About this course:
The purpose of this module is to increase the nurse’s ability to interact with transgender patients comprehensively and compassionately in the healthcare setting after understanding some of their barriers to care.
The purpose of this module is to increase the nurse’s ability to interact with transgender patients comprehensively and compassionately in the healthcare setting after understanding some of their barriers to care.
At the completion of this module, the learner should be able to:
- obtain a better understanding of the psychology versus the science of gender identity
- identify four social considerations that transgender patients may face
- identify three patient populations that transgender patients may fall under
- identify three barriers to care for transgender patients within healthcare settings
- identify two effective communication techniques to utilize while working with transgender patients
Healthcare professionals (HCPs) have the opportunity to care for diverse patient populations. While HCPs may feel more comfortable naturally engaging with certain populations, other populations may require the HCP to gain new insight to provide high-quality, informative, and compassionate care. The transgender community has been stigmatized and denied access to primary health care due to organizational deficits and personal lack of knowledge or unconscious biases that may need to be resolved. This module will explore methods to advance the care of transgender patients in healthcare organizations and by HCPs to optimize outreach to this marginalized community.
The Psychology vs. Science of Gender Identity
Gender identity and sexual orientation are fundamental and independent characteristics of an individual’s sexual identity. The Human Rights Campaign (n.d.) defines gender identity as “one’s innermost concept of self as either male, female, or a blend of both or neither- how individuals perceive themselves and what they call themselves. One’s gender identity can be the same or different from their sex assigned at birth”. Gender expression is the “external appearance of one’s gender identity,” which may include their dress, behavior, hairstyle, or voice. Sexual orientation refers to “an inherent or immutable enduring emotional, romantic, or sexual attraction to other people.” They define transgender to be “an umbrella term for people whose gender identity and expression are different from cultural expectations based on the sex they were assigned at birth and does not imply any specific sexual orientation” (Human Rights Campaign, n.d., p. 1). Science demonstrates most genetic females identify as such and are attracted to males, and most genetic males identify as males and are attracted to females. The existence of these sex differences suggests that gonadal hormones, particularly testosterone, are involved, as testosterone is vital for developing most behavioral sex differences in other species. Establishing gender identity is a complex phenomenon, and the diversity of gender expression argues against a unitary or straightforward explanation. For this reason, the extent to which social versus biological factors determine gender continues to undergo vigorous debate. There is no single, conclusive explanation for why people are transgender; some hypotheses suggest biological factors such as genetics or prenatal hormone levels, combined with social and cultural factors such as childhood and adulthood experiences (Butler, 2020). Most experts believe all these factors contribute to each person’s gender identity. Unfortunately, transgender individuals are frequently discriminated against and are twice as likely to experience assault or discrimination as cisgender (non-transgender) individuals. Transgender individuals are also one and a half times more likely to be victims of intimidation and violent crime (Dinno, 2017). Recent estimates are that between 0.35% and 0.53% of Americans identify as transgender, most of which identify as transgender females (Downing & Przedworski, 2018).
Social and Economic Barriers
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 LGBTQ+ community frequently faces upon contact with the healthcare system. Since LGBTQ+ individuals are less likely to seek care, these issues are critical to address when the patient is in the office.
1. Violence and murder risk – several studies demonstrate an epidemic of violence against transgender individuals in the US, as well as significant underreporting of these violent crimes. The underreporting is attributed to societal stigmatization and personal fear that reporting these crimes would not be believed. According to the 2015 US Transgender Survey (USTS):
- Nearly half (46%) of respondents were verbally harassed in the past year because of being transgender.
- Nearly one in ten (9%) of respondents were physically attacked in the past year because of being transgender (James et al., 2016; Kcomt et al., 2020).
