Healthcare providers are committed to delivering optimal care to all patients as part of their legal and ethical responsibilities. But fulfilling that commitment requires an understanding of the unique needs of various patient populations, including those who are transgender. Being attuned to the needs of transgender patients helps nurses ensure their patients' health requirements are met and reduces their risk of legal liability.

Terms to Know

For starters, it's important to understand some basic transgender terminology. According to Lambda Legal (lambdalegal.org), gender identity is a person's inner sense of being male, female, or another gender; this identity isn't necessarily the same as sex assigned or presumed at birth. Gender expression is demonstrated through dress, grooming habits, mannerisms, and other characteristics. "Transgender" refers to people whose gender identity and/or gender expression differs from their assigned or presumed sex at birth. And "transitioning" refers to a complex, individualized process that can include an inward and/or outward change in one's gender identity.

Healthcare Challenges

Transgender people face significant challenges when it comes to health and healthcare. In the 2015 U.S. Transgender Survey (http://www.ustranssurvey.org/), an alarming 39% of respondents reported experiencing serious psychological distress in the month before completing the survey, compared with just 5% of the U.S. population. In addition, 40% had attempted suicide in their lifetime, nearly nine times the rate (4.6%) of the overall U.S. population.

Unfortunately, when transgender people seek treatment they too often encounter mistreatment. The 2015 report noted that in the year before the survey, 33% of those who saw a healthcare provider had at least one negative experience related to being transgender. In a 2010 Health Care Fairness Study from Lambda Legal that didn't specify a time frame, 70% of transgender and gender-nonconforming respondents reported at least one of the following experiences: being refused needed care; healthcare professionals refusing to touch them or using excessive precautions; healthcare professionals using harsh or abusive language; being blamed for their health status; or healthcare professionals being physically rough or abusive.

The potential for a negative experience can hold people back from getting care. Twenty-three percent of respondents to the 2015 Transgender Survey didn't seek the healthcare they needed in the year before the survey because they were afraid of being mistreated as a transgender person. And Lambda Legal's 2010 fairness survey found that nearly 86% of transgender respondents felt that overall community fear or dislike of people like them is a barrier to care.

Transgender people also experience health disparities. For example, the 2015 survey found that the percentage of transgender persons living with HIV was five times the rate in the U.S. population (1.4% vs. 0.3%). Overall, 29% of respondents reported illicit drug use, marijuana consumption, and/or nonmedical prescription drug use in the past month, nearly three times the rate in the U.S. population (10%). People of color who are transgender have even greater health disparities.

Legal and Regulatory Requirements

Healthcare providers aren't just bound by ethical standards when caring for transgender patients; they, along with the organizations they work for, must also adhere to related laws and regulations. For instance, the Affordable Care Act of 2010 banned sex discrimination in healthcare settings that receive federal funds. The U.S. Department of Health & Human Services Office for Civil Rights has noted that this means discrimination based on gender identity in the healthcare setting is banned. States have also weighed in. In all, 18 states, plus the District of Columbia, have laws prohibiting discrimination on the basis of gender identity or expression.

Gender discrimination can be deliberate or inadvertent, caused by a lack of knowledge. However, "I didn't know" is not an excuse that will hold up in court if a healthcare provider is sued by a patient who believes he or she experienced discrimination based on gender identity. Discrimination may not be as obvious as outright refusing to care for a patient. For example, making it unusually difficult to schedule visits can lead to delayed care. Or insisting on an exam for a patient who is reluctant to be examined could result in a charge of battery.

Know Organizational Policy

Know-and follow-the policy related to treating patients fairly; if a professional organization doesn't have such a policy, collaborate with others to create one. In a publication discussing these issues, Lambda Legal recommends the policy have a clear statement: "[Name of organization] does not discriminate against any person on the basis of gender identify or gender expression." As an advocate, be sure information related to the policy is readily available to your patients by posting it in waiting areas or distributing it with registration materials.

Be Culturally Competent

You can supplement your knowledge of the special physical and emotional needs of this patient population by seeking out training and education. Several resources are available.

* The Center of Excellence for Transgender Health, University of California, San Francisco, has an online course on how to create a welcoming environment for transgender people.

* The National LGBT Health Education Center, a program of the Fenway Institute, offers webinars such as one on sexual health among transgender people and another on meeting the healthcare needs of transgender people.

* TransLine provides healthcare providers up-to-date clinical information and individualized case consultation.

Protect Privacy

Healthcare providers are well versed in the Health Insurance Portability and Accountability Act requirements, but they should know that privacy is particularly important for transgender patients. In fact, the court case Love v. Johnson, No. 15-11834, 2015 WL 7190471 (E.D. Mich. Nov. 16, 2015) found that transgender people have a fundamental right of privacy that protects them from being required to disclose their transgender status. To avoid problems, don't ask patients about transgender status unless it's medically necessary. In that case, tell patients why it's important and reassure them that the information will be kept in a confidential manner.

Treat the Patient With Respect

If you inadvertently use the wrong pronoun when first meeting the patient and are corrected, use the requested pronoun and be sure to document preferences in the health record so other caregivers know as well. If unsure what pronoun to use, politely (and privately) ask the patient. If you work in a setting where there can be more than one person assigned to a patient, be sure the assignment is based on the patient's self-identified gender. Failure to use preferred pronouns, for example, could lead to charges of harassment.

Discriminating against transgender patients is against the law, but too often it can happen in healthcare settings, either intentionally or through lack of knowledge. Ensure transgender patients receive the care they deserve by being knowledgeable about their needs, treating them with respect, and advocating that others treat them with respect as well. Doing so improves care, helps avoid legal action, and promotes ethical behavior.