EM is a 25-year-old transgender patient. During a recent visit to her mother, EM reported a painful ear infection. Her mother accompanied her to their local healthcare clinic, where she hadn't been seen since she transitioned from male to female. EM hesitated to go because she felt anxious about the healthcare staff judging her. She also didn't trust the staff because the clinic doesn't have a way to record preferred names and pronouns; the receptionist wrote a reminder not to use her former name since her "dead" name had been in their system since she was a child. To EM's dismay, when the provider entered the room, she used her "dead" name, not noticing the note from the receptionist.
What is gender dysphoria?
Individuals who transition due to gender dysphoria (GD) require specialized care and treatment. GD is a medical diagnosis that describes the discomfort or distress that a person feels when their physical attributes and sex assigned at birth don't align with their innate or affirmed gender. In recent years, society has witnessed an increase in GD awareness; however, many healthcare professionals still don't understand what a person must go through to transition from the sex assigned at birth to their affirmed gender. Nurses are often the first healthcare providers these patients will encounter during their transition. It's imperative for nurses to understand the whole transition process and to become culturally prepared to communicate and advocate for patients who are contemplating or undergoing transition. Due to conflicting beliefs about assigned sex at birth versus affirmed gender, it's possible for nonmedical media and misinformation on transgender care to influence a nurse's perception of these individuals. Healthcare providers may have limited experience working with transgender patients; therefore, nurses need to continue their education about this vulnerable population through local, state, and national continuing-education opportunities. Schools of nursing and medicine can also add gender-affirming care to their curriculum. How do we work toward individualized and thorough care for individuals who are transgender? Nurses must first understand the needs of these patients. As nurses, we're taught to respect diverse patients, including those who don't identify with the gender they were assigned at birth. Nurses are ethically responsible for treating their patients with dignity and respect; therefore, they must check for biases, including their own. This article provides essential information that nurses must know to work with individuals who are transitioning. This will include processes, treatments, and ongoing considerations to support this population as they work through this often silent and misunderstood diagnosis.
Background
Individuals who are transgender have diverse experiences and individualized healthcare needs.2 Healthcare access for the transgender population is an evolving field. For several, the diagnosis of GD increases access to healthcare treatment availability.3 The number of adolescents and adults who are transgender includes 1.6 million individuals in the US, ranging from ages 13 to 65.4 Among these individuals, 38.5% are transgender women, 35.9% are transgender men, and 25.6% are gender nonconforming.4 Addressing the unique needs of such a wide age range of patients presents a challenge. Researchers, clinicians, and mental health specialists understand the criteria for diagnosis and the diversity of the patient population to manage the process, procedures, and treatment; this care is evolving as more people seek this process.
Treatments and cost
For individuals who are transgender, the transition process is deeply personalized. For instance, the person transitioning may choose to socially transition (such as by "coming out" to family), legally transition (by changing their sex and/or name on legal documents), and/or medically transition (hormone therapy or surgery).2 The patient may also require lifestyle changes such as updating their wardrobe, asking others to refer to them by their affirmed gender pronouns, and learning how to navigate their social group's acceptance levels and adjust their social group if needed. Some children will change schools; adults may choose to change jobs to start a new life.
