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Caring for...Transgender patients

Hein, Laura C. PhD, RN, NP; Levitt, Nathan RN

doi: 10.1097/01.NME.0000454745.49841.76
Feature: CE Connection
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Understanding the unique health concerns of transgender patients will help you provide culturally competent care.

Laura C. Hein is an Associate Professor at University of South Carolina College of Nursing in Columbia S.C. Nathan Levitt is a Community Outreach and Education RN at Callen Lorde Community Health Center and a nurse on the Oncology Unit at Maimonides Medical Center, both in New York, N.Y.

The authors weren't involved in the selection of photos accompanying this article.

The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

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Many lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) individuals avoid care for preventable and life-threatening conditions due to fear and experiences of discriminatory treatment. Understanding how patients self-identify is vital to improving access to care, building trust between patient and nurse, and improving patient outcomes. Enhancing your interpersonal and clinical skills working within this community will help address health disparities and create a welcoming environment.

In this article, we show you how to provide culturally appropriate care for the transgender patient population.

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Terminology 101

Transgender is an umbrella term that refers to people who don't identify with the gender they were assigned at birth. The word transgender encompasses many different types of gender identities, including, but not limited to, genderqueer, gender nonconforming, or transsexual. Genderqueer and gender nonconforming refer to individuals who may not identify with a binary (male/female) gender. Transsexual has historically been used as a clinical term referring to those pursuing medical treatment, such as hormones or surgery. Not commonly used today, this term is often not preferred.

Transgender individuals feel that the binary gender assigned to them at birth doesn't match how they feel on the inside. Transwoman refers to someone who was assigned male at birth and lives and/or identifies as a woman. Transman refers to someone who was assigned female at birth and lives and/or identifies as a man. You may see a * following trans; this is a shorthand way to designate inclusion of all non-cisgender individuals. Cisgender refers to people whose gender identity and expression align with the sex they were assigned at birth.

Sex assigned at birth (biological sex) is an interpretation of genitalia: male, differences of sex development (DSD, also known as intersex), and female.

Gender refers to a socially constructed system that assigns roles, qualities, and attributes of masculinity and femininity.

Gender expression is how one conveys gender, which can be expressed anywhere on the masculine, androgynous, or feminine continuum.

Gender identity is the gender one feels on the inside. Gender identity is determined by the individual, so it's important that you ask how your patient identifies; it isn't always apparent on the outside. We all have a gender identity—for some of us, this matches our assigned gender, our bodies, and social perceptions (cisgender); for others, it doesn't.

Sexual orientation is to whom one is sexually and emotionally attracted. Transgender people may identify as heterosexual, lesbian, gay, bisexual, or queer (a previously pejorative word reclaimed by the LGBTQ community). In a recent study of transgender adults in Massachusetts, 42% self-identified their sexual orientation as queer.

For a visual representation of the differences between biological sex, gender expression, gender identity, and sexual orientation, see The genderbread person.

Gender transition is the process of changing one's gender expression and/or physical appearance to align with gender identity and can involve changing one's name and/or gender designation on legal documents and/or medical intervention. Transition means different things to every patient, so it's best to ask your patients what transition means to them.

Coming out is a process that varies for each person and can refer to 1) the process of no longer repressing this realization (self-disclosure) and 2) being open with others (disclosing to others). The process is individual, intimate, and can be painful. Some individuals feel early on in childhood that they don't identify with the gender assigned at birth. Others don't recognize this in themselves until adulthood. Disclosing one's transgender identity can be difficult. Some of this difficulty stems from the belief that gender is immutable. Additionally, there may be fear of the social and financial repercussions of coming out. If a patient comes out to you, it's important that you keep this information confidential and ask your patient's permission to share it with other members of the healthcare team.

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Introduction to barriers faced

One study found that heterosexual individuals had significantly more negative attitudes toward transgender individuals than toward lesbian, gay, or bisexual individuals—a similarly marginalized group. Transgender people are at heightened risk for violence and discrimination in public accommodations. Gendered spaces, such as shelters and facilities with gendered bathrooms, may not be sensitive to transgender individuals.

