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

Patients who are transgender require special consideration as they face barriers to care due to stigmatization, discrimination in insurance coverage, and healthcare professional knowledge gaps. 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.
 
Individuals who are transgender may seek to align their bodies with their gender identity (“transition”) and may explore Cross-Sex Hormone Therapy (CSHT) or surgical procedures. For transgender women, 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 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	Transgender Man
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

Patients who are transgender 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), adults and adolescents who are transgender 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 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 your gender?”
• “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/LGBTQ+ 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.
• Maintain an open, reflective, and individualized approach to each patient.
  • Avoid assumptions about sexual orientation and gender 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, genders, 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.
• 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.