Authors

  1. Sedlak, Carol A.
  2. Veney, Amy J.
  3. Doheny, Margaret O'Bryan

Abstract

Issues about transgender individuals (TIs) as a disparate population are now being more openly discussed in the general public. However, healthcare providers often express feeling uncomfortable in interacting with TIs because they have not been educated about care of TIs and often base their care on insensitive stereotyping. The purpose of this informational article is to provide a foundation of knowledge for nurses and healthcare professionals for providing competent patient-centered care for TIs. Topics discussed include a description of the transgender population, commonly used terms to describe TIs, health risks and healthcare needs of TIs, and how to provide quality healthcare for TIs.

 

Article Content

Recently, issues related to gender identity have become a hot topic of conversation in the news and other arenas. Many people, including healthcare professionals, are being challenged to consider their knowledge and views related to gender identity for the first time. As a healthcare provider (HCP) for orthopaedic patients whether it be in primary care, acute care, or long-term care settings, what are your thoughts about caring for transgender individuals (TIs)? What questions do you have about how gender identity impacts care? Do TIs experience specific healthcare risks? How should you address TIs and what pronouns should you use? Is it appropriate to ask your patient questions to help you become more educated about these issues? Are there resources or standards of care available to you to help answer these questions about caring for TIs?

 

The focus of this article is to present a foundation of knowledge for nurses and healthcare professionals in providing competent patient-centered care for TIs, regardless of the healthcare setting. This includes developing an understanding of who TIs are, health risks and healthcare needs TIs experience, and practical information for providing quality healthcare for TIs.

 

The Transgender Population

In the United States, about 0.3% of adults (700,000) identify as transgender (Gates, 2011). Estimates of the total number of TIs are likely to be higher, but there is an underreporting and paucity of research that focuses on TIs. The first step in providing patient-centered care for TIs is understanding the terminology and unique physiological considerations of this population.

 

Terminology

There are a variety of terms that HCPs need to be knowledgeable about when learning to provide care for the transgender population. The Fenway Institute (Fenway Health, 2010), a leader in the care of gender and sexual minorities, has developed an extensive glossary of gender and transgender terms. Refer to Table 1 for terms associated with TIs.

  
Table 1 - Click to enlarge in new windowTable 1. Glossary of Terms

The word transgender refers to persons whose gender identity differs from their sex assigned when born (natal gender or cisgender) (Fenway Health, 2010). A transgender woman is a person assigned as male at birth but whose gender expression is female (male to female, transwoman, or MTF). A transgender male is an individual assigned as female at birth but whose gender expression is male (female to male, transman, or FTM).

 

Gender identity refers to one's self-concept as either male, female, a blending of male and female, or as none of these. Gender expression refers to an individual's characteristics shown in their appearance, personality, and behavior as either masculine or feminine (The Joint Commission [TJC], 2011), which may or may not conform to an individual's assigned sex at birth (Fenway Health, 2010). Sexual orientation is one's attraction to another that may be physical, romantic, emotional, and/or spiritual and is different from gender identity and gender expression (Fenway Health, 2010).

 

The term transition is commonly used to describe the process that individuals may choose to go through to change their gender expression and/or physical appearance so their lived experience is consistent with their perceived gender (Ard & Makadon, 2012). The length of time for transitioning varies and may involve coming out to relatives and friends, using medical interventions such as cross-sex hormones (CSHs) and/or surgical interventions, or not having any interventions.

 

Physiological Considerations

In addition to understanding the various terms associated with TIs, there are physiological aspects to consider. The use of CSHs and hormone-blockers with or without gender confirming surgery is common. Cross-sex hormones may be obtained through prescription by an HCP or illicitly from laypersons or online sources. Nurses should be aware that TIs may or may not be forthcoming with CSH use if they are obtaining the hormones from illicit sources (Center of Excellence [CoE] for Transgender Health Department of Family and Community Medicine, 2016; Institute of Medicine [IOM], 2011). Risks from the use of CSHs, depending on the specific hormones that are used, may include venous thromboembolic disease, cardiovascular disease, diabetes mellitus, cancer, and osteoporosis. However, the long-term effects are not well known (IOM, 2011; Coleman et al., 2012).