According to a report from the National Transgender Discrimination Survey, 48% of transgender adults have delayed or avoided medical care, compared with 29% of lesbian, gay, and bisexual adults and 17% of heterosexual adults. In addition, data showed that 55% of transgender individuals lost a job due to bias, 51% were harassed or bullied in school, 61% were victims of physical assault, and 64% were victims of sexual assault. The survey also showed that 19% of the 6,000-plus respondents reported having been refused healthcare because of their transgender status, 28% postponed necessary care when they were sick or injured, and 33% delayed or didn't seek preventive care because of prior healthcare discrimination. Forty-one percent of transgender adults couldn't change their gender on their IDs, 57% of transgender people were rejected by their families, 19% have experienced homelessness, and 47% have attempted suicide.

Transgender individuals can face lack of insurance coverage for medically necessary gender-related care or inappropriate care within gender-segregated services. Sufficient time hasn't yet elapsed for the Affordable Care Act's requirement of coverage for transition-related care to apply to grandfathered policies. Although the Affordable Care Act prohibits discrimination on the basis of sex, including gender identity, in any hospital or health program that receives federal funds and The Joint Commission requires that discrimination on the basis of gender identity is prohibited to maintain accreditation, this information isn't widely known and many transgender patients still experience discrimination.

Transgender individuals may experience or fear reprisal at work related to their gender identity. Employment was noted as one of the top three immediate perceived needs in the Washington D.C. Transgender Needs Assessment Survey. Some employers now have nondiscrimination policies inclusive of transgender persons. More legally significant is a 2012 Equal Employment Opportunity Commission ruling that included transgender employment discrimination as gender discrimination and consequently protected under Title VII of the Civil Rights Act (Pub. L. 88-352).

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Healthcare concerns

Transgender individuals may delay seeking healthcare when ill due to financial costs, fear of discrimination, or previous negative experiences within the healthcare system. According to Lambda Legal, transgender adults experience significantly higher rates of healthcare providers being unaware of their health needs, refusing to provide care, providing substandard care, or treating them poorly during provision of care than lesbian, gay, and bisexual adults.

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HIV and sexual health

According to the CDC, transwomen are at high risk for HIV; in particular, Black transwomen have the highest newly diagnosed HIV rates within the transgender community. The CDC reported that the highest percentage of newly identified HIV-positive test results was among transgender people (2.1%). A 2013 meta-analysis found that 18% to 22% of HIV infections were in transwomen. Researchers have found a significant relationship between high-risk sexual behaviors and substance use/abuse in transwomen.

There are many challenges to HIV prevention work in the transgender community, such as working within data systems that don't collect information on transgender identity; lack of data on the sexual health of transmen; discrimination and stigma; lower rates of health insurance; high rates of homelessness, substance abuse, and alcohol abuse; survival sex work; violence; and insensitivity in the healthcare system. The transgender community is often less likely to get tested for sexually transmitted infections because of the discrimination and fear faced when having to talk about bodies and identity. This is why it's so essential to conduct transgender sensitive sexual histories and provide inclusive and affirming resources.

The CDC offers guidance on HIV prevention within the transgender community. As noted earlier, transgender people can have any sexual orientation, therefore needs vary with each patient. As with any patient, it's important to discuss condom use during intimacy. Preexposure prophylaxis may be appropriate for some patients. Providing safer sex resources that are specific to transgender populations can help patients take care of their bodies by seeing themselves represented. Learning how to take a transgender sensitive sexual history is important to assess risks.

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Substance use

Substance use may be found in any population; the transgender community is no exception. However, differences have been found between cisgender and transgender people regarding substance use.

There aren't many studies that are specific to transgender people and substance use, which indicates that more research and data are needed. The National Transgender Discrimination Survey showed that 26% of transgender individuals use or have used alcohol and drugs frequently compared with the National Institute of Health's report of 7.3% of the general population. In addition, 30% of the transgender participants reported smoking regularly compared with 20.6% of U.S. adults.

Minority stress or estrangement from family can play a role in transgender individuals' substance use. The discrimination faced, isolation, and lack of sensitive resources and support can lead to substance use as a coping strategy. It's important to refer patients to transgender-competent substance use programs if needed.

