In nursing school we cover a broad range of material, but as we provide care we encounter patient scenarios in which we find ourselves thinking, “I wish we learned this in school.” Transgender health care is a common knowledge gap for health care providers, but it does not have to remain that way. In this article, we will cover the in’s and out’s of gender affirming care, the role of the bedside nurse in assessing risk, and communication tips to foster an inclusive patient-provider relationship.
You can watch the full recording with Sondra Smith, MSN, FNP-C below!
Let’s start with the basics: Definitions.
Sexual orientation: An inherent or immutable enduring emotional, romantic or sexual attraction to other people.
Gender identity: One's innermost concept of self as male, female, 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: External appearance of one's gender identity, usually expressed through behavior, clothing, haircut or voice, and which may or may not conform to socially defined behaviors and characteristics typically associated with being either masculine or feminine.
Diving Deeper: Gender Identity vs. Sexual Orientation
Gender identity is the innermost concept one holds of themself: as male, female, a blend, both, or neither. Identity is separate from orientation; i.e. being transgender doesn’t imply a sexual orientation.
Sexual orientation is one’s inherent emotional, romantic, or sexual attraction to other people. In this sense, gender is a social construct, as both gender identity and orientation are two different spectrums.
Here are some specific examples of gender as a social construct:
- “Man up”: What exactly does this mean? Does it mean only men are brave or willing to put in the effort?
- Why is pink feminine? Are women delicate like pink flowers?
- Gender roles: Women are seen as nurturing and care for the family, but this isn’t the case everywhere, as on the Island of Sea Women (island of Korea where women work as divers and the breadwinners).
- Toys we give children teach gender roles (i.e. blue toy trucks and pink princess clothes).
- Same sex couples: “Who is the man in the relationship?”
- When thinking about a partner in your relationship, what do you like most about them is likely not their gender alone.
A Closer Look at Gender Identity
According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), the term (gender dysphoria) - which replaces Gender Identity Disorder - "is intended to better characterize the experiences of affected children, adolescents, and adults."
As such, another way to look at gender identity is through the following terminology:
Androgynous - Identifying and/or presenting as neither distinguishably masculine nor feminine.
Asexual - The lack of a sexual attraction or desire for other people.
Cisgender - A person whose gender identity aligns with those typically associated with the sex assigned at birth.
Gender dysphoria - Clinically significant distress caused when a person's assigned birth gender is not the same as the one with which they identify.
Gender-expansive - Conveys a wider, more flexible range of gender identity and/or expression than typically associated with the binary gender system (i.e. color spectrum vs. Black and White)
Gender non-conforming - A broad term referring to people who do not behave in a way that conforms to the traditional expectations of their gender.
Genderqueer or non-binary - Genderqueer people typically reject notions of static categories of gender and embrace a fluidity of gender identity and often, though not always, sexual orientation. People who identify as "genderqueer" may see themselves as being both male and female, neither male nor female, or as falling completely outside of these categories.
Gender transition - The process of aligning internal knowledge of gender with outward appearance (hormone therapy, voice training, top/bottom surgery, etc.)
Pansexual - A person who is sexually/romantically attracted to people of all genders.
Queer - A term used to express any person with a sexual orientation or gender identity varying from traditional societal norms.
Transgender - Umbrella term for people whose gender identity and/or expression is different from cultural expectations based on sex assigned at birth. Doesn’t imply any specific sexual orientation.
Types of Gender Affirming Care
Right now, there are three primary types of gender affirming care:
- Hormone therapy
- Surgical interventions
- Other interventions
Hormone Therapy
Hormone therapy typically entails the medical prescriptions of various hormones in order to alter bodily function and/or visual appearance.
For transgender women, estradiol plus an androgen blocker (spironolactone, and/or finasteride) are often prescribed. For transgender men, testosterone is the primary hormone used.
Lab monitoring typically follows a cadence of: before hormones, 3mo, 6mo, 9mo or 12mo, then Q6-12mo. The dose is based on desired effects, patient history, and lab monitoring
The primary goal of taking these substances is to affect skin, muscle, breast growth, body fat, hair growth, sex drive, sperm, and scalp hair (for transgender women); or alternatively, skin, muscle, voice pitch, body fat, hair growth, menses, clitoris, and scalp hair (for transgender men).
Surgical Interventions
Surgical interventions are relatively self-explanatory.
