Lippincott Nursing Pocket Card - July 2021

Affirming Care for LGBTQIA+ Patients

icon-howtouse.jpg

Background

A 2021 Gallup update on lesbian, gay, bisexual or transgender (LGBT) identification found 5.6% of U.S. adults identify as LGBT (Jones, 2021). This population has complex health needs and experience health disparities such as higher rates of substance abuse, psychiatric disorders, suicide, alcohol and drug abuse, smoking, cardiovascular disease, and interpersonal violence (Margolies & Brown, 2019). Affirming care recognizes the significant impact of sexual and gender minority (SGM) status on a person’s health and is critical to ensuring SGM patients receive culturally competent and clinically appropriate care (McElwain & Carr, 2021; Cottrell, 2019).

icon-info.jpg

Definitions

Providing affirming care requires an understanding of terms that are unique to the SGM population. In addition to lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual (LGBTQIA+), here are additional key terms you should know. Please note this list of terminology is not exhaustive and is ever-changing.

  • Assigned Sex at Birth: listed as male or female based on biological status (sex chromosomes), reproductive organs (penis or vagina), or the appearance of external genitalia present at birth.

    • M.A.A.B.: Male-assigned at birth
    • F.A.A.B.: Female-assigned at birth
    • U.A.A.B.: Unassigned at birth
    • Intersex: individual born with biological sex characteristics that aren’t traditionally associated with male or female bodies; possibly ambiguous genitalia or both male and female sex organs. Intersex individuals include a wide range of gender identities and sexual orientations. Intersexuality does not refer to sexual orientation or gender identity (see “intergender” below).
  • Gender: a social construct that identifies the traditional view of two sexes, male and female; indicates traits and behaviors considered to be masculine or feminine (Cottrell, 2019).
  • Gender Identity: describes an individual’s internal sense of maleness or femaleness; it refers to one’s chosen identity and can exist on a spectrum.
    • Cisgender: individual whose gender identity matches the sex they were assigned at birth.
    • Gender Dysphoria: psychological stress related to having a gender identity that differs from one’s assigned sex at birth.
    • Gender Expression: outward presentation or display of one’s gender, in appearance (i.e., hair, clothing), personality and behavior.
    • Gender Fluid: individuals whose gender identity shifts or fluctuates. These individuals may identify or express themselves as masculine on some days, and feminine on others.
    • Gender Incongruence: when gender identity and/or gender expression differ from what is associated with the gender assigned at birth (Rowe, Ng & O’Keefe, 2019).
    • Gender-Neutral: individual who prefers not to be described by a specific gender but prefers “they” as a singular pronoun or “Mx.” instead of “Mr.” or “Ms.”
    • Gender Nonconforming (G.N.C.): one who expresses gender outside traditional norms associated with masculinity or femininity. Not all gender-nonconforming people are transgender, and some transgender people express gender in conventionally masculine or feminine ways.
    • Genderqueer: individual whose gender identity is outside the strict male/female binary. They may exhibit both traditionally masculine and feminine qualities or neither.
    • Intergender: individual that possesses a gender identity that is in the middle between the binary genders of female and male and may be a mix of both.
    • Nonbinary (N.B.): individual that identifies as neither male nor female and sees themselves outside the gender binary; similar to genderqueer.
    • Transgender: individuals whose gender identity or gender expression differs from the biological sex they were assigned at birth; this may or may not have any bearing on sexual orientation. Transgender individuals may identify as heterosexual, homosexual, bisexual, nonbinary, gender queer or other term.
      • Trans or Trans+: umbrella terms for non-cisgender identities.
      • Transgender male: individual whose assigned sex at birth was female who has a gender identity of male.
        • FTM: female transitioning to male
        • May still have female organs which require breast, ovarian, or cervical cancer screening
      • Transgender female: individual whose assigned sex at birth was male who has a gender identity of female.
        • MTF: male transitioning to female
        • May still have male organs which requires testicular and prostate cancer screening
  • Sexual Orientation: identifies whom the person is romantically and sexually attracted to and may exist on a spectrum.
    • Asexual: individual who experiences little to no sexual attraction.
    • Bisexual: individual who is emotionally and sexually attracted to others of the same sex or different sex or gender and may partner with both men and women.
    • Demisexual: individual who does not experience sexual attraction unless they have formed a strong emotional, but not necessarily romantic, connection with someone.
    • Gay: individual who has or desires to have a relationship with a person of the same sex; this term often refers to men who are emotionally and sexually attracted to other men and may partner exclusively with men.
    • Heterosexual: individuals who are attracted to the opposite sex.
    • Homosexual: individuals who are attracted to the same sex.
    • Lesbian: women who are emotionally and sexually attracted to other women and may partner exclusively with women.
    • Pansexual: individual who is attracted to people of all gender identities; someone who is attracted to a person’s qualities regardless of their gender identity.
    • Questioning: individuals who are uncertain or exploring their sexual orientation or gender identity.
    • Queer: an all-encompassing term that is not gender- or sex-specific.
    • “+”: indicates anyone not included in the other terms; everything on the gender and sexuality spectrum that letters and words don’t yet describe.

