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Dimensions of inclusive care: A young transgender patient sparks the need for an immediate education action plan.

Kroning, Maureen EdD, MSN, RN; Green, Jonathan MSN, FNP-C; Kroning, Kayla

Nursing Management (Springhouse): January 2017 - Volume 48 - Issue 1 - p 22–26
doi: 10.1097/01.NUMA.0000511181.72676.0f
Feature: CE Connection: FOCUS ON DIVERSITY

A young transgender patient sparks the need for an immediate education action plan at one hospital. What can you learn from their experience?

Maureen Kroning is an associate professor of nursing at Nyack (N.Y.) College and a per diem nurse supervisor in Suffern, N.Y. Jonathan Green is a family nurse practitioner in Suffern, N.Y., and a DNP student at Dominican College in Orangeburg, N.Y. Kayla Kroning is a pre-med student at Gordon College in Wenham, Mass.

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

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Everyone is entitled to safe, quality healthcare. One of our roles as healthcare leaders is ensuring that our staff members receive the necessary education to provide such care. A young woman who had recent male-to-female gender reassignment surgery and came to the ED with excessive vaginal bleeding presented a learning opportunity. An NP was assigned to care for the young woman, but the NP, like many of us in healthcare, had little to no experience caring for a transgender patient. Understanding gender reassignment surgery, the complications associated with it, and the psychological implications were among the many lessons that occurred as a result. However, the real learning took place when the NP recognized just how difficult it was to get this young woman the medical care she needed.

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Our patient

The young patient and her parents presented to the ED early in the evening. The patient complained of vaginal bleeding; the NP estimated that there was at least 500 mL of blood loss on arrival to the ED. The patient also reported that she had already lost more blood at home. The NP called the patient's surgeon whose office was several hours away. The surgeon recommended consulting with the local urology office because the uterine tissue was similar to urethral tissue. The local urologists, however, had no experience treating complications of gender reassignment surgery.

The NP then contacted a local gynecologist who was also unfamiliar with the procedure and its postoperative care. The gynecologist provided assistance in the ED to stop the active bleeding. Based on the patient's acute blood loss, the NP decided to admit her for observation. However, the NP's hospital didn't have inpatient services for pediatric patients, so pediatric admissions were typically transferred to the closest tertiary care hospital. The NP was able to make arrangements with that hospital to send transport for the patient.

Between the time that the patient was accepted for transfer and the arrival of the transport team, the receiving ED called back to recommend that the patient be transferred to a different hospital—the specialists at the receiving hospital weren't comfortable taking a patient with complications related to gender reassignment surgery. After conferring with the patient's surgeon, it was decided that the NP would transfuse the patient, pack the bleeding area, apply tension support, observe in the ED for clinical improvement, and schedule an outpatient appointment to follow up with the surgeon the following morning.

The NP spoke to hospital administration to share the struggles she had arranging the patient's care. As a result, an education program was developed and implemented to increase the knowledge and sensitivity of the hospital's staff toward lesbian, gay, bisexual, and transgender (LGBT) patients.

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Understanding the disparities

The Fenway Institute's National LGBT Health Education Center indicates that 3.8% of Americans identify as LGBT.1 (See Table 1.) LGBT individuals are members of every community, from diverse races and ethnic backgrounds, and from all socioeconomic statuses, according to the CDC.2 Yet, 29% of lesbian, gay, and bisexual individuals and 30% of transgender individuals delay or avoid seeking healthcare services, compared with 17% of heterosexual individuals.1 (See Figure 1.)

Table 1

Table 1

Figure 1

Figure 1

Healthy People 2020 reports that LGBT individuals experience greater healthcare disparities during their lifetime than heterosexual individuals, including:

  • higher rate of tobacco use (30% compared with 20% of the general population)
  • increased alcohol and drug use
  • greater risk of sexually transmitted infections (STIs) and HIV among gay and bisexual men and transgender women, especially among communities of color
  • decreased utilization of preventive cancer services by lesbian individuals
  • very high rates of both victimization and suicide attempts for transgender individuals
  • additional barriers to healthcare for older LGBT adults due to isolation, less family support, and a deficiency in both social and support services.3

Healthy People 2020 also reports that healthcare disparities among LGBT youth include:

  • higher rate of suicide attempts (two to three times greater)
  • increased homelessness (20% to 40% greater)
  • greater risk of STIs and HIV.3

According to the U.S. Health Resources and Services Administration (HRSA):