2. HIV/AIDS and other sexually transmitted infection (STI) prevention & treatment – transgender women, particularly women of color, report unacceptably high HIV infection rates. Despite a national HIV infection rate of just 0.3% in the US, the self-reported rates of HIV infection in the 2015 USTS were 1.4% among all transgender respondents and 3.4% among transgender women. Rates among transgender women of color were even higher: 19% of Black transgender women, 4.6% of Native American women, and 4.4% of Latina women reported current HIV infection (James et al., 2016).
3. Lack of health insurance and underinsurance – transgender individuals report a lack of insurance at higher rates than cisgender Americans (Downing & Przedworski, 2018). Estimates are that 15% of LGBTQ+ Americans lack insurance coverage, compared to just 8.5% of the general population (Aisner et al., 2020). One in four USTS respondents reported difficulty with their insurance coverage in the past year directly related to being transgender. High unemployment rates and poverty among the transgender population likely contribute to inadequate insurance coverage. Further, for those who do have insurance, vital services such as hormone therapy and sex reassignment surgery are commonly excluded from coverage. 2015 USTS respondents reported denial of coverage for these services in 25% and 55% of cases, respectively (James et al., 2016; Kcomt et al., 2020). 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 three out of the four years analyzed.
4. Lack of health maintenance – nearly one-quarter (23%) of transgender USTS respondents reported not seeking medical care out of fear of mistreatment, and 33% of respondents reported not seeking care due to cost. Due to transgender individuals’ hesitancy to seek regular primary care, there is an increased incidence of obesity, cardiovascular risk factors, and cancer risk due to a lack of healthcare screenings (James et al., 2016; Kcomt et al., 2020). A 2014-16 national survey found a statistically significant increased odds of multiple chronic conditions among gender-nonconforming (as compared to all cisgender respondents) and female transgender (as compared to cisgender male) respondents. This same survey found a statistically significant increase in reports of avoiding medical care due to cost in transgender respondents compared to cisgender male respondents (Downing & Przedworski, 2018).
5. Intimate partner violence (IPV) – most studies indicate that the rate of IPV in the LGBTQ+ community is similar to the general population of similarly aged peers (Aisner et al., 2020). However, 54% of th
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6. Severe economic hardship and instability - nearly one-third (29%) of transgender individuals have reported living in poverty, compared to 14% of the general US population. A significant contributor to the high poverty rate is the 15% unemployment rate among transgender individuals, triple the 5% unemployment rate for the US population at large. Of those transgender respondents who held or applied for a job last year, 27% reported being fired or not hired/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 US 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 US. 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 being transgender (James et al., 2016; Kcomt et al., 2020).
7. Psychological distress and suicidality- while the lifetime rate of suicide attempts among the US population is 4.6%, the rate among transgender respondents to the 2015 USTS was 40%. Similarly, 7% reported a suicide attempt last year, compared to a national average of just 0.6%. In the month before completing the survey, 39% of transgender respondents reported experiencing serious psychological distress, compared to just 5% of the general population (James et al., 2016). The LGBTQ+ community is also at increased risk for substance use disorders and depression (Aisner et al., 2020). In a recent study involving over 60,000 adults, transgender adults were found to have triple the prevalence of nicotine use, almost triple the prevalence of alcohol use disorder or illicit drug use (Hughto et al., 2021).
The Compounding Impact of Other Forms of Discrimination/Special Populations
When transgender individuals’ experiences are examined by 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 US population. Transgender people of color, including Latinos (43%), Native American (41%), multiracial (40%), and Black (38%) individuals, are up to three times as likely as the US population (14%) to be living in poverty. The unemployment rate among transgender people of color (20%) was four times the US unemployment rate at that time (5%; James et al., 2016; Kcomt et al., 2020).
Undocumented transgender individuals are also more likely to face severe economic hardship and violence than others. Nearly one-quarter (24%) of undocumented transgender individuals report being physically attacked. Additionally, half (50%) of undocumented transgender individuals have experienced homelessness in their lifetime, and 68% have faced IPV (James et al., 2016; Kcomt et al., 2020).