 

Transgender individuals may have surgery for transitioning from MTF or FTM. There are a variety of terms used to describe the surgeries such as gender confirming surgery, gender affirmation surgery, and gender reassignment surgery (Ard & Makadon, 2012; TJC, 2011). The surgery may include top or upper body surgery, bottom or lower body surgery, or a combination of both. Top surgery involves removal of breasts for a transmale and breast augmentation for a transfemale. Lower or bottom surgery may include removal of the testicles (CoE for Transgender Health Department of Family and Community Medicine, 2016; Fenway Health, 2010). Genital reconstruction may involve surgical construction of a vagina or a penis. However, not all TIs may pursue having surgery to transition due to the high cost, lack of insurance coverage, and/or limited access to healthcare. Gender identity can be expressed in a variety of ways. Some nonmedical alternatives include breast binding to flatten breasts, hairstyle changes, and clothing choices. Individuals may also choose to undergo hair removal procedures and/or voice therapy as part of transition.

 

Becoming knowledgeable about the terminology and physiological considerations associated with TIs is the first step in providing patient-centered care to this unique population. Developing an awareness of the process of transitioning and the various strategies that TIs may select to transition will help you in developing individualized, competent patient care.

 

Health Risks and Healthcare Needs of Transgender Individuals

It is important to understand TIs' unique health risks and healthcare needs to provide competent care. Transgender individuals face many healthcare risks as a discriminate group who has limited access to primary healthcare (Corneil, Eisfeld, & Botzer, 2010). They are confronted with healthcare disparities and potential discrimination that cisgender individuals usually do not face. Transgender individuals are at an increased risk for HIV, sexual violence, and mental health issues such as depression, anxiety, self-harm, and suicide (CoE for Transgender Health Department of Family and Community Medicine, 2016; Giami & Le Bail, 2011; Grant et al., 2010; IOM, 2011; Williamson, 2010). They have high rates of smoking, alcohol, and substance abuse, and are more likely to be victims of domestic violence, discrimination, and bullying. As a result of these risk behaviors, TIs may not engage in wellness behaviors such as eating a healthy diet nor engaging in adequate exercise and may become overweight (Allison, 2012).

 

Primary care is an essential component of healthcare for TIs. Like the general population, TIs are at risk for chronic conditions such as cancer, cardiovascular disease, diabetes mellitus, and osteoporosis (CoE for Transgender Health Department of Family and Community Medicine, 2016; IOM, 2011). General prevention and screening protocols for health promotion of TIs who are MTF or FTM, either currently on hormonal therapy or had hormone therapy in the past, are delineated and summarized by the Center of Excellence for Transgender Health University of California, San Francisco (CoE for Transgender Health Department of Family and Community Medicine, 2016). This valuable resource gives screening recommendations based on the TIs' existing anatomy and emphasizes the promotion of supportive and respectful healthcare.

 

Risks associated with the use of CSHs may include elevated liver enzymes, insulin resistance, hormone-dependent cancers, and hypercoagulability, leading to cardiovascular threats such as venous thromboembolic events, particularly in MTF (Smith, Madison, & Milne, 2014; Wierckx et al., 2012). Transgender individuals are more likely to experience complications from these conditions because of their hesitancy to seek treatment (Ard & Makadon, 2012). In addition, TIs are less likely to have health insurance than heterosexual, lesbian, gay, or bisexual individuals (Grant et al., 2010; Healthy People 2020, 2016; TJC, 2011).

 

Perhaps the most disturbing contributor to the health disparities that TIs face is their fear of mistreatment and discrimination by HCPs. Transgender individuals experience discrimination when accessing healthcare that ranges from being disrespected to being denied healthcare (Grant et al., 2010). Transgender individuals risk having delayed or inferior care and being mistreated because of inappropriate institutional policies and practices. These issues may lead to TIs not trusting HCPs and ignoring their own healthcare to avoid the risk of discrimination. Because TIs often experience negative interactions that can lead to stigmatization, victimization, and lack of social support, they may internalize these experiences to the degree of becoming stealth (transitioned into a different sex or gender but not divulging the transition) (Ard & Makadon, 2012).

 

There is not much known about how TIs even begin to access healthcare. A theoretical framework on the process by which TIs engage in healthcare developed by Roller, Sedlak, and Draucker (2015) revealed the core process of "navigating the system" to obtain healthcare. This complex process is composed of four subprocesses that include (1) needing to move forward (deciding to seek healthcare to meet their unique needs; (2) doing due diligence (locating heath care wanted/needed); (3) finding loopholes (negotiating systems and dodging obstacles); and (4) making it work to access transgender-sensitive healthcare and HCPs. Although there is still much to be learned about how TIs engage in healthcare, the process of "navigating the system" demonstrates how complicated it can be for TIs to access healthcare.