Pronouns

Addressing an individual using correct personal pronouns shows respect and creates an inclusive environment. A person could be a man or a woman or both or neither and choose any set of pronouns to use, and no pronoun choice is wrong. The pronouns selected may not necessarily be indicative of their gender.
  • Cisfemale: She/Her/Hers
  • Cismale: He/Him/His
  • Transgender male: he/him/himself
  • Transgender female: she/her/herself
  • Gender nonconforming (non-binary): They/Their/Theirs/them/themselves
  • Gender neutral: Ze/Hir/zhe/zhim/zher/zhimself/zherself

Transgender Care (Rowe, Ng & O’Keefe, 2019)

Transgender patients require special consideration as they face extraordinary barriers to care due to stigmatization, discrimination in insurance coverage, and healthcare professional knowledge gaps. They may choose social expressions of gender such as changes in hairstyle and clothing. For patients experiencing gender dysphoria, gonadotrophin-releasing hormone (GnRH) therapy helps suppress puberty hormones and may improve self-esteem and the ability to cope with stress.
 
Transgender individuals seeking to align their bodies with their gender identity (“transition”) may explore Cross-Sex Hormone Therapy (CSHT) or surgical procedures. For transgender women (male transition to female), CSHT includes estradiol for feminization therapy and antiandrogens for androgen deprivation (lower testosterone levels). This will cause a decrease in size of male genitalia, development of fat around the hips, increase in size of breasts and a reduction in facial and body hair. CSHT for transgender men (female transition to male) includes testosterone for masculinization therapy. This will increase facial and body hair, increase muscle development, and stop menstruation. Surgical procedures for male to female transition include breast augmentation, orchiectomy, penectomy, vaginoplasty, vulvoplasty, and trachial cartilage shaving. For female to male transition, procedures include masculinizing chest surgery, hysterectomy, metoidioplasty, testicular implants, and phalloplasty. To legally transition from one gender to another requires a legal name change, changing the sex designation on your birth certificate, Social Security card, driver’s license, and passport.
 
  Transgender Woman
(Male to Female transition)
Transgender Man
(Female to Male transition)
Cross-Sex Hormone Therapy (CSHT)
  • Estradiol for feminization
  • Antiandrogen (lower testosterone levels)
  • Decreases size of male genitalia, increases development of fat around the hips, increase in size of breasts, reduces facial and body hair
  • Testosterone for masculinization therapy
  • Increases facial and body hair, increases muscle development, and stops menstruation
Surgical Procedures
  • Breast augmentation
  • Orchiectomy
  • Penectomy
  • Vaginoplasty
  • Vulvoplasty
  • Tracheal cartilage shaving
  • Masculinizing chest surgery
  • Hysterectomy
  • Metoidioplasty
  • Testicular implants
  • Phalloplasty

Transgender people experience higher rates of discrimination, stigmatization, mental health issues, suicide, alcohol, drug use, smoking and sexually transmitted diseases. According to the Centers for Disease Control and Prevention (2021), adult and adolescent transgender people made up 2% of new HIV diagnoses in the US in 2018. It is important for nurses to promote HIV testing with their transgender patients and to discuss pre-exposure prophylaxis (PrEP) medications that can be taken to prevent getting HIV from sex or injection drug use. Mental health care and substance use disorder counseling are critical services that should be provided to the transgender community.
 