An individual's transition may involve psychological and medical treatment for GD, including hormone treatment, surgery, or a combination (see Options for psychological and medical treatment of GD).5 The healthcare team must also address psychological factors, such as abuse, neglect, anxiousness, depression, and sometimes suicide.6 Recommendations from the World Professional Association for Transgender Health include seeking a GD diagnosis and psychotherapy treatment before starting medical treatment such as the administration of masculinizing or feminizing hormone therapy. Healthcare providers should require a GD diagnosis. In addition, the presence of a supportive mental health professional can be an asset to the patient's interprofessional team by addressing the emotional, positive, and negative impacts of how transitioning will change the person's life and discussing what they should know in advance.5
Being in various stages of treatment spanning over several years can create problems such as depression, anxiety, and thoughts of suicide, leading to increased emotional and mental health concerns.6 The medical team, including nurses, specialists, and mental health professionals can assist in making decisions and discussing different treatment options for addressing GD. They can guide the patient and the family in the timing of social transitioning, prescribing, and overseeing medical management and support systems within the community.3
Duration and type of treatment for patients who are transgender may differ according to the individual's developmental age.3 It's also essential to consider that the onset of puberty can influence decisions (by both the provider and the patient) related to medical interventions, including fully reversible interventions, (GnTH hormone), partially reversible interventions (feminizing/masculinizing hormone therapy), and irreversible interventions (surgical procedures).3
For example, the transgender man who decides to medically transition years after the onset of puberty may require additional surgeries to remove breasts, such as a bilateral mastectomy. Similarly, the transgender female who chooses to medically transition after puberty can experience decreased testosterone levels, notable fat collecting at the hips and thighs, and anatomical development changes, requiring further treatments and procedures. As estrogen is introduced, the gonads will decrease, and more feminine features will occur. Nurses should educate the patient about feminizing hormonal therapy and possible adverse reactions, including blood clots (pulmonary and deep vein), elevated triglycerides and potassium, nipple discharge, infertility, high BP, or stroke. The transitional process for a child/adolescent requires additional time and adjustment for the entire family unit, adding complexity to the care. This decision can take several months to years. The patient and family should discuss the risks and benefits, preferably with a provider experienced with transgender care. A health history is important as breast and prostate cancer screenings and bone health are important. The patient and family should also consider freezing sperm or eggs before gender-affirming treatments if future biological children are considered.
Transgender patients often spend many years living with GD. Left untreated, GD can lead to depression, anxiety, suicidal thoughts, and an increased risk for sexually transmitted infections (STIs) moving forward into adulthood.7 Although the patient's medical and social support system plays a significant role in the treatment plan, ultimately the interprofessional team, including the nurse, must make sure that the patient is sufficiently educated regarding informed consent and insurance coverage.
Out-of-pocket costs for gender-affirming hormone therapy vary and can be substantial.8 Insurers often require proof of referral letters from mental health professionals recommending hormone initiation and surgical procedures. The referral process creates a further barrier to healthcare access. Insurance coverage for treatments and hormones has expanded in the US. Still, the complete transition process remains fiscally challenging for uninsured or minimally insured patients. Since nurses have more patient interaction, culturally competent nurses can provide high-quality care by understanding the costs of medical treatments. Nurses should be informed of the financial burden patients incur while transitioning, including treatments (pharmaceutical, surgical, counseling) that may not be covered by insurance or the lack thereof.9
Considerations for care
Transgender individuals share health disparities and barriers to care. These disparities can range from discrimination, violence, and stigmas held by nurses, staff, and other patients. These disparities can lead to suicidal thoughts, anxiety, substance and physical abuse, and sexually transmitted infections, as transgender people face stigma and discrimination when seeking help for testing and medical or mental health care.6,9 Many transgender patients have inpatient and outpatient psychiatric treatments, and nurses can aid their patients through these visits.
As a first step, nurses should consistently address patients by their preferred pronouns and name. Keep in mind that the patient may not disclose their preferred identity, name, or pronoun(s) upon admission until they've established trust with the provider. The environment should be welcoming with transgender-themed posters or artwork, informational pamphlets, and gender-neutral bathrooms. Staff should be supportive by adopting preferred terminology and supporting patients with no preconceptions. Unfortunately, staff may not have the same support and may need to be reprimanded or reminded of the entity's policy and commitment.10 Patients often feel that knowledge of their transgender status may negatively impact their care. Nurses can combat this fear by using a positive, reassuring tone during the patient's visits.11 The nurse must understand that transgender individuals don't identify with their sex assigned at birth, and that this is unrelated to an individual's sexual orientation.11 Transgender patients require an interdisciplinary team that includes the primary care provider; a urologist if undergoing medical or surgical transition; a gynecologist to include annual cervical screenings, HIV, and other STI screenings; a reproductive specialist if the patient is planning on having a family; and a counselor or psychiatrist/psychologist.10 As the transgender population feels more comfortable sharing their lives, they'll seek supportive and trained providers. Nurses need current knowledge of what it means to be transgender, including specific healthcare needs. In caring for a transgender patient, the nurse needs to educate the patient on STIs (such as gonorrhea, syphilis, HIV, and chlamydia), screen for STIs, and provide treatment. Nurses should promote equality of all genders in healthcare for the risk of STIs through education and destigmatization.