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Hormone therapy/surgery

Although not all transgender individuals are interested in hormones, the use of cross-gender hormones can help create more of a balance between a transgender person's gender identity and outside appearance. It's important for healthcare providers to understand the administration and monitoring of this treatment.

Transwomen interested in hormone therapy may start estrogen, as well as antiandrogen therapy. Estrogen is available sublingual, transdermal, injectable, and oral. Transmen interested in hormone therapy may start testosterone, which is available I.M., transdermal (patch or gel), or as a subcutaneous implant.

For dosing, monitoring, administration, prescribing, and current protocols, refer to the Center of Excellence for Transgender Health (http://transhealth.ucsf.edu), local LGBTQ healthcare centers, or the World Professional Association for Transgender Health (http://www.wpath.org).

Transgender people may be interested in gender-affirming surgery. These surgeries are incredibly expensive and rarely covered under any insurance plan, which creates many barriers for transgender individuals. Sometimes patients won't feel comfortable telling or asking their healthcare providers about surgeries related to their bodies. It's important to ask about this in sensitive and affirming ways. One technique is asking: “Can you tell me about what transition means to you?” or “Are you interested in or have you had any gender-affirming surgeries?”

There are different surgeries that transgender individuals may undergo to align their body with their gender identity. Transwomen seeking surgery may have an orchiectomy (removal of the testes), vaginoplasty (construction of a vagina), penectomy (removal of the penis [not commonly done]), breast augmentation, reduction thyroid chondroplasty (reduction of prominent thyroid cartilage), or facial feminization.

Transmen interested in surgery may have chest reconstruction (removal of the breasts), hysterectomy, metoidioplasty (procedure involving enlarging the clitoris), phalloplasty (construction of a penis), scrotoplasty (construction of a scrotum), urethroplasty (creation of the urethral canal in conjunction with genital reconstruction), or a vaginectomy (removal of the vagina).

For more information on the types of surgery transgender people may have, refer to the Primary Care Protocols for Transgender Patient Care (http://transhealth.ucsf.edu/trans?page=protocol-00-00). It's important for healthcare providers to know how to provide pre- and postsurgery care for transgender patients. Remember to talk to your patients about their reproductive options when considering hormones and surgery.

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Families of choice

Due to rejection from family and friends related to transitioning, transgender individuals often have to create support systems for themselves (families of choice). These close friends can serve the function of family. Consequently, when a transgender person comes to a clinic or hospital, they may not seek visitation from biological family members, but rather from family members of choice (see “Caring For...Nontraditional Families” on page 14).

Per a 2011 U.S. Department of Health and Human Services rule, facilities receiving Medicare/Medicaid must recognize families of choice for the purposes of visitation to maintain Medicare/Medicaid funding. The Joint Commission has set similar standards for maintaining accreditation.

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Nursing considerations

It's imperative that we break the silence and play a vital role in improving LGBTQ health. We're integral in creating an environment that incorporates transgender sensitivity from assessment to care planning. Nurses are rarely trained on how or why to ask patients about their sexual orientation and gender identity. The Fenway Institute has published recommendations for relevant questions in the clinical setting (http://thefenwayinstitute.org) and argues that collecting this information in a patient's electronic health record guides clinicians, researchers, and policymakers, as well as creates a more comfortable environment for patients.

Transgender people are often asked invasive questions about their bodies and transgender identity on a daily basis. Asking transgender patients what words they use to describe their body can help create a safe and affirming experience. Using transgender affirmative and inclusive language has a direct impact on healthcare and screenings. It can help transgender patients feel more comfortable talking about their bodies and overall health.

For example, using transgender affirmative language for transmen during gynecologic care can help increase Pap smears in this population. Knowing that cervical and breast cancer screening rates are lower for transmen, we can provide sensitivity and act as patient advocates. Similarly, we can increase comfort for transwomen in regards to prostate screenings.

