Transgender Care Considerations Nursing CE Course

compared to just 5% of the general population (James et al., 2016). The LGBTQIA community is also at increased risk for substance use disorders (SUDs) and depression (Aisner et al., 2020). In a recent study involving more than 60,000 adults, transgender adults were found to have triple the prevalence of nicotine use and almost triple the prevalence of alcohol use disorder or illicit drug use (Hughto et al., 2021).

 

The Compounding Impact of Other Forms of Discrimination and Special Populations 

When transgender individuals' experiences are examined through the lens of race and ethnicity, explicit and disturbing patterns emerge regarding special populations. Transgender people of color experience more profound and broader patterns of discrimination than White patients and the U.S. population as a whole. Transgender people of color, including Latinx (43%), Native American (41%), multiracial (40%), and Black (38%) individuals, are up to three times as likely as the general U.S. population (14%) to be living in poverty. The unemployment rate among transgender people of color (20%) was four times the U.S. unemployment rate at that time (5%) (James et al., 2016).

 Transgender individuals who are undocumented are also more likely to face severe economic hardship and violence than others. Nearly one-quarter (24%) of transgender individuals who are undocumented report being physically attacked. Additionally, half of these individuals have experienced homelessness in their lifetime, and 68% have faced IPV (James et al., 2016).

Transgender individuals with disabilities also face higher rates of economic instability and mistreatment. Nearly one-quarter (24%) are unemployed, and 45% are living in poverty. Transgender people with disabilities are more likely to experience severe psychological distress (59%) and attempt suicide in their lifetime (54%). They also report higher rates of mistreatment by HCPs than their cisgender peers (42%) (James et al., 2016). To compound these concerns, the transgender community faces higher rates of disability when compared to the general population (Schein et al., 2022).

Special considerations for transgender youth include increased risk for suicide, depression, anxiety, and SUDs. Transgender youth experience more violence, victimization, and harassment (including bullying in school). According to the 2015 USTS, more than three-quarters (77%) of those who were out or perceived as transgender at some point between kindergarten and grade 12 experienced some form of mistreatment, such as being verbally harassed, prohibited from dressing according to their gender identity, disciplined more harshly, or physically or sexually assaulted because people thought they were transgender. Nearly one-quarter (24%) of people who were out or perceived as transgender in college or vocational school were verbally, physically, or sexually harassed (James et al., 2016). Wang and colleagues (2020) identified that among Chinese adolescents, those who identified as transgender reported significantly higher rates of depression, self-harm, and suicidality compared to their cisgender peers. LGBTQIA adolescents are also at increased risk for STIs and obesity (Aisner et al., 2020).

Special considerations for LGBTQIA older adults include stigma, discrimination, violence, isolation, and a lack of family support, leading to a diminished social network. As they age and require additional assistance, these adults are forced to relocate, subjecting them to the rules and attitudes of a skilled nursing or assisted living facility, where they may experience homophobia or transphobia. Although federal regulations ensure nondiscrimination for hospital visitation rights, this may still occur at some hospitals. Community programs and resources designed for LGBTQIA adults may also be inadequate (James et al., 2016).

 

Social and Economic Barriers to Care

Many societal and logistical factors can impact a transgender individual's access to quality health care. Although HCPs cannot solve the more significant societal problems, it is crucial to be aware of them, as they play an essential role in the lives of transgender patients. HCPs should be mindful of the most common issues that the LGBTQIA community frequently faces upon contact with the health care system. Since LGBTQIA individuals are less likely to seek care, these issues are critical to address when the patient is in the office.

Transgender individuals report a lack of insurance at higher rates than cisgender Americans. While 8.4% of the general population reports health insurance coverage (Cohen & Cha, 2022), 13% of 2022 USTS respondents reported being uninsured (James et al., 2024). One in 4 USTS respondents reported difficulty with their insurance coverage in the past year directly related to being transgender. High unemployment rates (18%) and poverty rates (34%) likely contribute to this inadequate insurance coverage (James et al., 2024). Further, for those who do have insurance, vital services such as hormone therapy and sex reassignment surgery are commonly excluded from coverage. USTS respondents in 2015 reported denial of coverage for these services in 25% and 55% of cases, respectively (James et al., 2016). When McDowell and colleagues (2020) reviewed nearly 30,000 transgender or gender-diverse individuals, they found reduced rates of suicide after the implementation of statewide nondiscrimination policies targeted at private insurance companies in 3 out of the 4 years analyzed.