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; Kcomt et al., 2020). To compound these concerns, the transgender community faces higher rates of disability when compared to the general population (Downing & Przedworski, 2018).
Special considerations for transgender youth include increased risk for suicide, depression, anxiety, and substance use disorders. 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; Kcomt et al., 2020). Wang and colleagues (2020) identified that among over 12,000 Chinese adolescents, 5.3% of those assigned as male at birth identified as transgender or nonbinary, and 4.9% as questioning. Of those assigned female at birth, 17.4% identify as transgender or nonbinary and 8.5% as questioning. These transgender adolescents reported significantly higher rates of depression, self-harm, and suicidality compared to their cisgender peers (Wang et al., 2020). LGBTQ+ adolescents are also at increased risk for STIs and obesity (Aisner et al., 2020).
Special considerations for LGBTQ+ 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. They may receive fewer Social Security and pension plan benefits through their spouse if their relationship is not legally recognized (Dinno, 2017). Although federal regulations have passed to ensure nondiscrimination for hospital visitation rights, this may still occur at some hospitals. Community programs and resources designed for LGBTQ+ older adults may also be inadequate (James et al., 2016; Kcomt et al., 2020).
HCP and Organizational Barriers to Care
These unique factors are then compounded by HCP (e.g., a lack of training and sensitivity) and organizational barriers (e.g., 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). Healthcare training programs are increasing awareness and efforts to integrate this content into the curriculum. Without proper training, many HCPs feel unprepared to serve transgender patients (James et al., 2016; Kcomt et al., 2020). Transgender 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 (Keuroghlian et al., 2017).
Transgender adult patients report significantly more lack of awareness regarding their health needs, refusal to provide care, inadequate care, or unprofessional conduct by HCPs than cisgender adults. One in three USTS respondents in 2015 reported at least one negative experience in the last year when seeking care that they believe to be related to being transgender. 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. LGBTQ+ individuals may be discouraged from obtaining medical care by previous negative experiences leading to long-term consequences (James et al., 2016; Kcomt et al., 2020). This insensitivity and hostility towards 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 healthcare obligation to provide quality, equitable care to all and has been shown to decrease if the HCP continues to work with members of the LGBTQ+ community (Aisner et al., 2020).
It may be difficult for a transgender individual to acknowledge or come to terms with biological body parts that conflict with their gender identity. Some transgender patients may be uncomfortable using anatomically correct terms or hearing HCPs discuss their body parts. For instance, someone who identifies as a male may not want to acknowledge or talk about their vagina. HCPs should be sensitive to this possibility. If necessary, ask the patient how they would prefer to talk about medical issues (through different language, slang, pictures, anatomical models, or other methods). This sensitivity becomes very important when performing intimate exams such as pelvic, breast, and prostate exams. Lacking sensitivity to this issue can be traumatizing to the patient or result in patients avoiding essential health screening exams (Johnson, 2016).
Gender identity is a personal and unique part of everyone; transgender patients may not be recognized as such unless they voluntarily provide this information. A patient’s appearance may not be indicative of any specific gender identity. Being an inclusive facility or HCP is not about correctly identifying which patients are transgender. Inclusive services should be provided to all gender identities (even if gender is unknown) while organizations and HCPs remain receptive to change and willing to grow. Section 1557 of the Affordable Care Act prohibits healthcare organizations and activities from discriminating against any federally protected group or individual (Johnson, 2016). Some common problem areas within healthcare settings that warrant improvement in the delivery of inclusive and high-quality care to all patients include the following:
1. Health history forms – some healthcare entities have separate health history and intake forms for male and female patients, which can confuse both staff and transgender patients. Staff may not know the gender of a patient immediately and may be uncomfortable asking this information. Patients may also have health concerns that are not included in the form they are given. Combining male and female health history forms into one all-inclusive form will allow all patients to complete pertinent portions of the document and eliminate the pressure on staff to determine the patient’s gender identity. This change also allows the patient to inform the HCP of their gender identity freely and without feeling judged or targeted (Johnson, 2016).