Knowing how and why to ask about a history of feminizing/masculinizing interventions, such as surgery or hormones, is important for assessment. It's essential to explain to your patient why the information is needed, such as to assess drug interactions, health risks, surgical health, and cancer risks. Screening may differ depending on hormones and/or gender-affirming surgeries. Physical exams shouldn't be based on the perceived gender of the patient, but instead based on the patient's current body and identity. Degendering the language, screening, and treatment of bodies is paramount.

If you're a nurse working in a hospital, you can refer to Lambda Legal and the Human Rights Campaign Foundation publication “Creating Equal Access to Quality Health Care for Transgender Patients: Transgender-Affirming Hospital Policies” (http://www.lambdalegal.org/publications/fs_transgender-affirming-hospital-policies), which addresses such issues as confidentiality; bathroom access; registration procedures; room assignments; and how to create sensitive, welcoming hospital environments.

Creating a welcoming environment includes:

  • transgender inclusive patient education materials
  • not assuming sexual orientation or gender identity
  • asking what preferred name and pronouns patients use
  • using terms such as partner
  • displaying signs of LGBTQ acceptance
  • mirroring language that patients use for themselves, their partners, and their bodies
  • providing LGBTQ training for all staff.
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Your sensitivity is needed

Transgender individuals experience many barriers to obtaining culturally and medically appropriate healthcare. These barriers may be sociocultural, institutional, and financial. Educate yourself and your colleagues on medical transition for transgender patients, such as hormones and surgery, and incorporate sensitive questions into your health assessment. By educating yourself about transgender health, you can help remove barriers to care and create safe, inclusive, and supportive healthcare environments.

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cheat sheet

Definitions

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  • Transgender: individuals who don't identify with the gender they were assigned at birth (an * following trans designates inclusion of all non-cisgender individuals)
  • Transwoman: an individual who was assigned male at birth and lives and/or identifies as a woman
  • Transman: an individual who was assigned female at birth and lives and/or identifies as a man
  • Genderqueer and gender nonconforming: individuals who may not identify with a binary (male/female) gender
  • Cisgender: individuals whose gender identity and expression align with the sex they were assigned at birth
  • Sex assigned at birth: an interpretation of genitalia (male, DSD, and female)
  • Gender: a socially constructed system that assigns roles, qualities, and attributes of masculinity and femininity
  • Gender expression: how an individual conveys gender (expressed anywhere on the masculine, androgynous, or feminine continuum)
  • Gender identity: the gender an individual feels on the inside
  • Sexual orientation: to whom an individual is sexually and emotionally attracted (heterosexual, lesbian, gay, bisexual, or queer)
  • Gender transition: the process of changing one's gender expression and/or physical appearance to align with gender identity
  • Coming out: the process of self-disclosure or disclosing to others
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key points

Nursing considerations

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  • Create a welcoming environment for transgender patients; understand that they may have experienced many barriers before reaching you and accessing healthcare can be a vulnerable experience.
  • Ask patients what name they'd like to be called and their preferred pronoun; create intake forms that ask about sexual orientation, gender identity, and preferred name/pronoun.
  • Don't out patients unnecessarily without their permission.
  • Provide transgender sensitive healthcare referrals.
  • Include gender identity and expression in all nondiscrimination policies.
  • Create gender neutral bathrooms, if possible; if not possible, create a policy that transgender patients can use the bathroom that matches their gender identity.
  • Provide transgender sensitive and informed patient education materials.
  • Don't ask unnecessarily invasive questions; make sure your questions are related to your patients' healthcare.
  • Ask patients what language they'd like used to refer to their body.
  • Provide training for all staff members on transgender health and sensitivity.
  • Educate yourself and other healthcare providers on current transgender health protocols and standards of care.
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consider this

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  • Your new patient identifies as transgender and they've already been called the wrong name and pronoun at the front desk. They're scared and want to leave the hospital/health center. What can you do to develop trust, create comfort, and keep your patient engaged in care?
  • You're doing an intake and assessment for a transgender patient with genitourinary complaints. What are transgender sensitive and informed ways to ask questions, provide information, take a sexual history, discuss the patient's body, and provide referrals?
  • Your patient just came out to you as transgender and would like to discuss medical transition. What's the information you need to provide the best patient care?
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on the web

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Learn more about it

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