Environmental considerations
Parents', family members', friends', and the community's attitudes toward transgender affirmation and support have improved, resulting in higher-quality care in recent years.13 Maintaining a good quality of life during the transition for a transgender patient can be critical to the parent or loved one's support system, which helps them with struggles from stigma, prejudice, and violence leading to mental health challenges such as depression, suicide, and homelessness.6,12 Unfortunately, this is a newer field, and there's a lack of studies that develop interventions for transgender patients and their support systems.
Politics, social media, and personal biases impact transgender individuals adjusting to the changes associated with their transitions. More children (K-12 in the US) are sharing their private lives in primary and secondary school ages and settings.15 Diversity, equity, and inclusion practices are being adopted by various community entities. Educators and administrators in educational backgrounds lack support for knowledge of transgender needs. Local, state, and national policies are evolving to address transgender concerns and rights. Several areas need addressing or reframing, such as good practices (removing barriers to trans-inclusivity) and protection from violence and harassment for the transgender population. In addition, educators and administrators should be allies for transgender people and their education. The American Nurses Association (ANA) is against any legislation or policies that impose restrictions on transgender healthcare, moreover criminalizing gender-affirming care. The ANA's Position Statement for Nursing Advocacy for LGBTQ+ Populations from 2018 emphasizes that nurses deliver cultural care and advocate for the LGBTQ+ populations. By nurses providing gender-affirming care, transgender and gender-diverse people have reported improved health and mental wellness after receiving gender-affirming care.15
Back to the case scenario
After the encounter, the provider recognized the need for the electronic health record (EHR) to visualize and record the preferred name and pronouns. A meeting was called for educational purposes, and IT was consulted to make changes within the EHR. When the clinic called the client for a follow-up appointment, the correct name and pronouns were used because of the implementation and visualization in the EHR. The patient thanked the receptionist for acknowledging her name. EM wrote a letter to her provider and said she felt relieved they had made these changes. She also shared the importance of listening to each individual's needs since being transgender is not a one-size-fits-all. EM encouraged the staff and provider to be open-minded, and if that's difficult, to please be respectful.
Respect for all
In the US, 1.6 million individuals are transgender.4 Positive, affirming medical and psychological care and family members' and friends' support for the transgender patient have been shown to contribute to lower rates of adverse mental health outcomes, better self-esteem, and improved overall quality of life. A lack of support may result in rejection, depression, suicide, and homelessness.16 To mitigate barriers to and discrepancies in care, nurses must fully understand the components of a GD diagnosis, transition steps, and appropriate communication techniques. A supportive medical team can help aid transgender patients as they navigate through any healthcare environment.
Did you know?
According to the World Professional Association for Transgender Health (WPATH) Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, individuals who are transgender should meet the criteria for GD to participate in the assessment for readiness for medical treatment. The requirements for GD are clinical guidelines and may need to be modified with the patient. The GP criteria include at least 6 months of the desire to be the opposite gender, a solid preference for wearing clothes opposite of their gender, a strong desire to be treated as the other gender, intense feelings and reactions to the other gender, and a strong desire to be rid of the current sex characteristics with the desire to replace these with the affirmed gender.2,3
INSTRUCTIONS Creating a supportive environment for patients who are transitioning
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REFERENCES