patients. Can J Nurs Res. 2012;44(3):18–43.
4. Carabez RM, Eliason MJ, Martinson M. Nurses' knowledge about transgender patient care: a qualitative study. ANS Adv Nurs Sci. 2016;39(3):257–271.
5. Carper BA. Practice oriented theory. fundamental patterns of knowing in nursing... part 1 (2). ANS Adv Nurs Sci. 1978;1:13–23.
6. Singer M, Clair S. Syndemics and public health: reconceptualizing disease in bio-social context. Med Anthropol Q. 2003;17(4):423–441.
7. Brennan J, Kuhns LM, Johnson AK, Belzer M, Wilson EC, Garofalo R. Syndemic theory and HIV-related risk among young transgender women: the role of multiple, co-occurring health problems and social marginalization. Am J Public Health. 2012;102(9):1751–1757.
8. Clements-Nolle K, Marx R, Guzman R, Katz M. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: implications for public health intervention. Am J Public Health. 2001;91(6):915–921.
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