Collecting Sexual Orientation and Gender Identity (SOGI) Data

It is important for nurses to appropriately communicate and assess patients based on their sexual orientation and gender identity (SOGI). Collecting SOGI data improves health screening, detection, and prevention of conditions more common in SGM groups. Use open-ended questions with an unbiased attitude and allow patients to describe their bodies, pronouns, and relationship partners in their own words.
  • “How would you like to be addressed and what are your preferred pronouns?”
  • “To eliminate discrepancies in billing, or errors in the medical record, what name is noted on your health insurance card and driver’s license?”
  • “Can you tell me your assigned sex at birth? Is this how you identify?”
  • “Have you had any surgical procedures or taken any medications to change your body to align with your gender?”
    • “Do you have the organs that were present at birth? It is important that we know what organs are present so we can conduct appropriate health screenings.”
  • “Are you attracted to males, females, both, or neither?”
  • “Are you in a relationship and, if so, how do you express physical intimacy?”
  • “Who are the important people in your life?” or “Who is family to you?”
  • “Is it ok to document this information in your medical record?”

Creating a Gender-Affirming Environment (McElwain & Carr, 2021; Rowe, Ng & O’Keefe, 2019):

Tips for creating a welcoming and gender-affirming environment include:
  • Integrate SGM/LGBTQIA+ education into nursing curriculums.
  • Develop educational brochures for hospital staff.
  • Use appropriate terminology and a normalizing assessment of SOGI to decrease stress, build rapport, and increase patients’ feeling of safety.
  • Institute non-discriminative policies that prevent discrimination against a patient because of sexual orientation or gender identity.
  • Maintain an open, reflective, and individualized approach to each patient.
    • Avoid assumptions about sexual orientation and gender identity based on appearance
  • Institute nondiscriminatory policies:
    • Ensure all staff address patients using their preferred names and pronouns.
    • Revise intake forms to include more sexual orientations, gender identities, and neutral terms such as “partner” rather than “husband” or “wife”.
    • Display an organizational nondiscriminatory statement in waiting rooms specifically mentioning sexual orientation and gender identity.
  • Create multidisciplinary teams comprised of specialists such as endocrinologists and mental health professionals.
  • Develop patient education materials that reflect and include a diverse patient population.
  • Designate bathrooms with unisex signs and other SGM-friendly symbols.

Resources:
American Nurses Association (ANA): Nursing Advocacy for LGBTQ+ Populations. http://www.nursingworld.org/~49866e/globalassets/practiceandpolicy/ethics/nursing-advocacy-for-lgbtq-populations.pdf
 
Centers for Disease Control and Prevention (CDC): Lesbian, Gay, Bisexual, and Transgender Health https://www.cdc.gov/lgbthealth/
 
Health Professionals Advancing LBGTQ Equality. Cultural Competence Webinar Series: http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageId=1025&grandparentID=534&parentID=940&nodeID=1
 
The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/health-equity/lgbtfieldguide_web_linked_verpdf.pdf
 
U.S. Department of Health and Human Services (HHS). LGBTQ+ Communities and Resources. https://www.hhs.gov/programs/topic-sites/lgbtq/enhanced-resources/index.html
 
References 
American Nurses Association (2018). Nursing Advocacy for LBGTQ+ Populations, Position Statement. www.nursingworld.org. https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/nursing-advocacy-for-lgbtq-populations/
 
Centers for Disease Control and Prevention (2021, April 15). Transgender Persons. https://www.cdc.gov/lgbthealth/Transgender.htm
 
Cottrell D. B. (2019). Fostering sexual and gender minority status disclosure in patients. The Nurse practitioner44(7), 43–49. https://doi.org/10.1097/01.NPR.0000559846.83872.da
 
Jones, J. (2021). LGBT Identification Rises to 5.6% in Latest U.S. Estimate. Gallop. https://news.gallup.com/poll/329708/lgbt-identification-rises-latest-estimate.aspx
 
Margolies, L., & Brown, C. G. (2019). Increasing cultural competence with LGBTQ patients. Nursing49(6), 34–40. https://doi.org/10.1097/01.NURSE.0000558088.77604.24

McElwain, S.D. & Carr, K.L. (2021). Providing affirming care for LGBTQ patients. Nursing Made Incredibly Easy!, 19(3), 36-43.
 
Rowe, D., Ng, Y. C., & OʼKeefe, L. C. (2019). Addressing transgender patients' barriers to access care. The Nurse practitioner44(6), 30–38. https://doi.org/10.1097/01.NPR.0000558155.38478.8f