Authors

  1. Eliason, Michele J. PhD
  2. Martinson, Marty PhD
  3. Carabez, Rebecca PhD, RN

Article Content

RESPONSE TO LETTER TO THE EDITOR: EXAMINING EPISTEMOLOGICAL ASSUMPTIONS ABOUT NURSES' KNOWLEDGE DEFICIT IN TRANSGENDER PATIENT CARE

We would like to thank Asa Smith for comments about our article, "Nurses' Knowledge About Transgender Patient Care." It is time to create dialogue about the ways that nurses learn about and treat patients from stigmatized groups so that we can reduce health disparities and improve the quality of care that all patients receive. We would like to respond to a couple of the comments that Smith makes about our article.

 

First, related to the comment about the "paucity of discussion surrounding internal stigma" in our article, we would like to point out that our focus was on nurses, who were presumably mostly heterosexual and cisgender (we did not ask their identities, but nearly 10% volunteered that they were LGB [lesbian, gay, and bisexual], and none reported identifying as transgender). Most nurses are in the dominant majority in regard to gender identity. The term "internalized stigma" is almost exclusively used in regard to people with the stigmatized identities, who internalize the negative stereotypes and belief systems of society in a way that affects their perceptions of themselves as flawed or deviant. This internalized stigma results in feelings such as shame, guilt, and self-hatred and often leads to some of the self-harm behaviors seen in these populations (substance abuse, suicide, and unhealthy coping strategies for stress). People in the dominant group, on the contrary, internalize stereotypes that generally do not affect their own perceptions of themselves. Nurses, as a collective, have power over patients and are agents who enact stigma. Our study revealed many ways that nurses created or maintained stigma through their bungling of names and pronouns, gossiping, and isolating of patients; however, the intent of our study was not to study stigma in individual nurses but to assess their knowledge of transgender patient care issues.

 

Second, Smith notes that empathy is a "key determinant of knowing." We did not find much evidence of lack of empathy in our study, as most of the respondents reported negative behaviors that they had witnessed, rather than conducted, and many indicated that transgender patients were poorly treated in general. They did, however, frequently mention their lack of knowledge regarding transgender patients as a factor.

 

Smith also mentions syndemic theory as a good model for the study of health outcomes of transgender patients, and we agree heartily. However, it was not an appropriate model for our study because our focus was on nurses' knowledge rather than causal factors related to a health outcome variable. Transgender patients experience many simultaneous and serial social, interpersonal, and community-level traumas that combine to increase their risk for negative health outcomes. It would be very useful for nurses to be aware of how stigma works in the lives of many of their patients and the syndemic relationships among health determinants.

 

Finally, Smith recommends the use of Carpers' epistemological model to better understand nurses' attitudes about transgender patients. This does seem like a potentially useful model, and we would argue that gender binary systems in place in health care settings and society at large impact the ways of knowing that Carper and other researchers have suggested (eg, gender stereotypes and binaries affect the way we construct ethical frameworks, aesthetic standards, personal attitudes, religious/spiritual beliefs, and so on). A paper on this topic would likely add much to our current knowledge and help in the understanding of how nurses approach the care of patients who do not fit into their worldviews.

 

In summary, as Smith notes, "It would be interesting to hear some clarification on how stigma education and awareness raising could improve the interventions that are provided to both student and practicing nurses." We would argue that stigma education is an intervention, but that has not been widely applied in nursing education or continuing education to date. We would love to hear of the experiences of others who have engaged in stigma education and suggest that in the case of transgender health care issues, the gender binary system must be addressed as a powerful source of stigma.

 

-Michele J. Eliason, PhD

 

Professor

 

Health Education,

 

San Francisco State University

 

San Francisco, California

 

meliason@sfsu.edu

 

-Marty Martinson, PhD

 

Assistant Professor

 

Health Education,

 

San Francisco State University

 

San Francisco, California

 

martym@sfsu.edu

 

-Rebecca Carabez, PhD, RN

 

Associate Professor

 

School of Nursing,

 

San Francisco State University

 

San Francisco, California

 

rcarabez@sfsu.edu