 

Being aware of the unique health risks and healthcare needs of TIs is a critical component for providing competent patient-centered care for TIs. Carefully reflect on your thoughts and behaviors as the HCP who can help improve care for this disparate population.

 

Care for the Transgender Individual

In planning nursing care for TIs, it is important to recognize that TIs' access to the healthcare system can be a challenge. A goal established by Healthy People 2020 (2016) focuses on improving the health, safety, and well-being of lesbian, gay, bisexual, and transgender (LGBT) persons. Emphasis is on the need for research and policy development that correctly depicts LGBT health and disparities and eradicates stigma and discrimination. Understanding standards of care, available resources, and tools for appropriate communication are key to providing quality care for TIs.

 

Standards of Care for Transgender Individuals

Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People by the WPATH (Coleman et al., 2012) help provide a basis for TIs' healthcare needs. These standards are clinical guidelines with global application addressing issues related to mental health, hormone therapy, reproductive health, voice and communication therapy, surgery, postoperative and follow-up care, and lifelong preventive and primary care. The top 10 priority issues that TIs should address with their HCPs include access to healthcare, health history, hormone use, cardiovascular health, cancer prevention, safe sex and prevention of sexually transmitted diseases, risk behaviors such as alcohol use and smoking, mental health and depression, use of injectable silicone for body enhancement, and health behaviors such as diet and exercise (Allison, 2012). There are clinical practice guidelines developed by the Endocrine Society for the prescription and monitoring of hormonal therapy for TIs (Hembree et al., 2009).

 

An area of confusion for many primary care providers is TIs' cancer risk and cancer prevention. Transgender individuals who have not undergone gender-affirmative surgeries or used hormonal therapy should be screened for prostate, breast, or cervical cancer according to established guidelines for their birth sex (CoE for Transgender Health Department of Family and Community Medicine, 2016). However, for those who have undergone surgery or hormonal treatments, screening recommendations need to be modified. For example, mammograms are suggested for MTF transgender persons older than 50 years who have taken feminizing hormones for more than 5 years because of an increased risk for breast cancer. Papanicolaou smears are not indicated for TIs who have a surgically constructed neovagina. For the transman who has not had a hysterectomy, the individual needs to adhere to the guidelines for natal females. Similarly, transwomen should continue to follow guidelines for natal males regarding prostate examinations.

 

Providing Quality Care for Transgender Individuals

An initial step in providing care for TIs should focus on HCPs reflecting on their knowledge and attitudes toward TIs and how these may affect their behavior. Because of limited formal education that nurses and physicians receive specifically addressing TIs' healthcare needs, HCPs may have inaccurate knowledge that could prevent the delivery of quality care (Lim, Brown, & Kim, 2014). Healthcare providers may be very uncomfortable when interacting with individuals whose gender identity and appearance do not resemble their natal assigned sex (CoE for Transgender Health Department of Family and Community Medicine, 2016). Therefore, awareness of resources to help increase one's understanding of care for TIs is important so that strategies (especially communication) can be enhanced for promoting patient-centered care.

 

Learning Resources

Care should be provided in a manner that is sensitive, courteous, and supportive that recognizes and accepts the individual's self-description or identification (CoE for Transgender Health Department of Family and Community Medicine, 2016) However, this may be difficult for HCPs who have limited or no experience in interacting with and caring for TIs. There are a variety of learning resources that are helpful for TIs to seek appropriate care, and for HCPs to provide quality care for TIs (refer to Table 2 for resources for HCPs and TIs). For example, TJC's field guide on Advancing Effective Communication, Cultural Competence, and Patient and Family Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community (TJC, 2011) provides guidance for developing awareness in meeting the healthcare needs of TIs. This guide can be easily used as a tool for self-assessment of a healthcare organization as well as an educational resource. With this resource, organizations can identify areas for improvement, evaluate compliance of regulations, and revise policies and practices. Strategies to facilitate patient-centered care for TIs include the development of interprofessional teamwork using evidence-based practice.