More than one-third (34%) of transgender individuals have reported living in poverty compared to 14% of the general U.S. population. A significant contributor to the high poverty rate is the 18% unemployment rate among transgender individuals (James et al., 2024), 5 times the 3.6% unemployment rate for the U.S. population at large during that period (U.S. Bureau of Labor Statistics, 2023). Of those transgender respondents who held or applied for a job in 2023, 27% reported that they believe they were fired or not hired or promoted due to their gender identity or expression. Transgender individuals are also far less likely to own a home, with only 16% of individuals reporting homeownership compared to 63% of the U.S. population. Even more concerning, nearly one-third (30%) of transgender individuals have experienced homelessness at some point in their lifetime compared to 17% of the general population in the U.S. When faced with a period of homelessness, 26% of transgender respondents reported avoiding homeless shelters out of fear of mistreatment, and 70% of those who stayed in a shelter in the past year reported being harassed, assaulted, or kicked out because of their gender identity or expression (James et al., 2016).

 

HCP and Organizational Barriers to Care

These unique factors are then compounded by HCPs (due to a lack of training and sensitivity, for example) and organizational barriers such as forms and facility features. Until recently, HCPs were not educated on caring for the transgender community comprehensively and compassionately. Insufficient education is cited as the most prominent HCP barrier preventing comprehensive transgender care (Aisner et al., 2020). Health care training programs are increasing awareness and efforts to integrate this content into their curriculum. Without proper training, many HCPs feel unprepared to serve transgender patients. These patients may feel pressured to educate their HCPs about various transgender issues and health concerns. The pressure to explain oneself or the frustration of encountering HCPs who are uneducated about transgender issues may prevent transgender patients from obtaining needed care. Transgender patients should not be expected to educate medical staff, nor should any single transgender patient speak for all transgender people (Hobster & McLuskey, 2020).

Transgender adult patients report significantly lower awareness regarding their health needs, refusal to provide care, inadequate care, or unprofessional conduct by HCPs than cisgender adults. Nearly half of USTS respondents in 2022 (48%) reported at least one negative experience when seeking care in the past year that they believed to be related to being transgender (James et al., 2024). When transgender individuals perceive insensitivity or hostility from HCPs, they are often unwilling to disclose their gender identity, which is a significant barrier to care. LGBTQIA individuals may be reluctant to obtain medical care due to previous negative experiences with HCPs, leading to long-term consequences (James et al., 2016). This insensitivity and hostility toward transgender people by HCPs may be related to fear or personal attitudes, values, and beliefs held by the HCP. This internalized implicit bias is in direct conflict with the health care obligation to provide quality, equitable care to all and has been shown to decrease if the HCP continues to work with members of the LGBTQIA community (Aisner et al., 2020).

 

Overcoming Barriers

HCP Opportunities

Gender identity is personal and unique to everyone, but transgender patients may not be recognized as such unless they voluntarily provide this information. A patient's appearance may not indicate any specific gender identity. As organizations and HCPs remain receptive to change and willing to grow, inclusive services should be provided to all gender identities, even if gender is unknown (Scheim et al., 2022). It may be difficult for a transgender individual to acknowledge or come to terms with biological body parts that conflict with their gender identity. Using anatomical language without associating body parts with a specific gender, such as "a person with a cervix" instead of "woman," may make transgender patients feel more comfortable, acknowledging that anatomy and gender identity are not always aligned. A provider should also ask the patient which terms they prefer in reference to their anatomy (Wascher et al., 2024). Using appropriate scientific language while speaking in gender-affirming language, can put transgender patients at ease, allowing them comfort to ask questions and ensuring they understand the nuances of their health care needs (Easterling & Bryam, 2022).

