The Transgender Sensitive Nurse

Beth Hawkes MSN, RN-BC - 03/21/19

“The world is not male or female, black or white” Hida Viloria, intersex person and advocate. For most people, gender is binary. People are either male or female.

But for transgenders, it is not that simple. The concept of gender as a spectrum is becoming more recognized. As an example, Facebook recently added 50 different gender options for its users to choose from. Today many are rejecting the limitation of the binary system to allow for gender expression.

Transgender is an umbrella term and signifies people who do not identify with the sex they were assigned at birth. Transgender people can present as their birth-assigned gender or as their self-identified gender. Some may be in process of transitioning and some may choose not to transition. Because of this, we have to avoid making assumptions about gender identity.

This can get complicated when transgenders need healthcare.

Devin, a 35-year-old female appearing patient was admitted to the ED complaining of abdominal pain. A pregnancy test was ordered as part of a standard work-up for any pre-menopausal female. But Devin is a transgender female, meaning male-to-female, and doesn’t have a uterus.

A transgender man (female to male) admitted to a hospital in Minnesota was banded as female and then subjected to a rough and painful examination by a hostile doctor despite his protests. He later sued the hospital.

The Transgender Patient

Transgender individuals who have had a negative experience or experienced discrimination may avoid seeking healthcare. The Joint Commission (JC) tells us that lesbian, gay, bisexual and transgender (LGBT) in general:

  • Experience stigma
  • Have less access to insurance and health care, and preventative care such as cancer screening
  • Have higher rates of STDs
  • Have higher rates of depression and anxiety
  • Higher rates of smoking, alcohol and substance abuse
  • Increased risk of some cancer

Gender Terms

Here are some terms to help in understanding:

According to Lambda, hospitals should have transgender affirming policies in place:

  • Sex assigned at birth: Typically sex is assigned by the appearance of external genitalia. This doesn’t always match with the individual’s gender identity. In some cases, the genitalia may present ambiguously- such as an enlarged clitoris or extremely small penis. Surgical “correction” may have even taken place to match the assigned sex.
  • Gender identity: this is the internal self-concept of gender felt on the inside, whether male, female, both, or ambivalent. Gender identity may or may not match the sex assigned at birth. For example, a child may be assigned as male at birth, but identify as female. Patients should be respectfully addressed based on their self-identified gender.
  • Gender expression: refers to how an individual perceives and expresses himself or herself and may be different than gender identity. Gender is expressed through clothing, style, and mannerisms. Gender expression may be male, female, or androgynous.
  • Gender affirming surgery: also called sex re-assignment surgery Transgendered patients may or may not be taking medications to alter masculine or feminine characteristics, e.g., male-to-female. Gender transition is a process along a continuum. For example, a transgendered patient may be taking estrogen to increase feminine characteristics and reduce masculine characteristics.
  • Sexual orientation: sexual orientation is about sexual and emotional attraction. Transgender people can be gay, lesbian, bisexual, queer, or straight. Sexual orientation can evolve and be fluid.
  • Intersex: When an individual has genitalia, organs or chromosomes that don’t fit the binary definition.

Lesbian, gay, bisexual, transgender (LGBT) community is heterogeneous; race, ethnicity, religion, political beliefs varyLGBT population located throughout United States; some regions of United States have reportedly greater numbers of LGBT persons due to greater community support.

Nursing Considerations

Identify your own biases some people think “it’s all in their head” and some are uncomfortable with the concept.

Avoid comments and questions about breasts, genatalia and other physical characteristics unless relevant to their care.

Let them lead in disclosure. Honor and respect their decision to disclose and the pace of their disclosure.

The nurse can ask, “How do you like to be addressed?” and “'I'd really like to be respectful and clarify which pronouns you use’.

Transgender individuals may be gender fluid, identifying as both male and female or alternating between male and female. Hence the preferred pronoun may be “they”.

Avoid making assumptions about an individual’s gender identity or sexual orientation based on appearance. On registration, patients can be asked “What is your current gender identity?” and “What sex were you assigned at birth?” “Is there anything regarding your gender identity you’d like for us to add to your medical record?”

Help educate colleagues and work within your facility to encourage documenting preferred pronouns, gender identity and gender expression.

Be accepting and non-judgmental. Once a patient discloses sensitive information with you, they will wait for your response. Avoid any awkward pauses that indicate you feel uncomfortable. Instead be ready to say ‘Thank you for that information- it helps us to take better care of you” immediately after a patient shares SO/GI information. Practice your response in advance, such as “Thank you for being open with me; this will help me provide better care for you.” Role-playing your response can increase your own comfort with these situations.

Don’t out your patient without their permission unless medically necessary. It would be a violation of HIPAA rights.

Gender-affirming room assignments should be made.

Being transgender sensitive is respectful and accepting. It creates an inclusive, safe patient care environment. As nurses, we are uniquely positioned to create a non-judgmental, welcoming environment and help to build trust to improve patient outcomes.