Here is a list of common surgical interventions that is by no means exhaustive:
- Masculinization chest surgery (“top surgery”)
- Augmentation, mammoplasty
- Oophorectomy
- Orchiectomy
- Vaginoplasty
- Phalloplasty/scrotal plasty
- Reduction thyroid chondroplasty (tracheal cartilage shave)
- Voice surgery
It’s important to keep in mind that these procedures are not always easy to find, paid for my insurance, or without their side effects.
Other Interventions
There are also other interventions that are largely cosmetic but still function to help create a more complete and comfortable transformation.
- Voice training
- Laser hair removal
- Genital tucking
- Breast binding
So, while it’s great to have all of the above knowledge, how can we, as nurses, use it?
The Role of the Bedside Nurse in LGBTQ+ Care
Ultimately, some biomarkers are difficult to assess fully due to the lack of research on transgender health care, but one universally prominent risk is thrombosis (or blood clots).
This is largely due to the varying levels of estrogen and testosterone in the body. With estrogen, the first first pass effect in the liver can affect clotting pathways; while, testosterone increases the red blood cell count and is why we monitor complete blood count.
Next, it’s important to be on the side of your patient, or an advocate. How?
Pronoun Usage
Make sure you address your patient with the appropriate pronouns. What if you’re not sure how to do this?
- Listen: Listen to the patient and those close to them; echo the pronouns they use.
- Lead: Introduce yourself and your pronouns, i.e. “Hi, my name is John — he, him, his”
- Ask: “What pronouns do you use?” or “What name would you like me to use?”
- Neutral: This isn’t the first choice, but when in doubt, you can use “they/them,” or substitute the patient’s name for pronouns
Biological and Chosen Family
Listen to your patient to pick up on who they most trust with medical information and procedures. It may be their biological family — a parent or a sibling, or it may be their chosen family — a significant other or friend. Involve these trusted members into their care.
Avoid Assumptions
Avoid assumptions surrounding their spouse or parents: i.e. instead of saying mom or dad, say parent; instead of saying husband or wife, say spouse or partner.
Good Red Flags
Some “good” red flags that help call out advocacy from nurse to patient could be a pride pin on your lapel or sharing where the gender neutral restrooms are located. These small gestures can help the patients feel welcomed and cared for.
HIV PrEP Candidates
What is HIV PrEP? HIV PrEP is HIV Pre-exposure prophylaxis. While gay and bisexual men account for approximately 70% of new HIV cases, one in seven people who are HIV+ are not aware of their HIV status.
So, who are the proper candidates?
- Currently HIV negative
- Partner living with HIV and detectable viral load
- Diagnosed with STI in past 6 mo
- IVDU and reports needle sharing
- Condomless anal sex (insertive or receptive) with >/= 1 partner in 6mo
- Any patient requesting PrEP
While rates of exposure and respective risk different depending on type of activity or interaction, sexual promiscuity in the LGBTQ+ community is a myth—the overall LGBTQ+ population does not have vastly different sexual activity rates than heterosexual individuals.
HIB PrEP Basics
Two possible drugs that can be taken proactively are Truvada and Descovy. They are once-daily medications that reduce risk of getting HIV by 99%. Typically, clinicians will check GFR & HIV status at: 3mo, 6mo, and then annually. Descovy, specifically, is approved for bisexual men, men who have sex with men, and transgender women.
Mental Health
Members of the LGBTQ+ community are at heightened risk for substance abuse, depression, and suicide.
LGBQ adults have 2x excess risk of suicide attempts compared to other adults, and transgender adults’ lifetime prevalence of suicide attempts is about 40%. The suicide risk is highest during teens-early 20s, and rates of completed suicides are hard to know because gender identity and sexual orientation are not reported in death records.
Factors affecting elevated suicide risk:
- Isolation from family and peers
- Mental health history (MDD and anxiety)
- Substance use disorders
- Victimization (target of bullying, being abused)
- Minority stress (deal with harassment, discrimination, and bias)
Factors that build resilience:
- Acceptance by family of origin
- Supportive social network: LGBTQ friend, allies, and family of choice
- Access to and use of LGBTQ inclusive medical and mental health care (LGBTQ-affirming counseling and medical care)
Additional Resources
- WPATH (Standards of Care)
- Fenway Institute (continuing ed opportunities: articles, guides, and recorded lectures)
- University of California San Francisco (transgender care guidelines)
- Finding LGBTQ friendly providers (OutCare & Included Health)
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