2. Preferred name vs. legal name – there are many reasons that healthcare entities are required to utilize 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. Most electronic medical record systems allow for the addition of a preferred name. However, this may not be readily displayed or utilized by all staff. Legal name changes are not simple, and the process varies based on the state of residency (Johnson, 2016). According to the 2015 USTS, only 11% of transgender individuals reported that all their IDs displayed the name and gender they preferred. More than two-thirds (68%) reported that none of their IDs contained this information. The study also identified that cost was one of the main barriers; approximately one-third of those who had not changed their legal name or gender on their IDs reported that it was because they could not afford it. Nearly one-third (32%) 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., 2016; Kcomt et al., 2020).
3. Bathroom facilities – in any setting where bathrooms are separated by sex, transgender people may feel uncomfortable or unwelcome in both. Unisex facilities are much easier to navigate. 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 (James et al., 2016; Kcomt et al., 2020).
4. 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 ‘preferred pronoun’ is. Facilities should include a space for preferred pronouns on physical and electronic forms, and staff should then utilize the patient’s preferred 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 utilizing these pronouns takes time (Boccomino, 2021).
Healthcare organizations can take steps to facilitate the delivery of equitable care for all patients. The National LGBT Health Education Center identified the following vital points for organizations working to create a welcoming healthcare environment: active engagement by organizational leadership; LGBTQ-protective policies; LGBTQ-inclusive processes, forms, and data collection; and representation of the LGBTQ+ community in the physical environment and workforce. Local transgender and non-binary individuals and organizations should be invited to participate in the discussion, decision-making, and implementation process of these critical policies and procedures. Organizations must provide general gender identity/expression training for staff to understand the basics and not misgender patients or colleagues. Pronoun usage should be voluntary and chosen by the person using them, never assigned by someone else. Individuals should not be forced to use them on email signatures, name badges, etc. Making them mandatory may “out” individuals who are not yet ready to share their complete identity in their work lives (Boccomino, 2021; Keuroghlian et al., 2017).
Healthcare institutions and HCPs need to develop realistic and practical change plans, especially if extensive changes are planned. Real 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 for all patients they already have. Providing more transgender-friendly services should be a part of what is already done as the healthcare team works to serve all populations that need healthcare services. This effort will improve the quality of care for all patients because it creates a welcoming and inclusive atmosphere throughout the healthcare setting (James et al., 2016; Kcomt et al., 2020).
As previously noted, increasing education for HCPs may help counteract many of the barriers described here (Kcomt et al., 2020). For trainees, this education should be incorporated throughout the clinical curriculum. 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. 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. The Association of American Medical Colleges has developed a curricular resource with suggested milestones that may be used as a reference for educational programs (Keuroghlian et al., 2017). Similarly, the National Organization of Nurse Practitioner Faculty (Selix, 2019) 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, 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 LGBT Health Education Center is another reliable resource for curricular guidance when developing training on the health needs of the LGBTQ+ community. HCPs who were not adequately trained in school on the provision of LGBTQ+ care should choose continuing education modules that allow for growth and learning about new/emerging topics within health care. If an HCP feels that they need more education to provide the best care, they should approach their healthcare organization for further training. Once identified and understood, the diverse health needs of transgender patients should be incorporated into the clinical services within all healthcare organizations by HCPs (Keuroghlian et al., 2017).