  • 77% of HIV diagnoses in 2012 were a result of men having sex with men
  • lesbian and bisexual women are at increased risk for obesity, poor mental health, substance abuse, and violence
  • LGBT individuals encounter barriers to receiving optimal healthcare services.4
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A deep dive into resources

A delay in or avoidance of seeking healthcare services can have detrimental effects on one's health. Therefore, it's essential that healthcare facilities provide LGBT individuals with accepting, supportive environments to treat and prevent illness. Healthcare institutions need to be ready to meet all patients' requirements, with processes in place to serve the unique needs of LGBT patients. Hospitals must respect, protect, and promote patient rights, and prohibit discrimination based on sexual orientation and gender identity or expression.

To help reduce disparities, The Joint Commission offers a field guide titled “Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community” to help U.S. hospitals “create a more welcoming, safe, and inclusive environment that contributes to improved healthcare quality for LGBT patients and their families.”5

The Institute of Medicine published The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding, with insight into the various factors that impact LGBT healthcare needs.6

The Fenway Institute also has resources for healthcare providers, such as Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health.7 In addition, its National LGBT Health Education Center provides the 10 best practices for LGBT-affirming healthcare environments and hosts webinars, video training, and online learning modules.1 (See Table 2.)

Table 2

Table 2

Other online resources include the Safe Zone Project, which houses free training workshops on how to provide a safe environment for the LGBT community.8 At the end of the 2-hour curriculum, participants receive a “Safe Zone” sticker to place in a visible space at their organization. The sticker tells LGBT individuals, “You're welcome here.”

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Taking action

As a result of our young patient's visit to the hospital, the need for education about gender reassignment surgery, LGBT healthcare disparities, and the importance of providing services sensitive to this patient population's needs was discussed with hospital administration. The 10 best practices for LGBT-affirming healthcare environments were shared with administrators to build a supportive environment for LGBT patients. As a result, administrators supported a LGBT sensitivity training program for the staff.

The goal used for the training program was the same as that of Healthy People 2020: “Eliminating LGBT health disparities and enhancing efforts to improve LGBT health are necessary to ensure that LGBT individuals can lead long, healthy lives.”3 The objectives for the training program were those provided by Healthy People 2020:

  • reduce disease transmission and progression
  • strengthen mental and physical well-being
  • decrease healthcare costs
  • increase longevity.3

To achieve our goal, The National LGBT Health Education Center's training and interactive learning modules were mandated for all staff members to complete, regardless of their role in the hospital.1 In addition, the hospital's nursing education team partnered with a local LGBT support organization to develop a short presentation for all hospital staff on LGBT awareness and the principles of inclusive care.

The presentation included:

  • an introductory message from the hospital's CEO affirming his commitment to the provision of inclusive care as part of the hospital's mission
  • definitions of current terminology and identification of terminology that's antiquated or inappropriate
  • discussion of the healthcare experiences of LGBT patients and the impact on their willingness to access healthcare services
  • fundamental communication techniques to provide patient-centered care
  • a video segment featuring patients describing the prejudice they've experienced from healthcare providers.

The presentation was assigned to all hospital staff members using the hospital's electronic learning management system; several in-person sessions were scheduled with speakers from the local LGBT support organization. The sessions were well attended and staff evaluations were very positive.

The hospital has committed to continue training so that not only are the physical needs of LGBT patients addressed, but also the psychological issues that this patient population faces.

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Care for all

As healthcare workers, we must implement best practices for delivering care to our LGBT patients. We need to offer effective, appropriate, and optimal care to prevent the healthcare disparities that exist among LGBT individuals. A goal of Healthy People 2020 is to provide quality care for all. Like Healthy People 2020, the aim of our healthcare institution is the same. The mandatory education for all hospital employees was only the first step in ensuring that LGBT patients receive competent healthcare services. Ongoing training and education are necessary to meet the healthcare needs of all individuals, regardless of their sexual orientation or gender identity/expression.

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INSTRUCTIONS Dimensions of inclusive care


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1. The Fenway Institute. The national LGBT health education center.
2. CDC. Lesbian, gay, bisexual, and transgender health.
3. Lesbian, gay, bisexual, and transgender health.
4. Health Resources and Services Administration. Lesbian, gay, bisexual and transgender (LGBT).
5. The Joint Commission. Advancing effective communication, cultural competence, and patient-and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community.
6. Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academies Press; 2011.
7. The Fenway Institute. Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health. 2nd ed. American College of Physicians; 2015.
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