  
Table 2 - Click to enlarge in new windowTable 2. Resources for Healthcare Providers and Transgender Individuals

Another valuable resource is the IOM Report The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding (IOM, 2011). This report contains detailed information about LGBT health issues, research gaps, and policy recommendations. It is important to note that the use of the term LGBT describes collective populations of LGBT individuals; however, this can obscure the differences of these sexual and gender minority groups. Transgender is an umbrella term that includes many groups with needs and concerns distinct from lesbians, bisexual men and women, and gay men. Gaps in research for the TIs include access to care, specific health needs, transgender youth, risk of homelessness, health outcomes of transgender elders, and long-term hormone use. Lack of health insurance is a major issue for TIs due to joblessness and poverty. Healthcare insurance plans limit/exclude TIs access to transgender medical treatment and gender-confirming surgery.

 

An additional resource is Fenway Health. Located in Boston, MA, Fenway Health (2016) has been providing healthcare for LGBT people since 1971. They maintain an active research program with the transgender population; an example of current research focuses on comparing human papilloma virus and cervical cancer screening methods among FTM individuals who have a cervix. For more information on current research, Fenway Health has an extensive website located at http://fenwayhealth.org/the-fenway-institute/research/

 

Using Appropriate Communication

Basic communication skills are key to providing quality care and culturally sensitive care for TIs. It is essential that a safe and positive environment be developed during initial and subsequent interactions to establish effective communication and trust (Gay and Lesbian Medical Association, 2006). Transgender individuals will search for cues of acceptance and respect from HCPs, and this will determine how much they will disclose about themselves. Tips for creating a welcoming environment include using eye contact, inquiring about the correct pronoun to use when addressing the individual, remembering and using the person's name, respecting the person's personal space and privacy, maintaining confidentiality, and having a friend or partner present with the patient during visits and procedures (Rounds, McGrath, & Walsh, 2013). Avoid behaviors that can lead to alienation such as belittling the person's responses, making assumptions, and using stereotypical comments.

 

When addressing TIs, ask how they want to be addressed and which pronoun is preferred, "him" or "her." Using the correct pronoun shows respect and helps to establish a trusting relationship. Some TIs may want to be addressed by their name or may prefer that a nongender pronoun is used such as "hir" or "zie" (Fenway Health, 2010). When conducting the health history, be sensitive to the use of categories for relationship questions. The typical response choices may not be appropriate for representing TIs such as never married, married, widowed, separated, or divorced (Ginsberg, 2011; TJC, 2010). Rather, ask: Are you are in a relationship? or, Do you have a partner or significant other? The word "partnered" could be used as an option for single, married, or divorced.

 

When planning general prevention and screening care, it is important to be aware that the TI's health history may reveal a lack of preventive screening and treatment (Lim & Bernstein, 2012). This may be due to poor healthcare access because of not having health insurance, fear of HCP perceptions of them, or a fear of discrimination that can lead to the individual concealing important health information.

 

Healthcare facilities need to have guidelines and policies in place that focus on promoting respect for sexual orientation and gender identity and the prevention of discrimination (Lim, Pace, Bailey, & Jones, 2013). This includes having a policy on equal visitation, monitoring the implementation of professional and competent care for all patients and families, and development of disciplinary processes that address disrespect and intimidation of TIs by staff. Although the number of TIs seeking care in a healthcare environment is small compared to the general population, this group includes victims of discrimination, isolation, violence, and poor access to healthcare resulting in delay of healthcare and treatment.

 

Take time to reflect on the initial questions posed at the beginning of the article and the discussion about effective and appropriate care. You should now have a more solid educational foundation of where to seek out information and support to dispel myths and stereotypes to provide quality, competent, and sensitive care for these individuals based on standards of care.

 

Conclusion

Caring for TIs with orthopaedic needs is no different than caring for an individual from the general population where safe care is based on standards of practice and open-mindedness. Unfortunately, there is poor sharing of the available information related to healthcare issues of TIs. The need for competent and sensitive care is clear, but the message is not being adequately disseminated. Healthcare providers need to be aware of the issues that make TIs more vulnerable, and there is a need for more research on their access to healthcare. Regardless of setting, the orthopaedic nurse and healthcare staff need to provide care in a compassionate, competent, and respectful manner that recognizes and accepts the transgender patient. Incorporating knowledge and best practices for care of TIs will lead to improved healthcare.

 

References

 

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For 4 additional continuing nursing education activities on topics related to transgender individuals, go to http://nursingcenter.com/ce.