As previously noted, increasing education for HCPs may help counteract many of the barriers described here. For trainees, this education should be incorporated throughout the clinical curriculum. Training for future or practicing HCPs should include a basic overview of the gender affirmation process and associated medical interventions, such as hormonal and surgical treatment options. This effort must start with training faculty at medical, nursing, and allied health education programs who received little to no formal training in this area. The National Organization of Nurse Practitioner Faculties has developed a toolkit for faculty and clinicians on the patient-centered care for transgender patients using evidence-based information to reduce health disparities. The toolkit contains multimedia resources, methods to enhance a facility's (or school's) comfort level for transgender patients and students, and peer-reviewed articles identifying evidence-based care guidelines for this subset of patients. It is available on the group's website, www.nonpf.org (Selix & National Organization of Nurse Practitioner Faculties, 2019).

For practicing HCPs, education must be done through continuing professional development to foster the skills, knowledge, and attitude to deliver affirmative care to all patients. The National LGBTQIA+ Health Education Center is another reliable resource for curricular guidance when developing training on the health needs of the LGBTQIA community. HCPs who were not adequately trained in school on the provision of LGBTQIA care should choose continuing education modules that allow for growth and learning about new and emerging topics within health care. If an HCP feels that they need more education to provide the best care, they should approach their health care organization for further training. Once identified and understood, the diverse health needs of transgender patients should be incorporated into the clinical services within all health care organizations by HCPs (National LGBTQIA+ Health Education Center, 2022).

Providers sometimes feel discomfort when interviewing patients regarding sexual orientation and gender identity (SOGI), and practicing such lines of questioning is an effective way to increase their comfort. Providers should be educated about social determinants of health affecting the transgender community and common comorbidities. Education about LGBTQIA populations and patient care has been shown to increase provider comfort, decrease standing bias or negative personal beliefs, and improve the quality and equity of care received by these patients. HCPs should explore their own biases and perceptions regarding these questions and potentially ask the questions of themselves. If an HCP cannot overcome their assumptions, values, beliefs, or biases, they should refer an LGBTQIA patient to a more capable provider (Aisner et al., 2020).

 There are a few effective communication techniques that can be helpful in the process of building comfort and rapport. Asking first for a patient's preferred name demonstrates an understanding that a transgender patient's legal name may not be their preference. HCPs should share their pronouns upon introduction, normalizing the use of pronouns and opening the opportunity for the patient to be comfortable sharing their own. Using gender-neutral terms and asking direct questions about SOGI demonstrates that an HCP is comfortable with these terms and can create an environment of openness with a patient during an intake interview or assessment (Pascua & Dyne, 2023).

HCPs should be trained to ask open-ended questions without assuming anything about the patient's relationships, partners, or sexual behavior. Patients may be attracted to one gender, multiple genders, transgender, and/or cisgender partners. HCPs should not assume that they know anything about the patient's sexual behavior based on their gender expression, how they identify, or with whom they are partnered (West-Livingston et al., 2021).

As a component of a thorough sexual history, all patients should be asked about their desire for biological children. Transgender patients considering gender-affirming hormonal therapy should have the opportunity to discuss reproductive planning and implications before starting treatment (Cheng et al., 2019). A thorough sexual history may be described as containing the five Ps: partners, practices, pregnancy prevention, past diagnosis of an STI, and STI prevention (Selix & National Organization of Nurse Practitioner Faculties, 2019). Sexual history discussions should also involve an assessment of sexual function or dysfunction. Relationships should be clarified as monogamous or open, and sexual activity should be characterized (casual, anonymous, frequency). The association of sexual activity with substance use or any exchange of material goods for sexual activity should also be established. Patients found to be at increased risk for HIV should be considered for pre-exposure prophylaxis. Current CDC screening guidelines have a 52% sensitivity and specificity when screening for increased HIV risk. The HIV Incidence Risk Index for Men Who Have Sex with Men has a sensitivity of 85% when using a cutoff score of greater than 10. Partner factors that should also be considered include SUD or an STI diagnosis in a partner within the past year, IPV, and age (such as a partner more than 10 years older than the patient). Other risk factors include race, the number of sexual partners, and methamphetamine use (Aisner et al., 2020).

Use discussions of gender identity and sexual orientation discussions beyond screening for STI risk and consider the patient's risk for several other associated conditions discussed previously, such as depression, SUD, and homelessness. Consider and screen for these risks using validated tools, such as the Patient Health Questionnaire-9, a screening tool for depression (Aisner et al., 2020).