Effective verbal communication is indispensable when delivering patient care. HCPs should implement therapeutic communication with every patient encounter in a compassionate yet comprehensive manner. Limited time makes establishing trust and rapport with patients more challenging. While insufficient time is a barrier often identified by HCPs for not completing a thorough sexual history, so is a lack of comfort and experience. Even when HCPs know how to ask intimate questions about sexual behavior, identity, and attraction, they may not feel comfortable doing so. HCP discomfort and uneasiness may be unintentionally communicated to LGBTQ+ patients. A basic understanding of commonly used terms (although these may vary by person, place, and over time) will help facilitate effective communication and should be included in all HCP training and continuing education programs. Practicing can help the process feel less like an interrogation and more like a conversation. This training can be done using patient simulation technology or direct observation of patient encounters with associated evaluation and feedback. The HCP should be prepared for questions that make them uncomfortable. If the HCP does not have the requested information, it is okay to admit that they do not know. The HCP should explain that they do not know how to answer that question right now but will get the answer. HCPs should explore their own biases and perceptions regarding these questions and potentially ask the questions of themselves (Johnson, 2016; Keuroghlian et al., 2017). If an HCP cannot overcome their assumptions, values, beliefs, and biases, they should refer an LGBTQ+ 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. First, transgender patients should not be treated differently or as an oddity or a peculiarity. HCPs should validate all patients through respect. The same questions should be asked of each patient. This repetition will help to build the muscle memory of the HCP. Standardized questions are all-inclusive and avoid singling out certain patient populations or groups. HCPs and staff should expect some patient resistance to answering personal questions or following new processes (Johnson, 2016). Patient privacy should be ensured for all sexual health interviews and examinations (Aisner et al., 2020).
HCPs should be trained to ask open-ended questions without assuming anything about the patient’s relationships, partner, or sexual behavior. This may include: “tell me about yourself? Are you involved in a relationship?” 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. A patient’s sexual orientation can be subdivided into desire (to whom they are attracted), identity (how they describe their patterns of attraction to others), and behavior (how or if they act on their sexual attraction). These three components may not align and may vary by person and over time. The information that emerges should guide the rest of the patient interview (Johnson, 2016; Keuroghlian et al., 2017).
As a component of the sexual history, all patients should be asked about the desire for biological children. Transgender patients considering gender-affirming hormonal therapy should have the opportunity to discuss reproductive planning and implications before starting treatment (Johnson, 2016; Keuroghlian et al., 2017). A thorough sexual history may be described as containing the 5 Ps: partners, practices, pregnancy prevention, past diagnosis of an STI, and STI prevention (Selix, 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 (i.e., 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 (PrEP). Unfortunately, current CDC screening guidelines have been shown to have a 52% sensitivity and specificity when screening for increased HIV risk. The HIV Incidence Risk Index for Men Who Have Sex with Men (HIRI-MSM) has a sensitivity of 85% when a cutoff score of > 10 is utilized. Partner factors that should also be considered include substance use disorder or an STI diagnosis in a partner within the last year, IPV, and age (i.e., partner > 10 years older than patient). Other risk factors include race, the number of sexual partners, and methamphetamine use (Aisner et al., 2020).
Gender identity and sexual orientation discussions should be utilized beyond screening for STI risk and consider the patient’s risk for several other associated conditions discussed previously, such as depression, substance use disorder, and homelessness (Johnson, 2016; Keuroghlian et al., 2017). These risks should be considered and screened for using validated tools, such as the Patient Health Questionnaire-9, a validated screening tool for depression (Aisner et al., 2020).
Understanding the issues that gender-nonconforming patients face creates the opportunity for building authentic and empathically attuned patient relationships that can be life-changing for both the HCP and the patient. 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. Thinking of the whole patient is instrumental to their overall well-being (Dillon, 2017). HCPs may have to grapple with their own gender identity, behaviors, and attitudes for a balanced sense of self before they can begin to utilize the assessment skills, implement treatment interventions, and improve their patients’ overall quality of life. Understanding one’s identities, values, beliefs, and confronting fears and prejudices is the first step to optimizing the care of transgender individuals. Finally, HCPs must be prepared to venture beyond the healthcare system to address social determinants that adversely affect the health outcomes of LGBTQ+ community members to achieve comprehensive health equity (Keuroghlian et al., 2017).
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