 

Health Care Organization Opportunities

Health care organizations can take steps to facilitate delivering equitable care for all patients. The National LGBTQIA+ Health Education Center (2022) outlines an implementation process for improving SOGI data collection and improving comfort and accessibility to LGBTQIA patients when they enter a health care setting. These implementation guidelines include staff training in cultural responsiveness and modification of electronic health record functionalities if needed. Health care organizations should invite local transgender and nonbinary individuals and organizations to participate in the discussion, decision-making, and implementation process of these critical policies and procedures to ensure any changes accommodate the needs of the community (National LGBTQIA+ Health Education Center, 2022).

Health care institutions and HCPs need to develop realistic and practical change plans, especially if planning for extensive changes. Lasting change does not happen quickly, and realistic timelines are the best way to approach these plans. Organizations should build on the accessible, comprehensive, and valuable services they already have for all patients. Providing more transgender-friendly services should be a part of what is already done as the health care team works to serve all who need health care services. This effort will improve the quality of care for all patients because it creates a welcoming and inclusive atmosphere throughout the health care setting (James et al., 2016).

The Affordable Care Act prohibits health care organizations and activities from discriminating against any federally protected group or individual (Scheim et al., 2022), and 24 states and territories have prohibited blanket exclusions of coverage for gender-affirming care. Some common problem areas within health care settings that warrant improvement in the delivery of inclusive and high-quality care to all patients include the following.

 

Health History Forms

Intake forms should include options that allow patients to clarify all possibilities of gender and sexual identity. It is important to provide the opportunity for a patient to describe their sex assigned at birth, as well as their current gender identity. Any "male only" and "female only" categories should be removed—all questions should be available to all patients, with an option to check "not applicable." Any gender identity questions should also include people with a nonbinary gender identity (National LGBTQIA+ Health Education Center, 2017).

 

Preferred Name vs. Legal Name

There are many reasons that health care entities are required to use legal names, such as for insurance or billing purposes and prescription medication management. It can be distressing for some patients to be called by their legal name rather than their preferred name, particularly if their legal name does not align with their gender identity. Organizations should have a space for "preferred name" on all intake forms, and this name should be used when talking to or about any patient (National LGBTQIA+ Health Education Center, 2017).

According to the 2022 USTS, only 19% of transgender individuals reported that all their IDs displayed the name and gender they preferred. Nearly two-thirds (59%) reported that none of their IDs contained this information. The survey also found that 22% of transgender individuals who have shown an ID with a name or gender that did not match their gender identity were verbally harassed, denied benefits or service, asked to leave, or assaulted (James et al., 2024).

 

Bathroom Facilities

In any setting where bathrooms are separated by sex, transgender people may feel uncomfortable or unwelcome in both. In Rhode Island, an official "Safe Zone" designation for sexual and gender minority patients requires health care facilities to provide access to at least one all-gender bathroom (Sandhu et al., 2024). Depending on the availability of bathrooms, this may be as easy as changing signage. In other cases, it may require reconfiguration of stalls and urinals.

 

Pronouns

It may be unclear to staff which pronouns (he/him, she/her, they/them) to use when speaking to or about a transgender patient. The only way for staff to know which pronouns to use is to acknowledge when they are uncertain and politely ask the patient what their pronouns are. Facilities should include a space for pronouns on physical and electronic forms, and staff should then use the patient's pronouns appropriately and consistently. Most patients appreciate the effort and will help correct the team if the wrong pronoun is used. For some individuals, correctly using these pronouns takes time (Boccomino, 2021).

 

Closing Thoughts

Understanding the issues that gender-nonconforming patients face creates the opportunity for building authentic and empathically attuned patient relationships that can provide patients with increased confidence that they will receive the care they need (Hobster & McLuskey, 2020). Having the competence and confidence to administer an assessment, such as sexual orientation and gender identity screening, can allow a patient to socially transition and integrate their gender identity with other aspects of themselves and significantly impact their lives. HCPs must address implicit bias and receive adequate training relating to the transgender patient population in order to use their assessment skills, implement treatment interventions, and improve their patients' overall quality of life (Scheim et al., 2022). Understanding one's identities, values, and beliefs and confronting fears and prejudices are the first steps to optimizing the care of transgender individuals. Finally, HCPs must be prepared to venture beyond the health care system to address social determinants that adversely affect the health outcomes of LGBTQIA community members to achieve comprehensive health equity (National LGBTQIA+ Health Education Center, 2017).

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