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Introduction   

Currently, there are an estimated 1.3 million people in the United States alone who identify as being transgendered (1). A large percentage report ongoing discrimination and intentional bias against them in all areas of their life, especially the healthcare arena.  

Transgender healthcare is a unique specialty, and healthcare providers need the knowledge and skillset necessary to deliver quality care in a supportive, nonjudgmental manner. With proper training and ongoing education, we, as healthcare professionals, will build the necessary trust from the transgender community to positively affect health and well-being (2). Studies have shown that trans-affirming responses, within the healthcare arena, positively impact patient satisfaction and health outcomes (3). 

Key Terminology 

The term transgender refers to individuals whose gender identity differs from the sex they were assigned at birth. The “sex” of a person refers to male or female (usually decided at the time of birth by visualization of external genitalia), while “gender” refers to personal identification and expression. 

There are many categories of “gender”, ranging from a person’s gender identity being the same as their assigned sex at birth (cisgender), to a person who identifies as neither female or male and prefers neutral pronouns (gender nonbinary).  

A transgender male is a person who identifies as a male, but was assigned the female sex at birth, while a transgender female is a person who identifies as a female but was assigned the male sex at birth. As healthcare professionals, our ability to have a baseline understanding of these differences enhances the overall patient care experience.  

Health Disparities 

Discrimination 

Transgender individuals report many health disparities in their routine healthcare. There is a lack of providers who are knowledgeable on the unique health and wellness needs of the transgendered community. In addition, there are also various financial and health system barriers inhibiting access to basic healthcare.  

Transgender treatments are not routinely taught in most medical school curriculums; thus, many providers lack both the knowledge and comfort level to provide holistic transgender focused care. Oftentimes, transgender issues are diagnosed solely as mental disorders, when in fact this population may have complex medical needs such as higher infection rates, depression, and risk of suicide, as well as injuries due to targeted violence.  

Oftentimes, even routine, preventive care is lacking due to cost, insurance coverage, inadequate staff training and provider discrimination. 

Restricting Laws 

An increasing number of states are banning numerous aspects of gender affirming health care, arguing that minor children and young adults are not capable of understanding the treatments and possible risks/complications of these therapies. In 2023, 30 states introduced legislation that negatively impacted access to gender affirming therapy and related specialty services (4).  

While initial bans on transgender treatments were aimed at protecting minor children, many states have now proposed bans through the age of 26 years old.  

Many transgendered persons have no access to start these therapies; still other transgendered persons are now forced to “medically detransition” when gender affirming therapies are no longer available.  

Additionally, these bans often imposed threats of criminal, civil, and professional penalties (from fines to jail time), further dividing the lines between healthcare providers and transgendered patients. 

Limited Access to Healthcare  

In addition to the ongoing legal battles regarding laws impacting actual access to gender affirming therapy, there is also limited access to necessary services as many providers have not received proper training necessary to fully support transition related therapies. (5) 

Traditional medical and nursing school curriculums sorely lack specific transgender- focused training. The lack of such initial training (and ongoing education) has further limited the numbers of trained professionals in this specialty area. 

Ongoing research has found favorable results with gender affirming therapies – improved medical and mental health status- when transgendered persons are treated in a supportive, knowledgeable healthcare environment. In many cases, these therapies also proved lifesaving, by lowering the risk of depression, and suicide. (6) 

Many of these therapies (such as puberty blocker medications) are actually temporary in nature (if stopped, puberty and related hormonal changes would resume). The use of these medications is prescribed to stop the changes associated with puberty, allowing the youth to further explore gender identity issues BEFORE making permanent changes.  

Effective use of these medications is dependent on initiation of treatment before the hormonal effects of puberty are completed. Many healthcare professionals lack knowledge and skillset in overseeing use of these medications in this population.  

Implicit Bias in Healthcare 

Bias is defined as a prejudice in favor of (or against) a thing, person or group that is considered unfair. It is often to a degree that a person may be viewed as “closed-minded”. While an explicit bias is usually easily identified (a specific attitude or belief system), implicit biases often occur without one’s personal awareness of the situation. Implicit bias may be viewed as a pre-judgment, often without any presenting evidence to substantiate a choice.  

The presence of implicit bias, specific to healthcare, is that healthcare professionals may unconsciously prejudge a transgendered person’s lifestyle, dress, mannerisms and more, solely on initial appearances or personal experiences. In doing so, the concern is that the delivery of necessary healthcare will be compromised at some level, further negatively impacting health outcomes (7). 

For more information on implicit bias and how it may be affecting your own behavior, check out the following link: https://edib.harvard.edu/implicit-association-test-iat  

Gender-Affirming Language 

Pronoun and name preferences 

The use of inclusive language is highly recommended in all healthcare settings. In doing so, patients will feel validated, and this alone will build a stronger provider/patient relationship of trust. As healthcare providers, we must become comfortable with acknowledging that we may need guidance in improving the overall patient experience.  

The National LGBT Health Education Center suggests the following phrases that validate a transgender person and support our efforts in improving our communication skill set.  

• How may I help you? (Avoid using sir or ma’am). 

• What pronouns do you use? What is your preferred name? 

• I welcome your questions.  

• I’m sorry……I did not mean to be disrespectful.  

As you can see, the questions are neutral, nonjudgmental, and encourage the patient to participate in the interview and examination. The comments on the healthcare providers behalf easily convey that you want to know more about the patient and how best to treat them (8). 

Sexual History: Intake Tips 

Disclosing sexual history may be particularly sensitive for transgender persons because of prior experiences of discrimination in health care. The most important aspect of the sexual history assessment is to convey that the questions asked are medically important to their care and the responses will be kept confidential.  

The provider must not assume a transgendered person (nor their partners) sexual identity and should verify if the person is actively going through medical or surgical gender affirming therapy. Sexual risk assessments (multiple partners, unprotected sex, high risk sexual practices) must be done and treated based on the individual’s personal history, not under any assumptions based on gender identity (9). 

Patient education must also be addressed, regarding lowering of any risk factors, medication side effects, routine follow-up care and access to community resources. In doing so, the provider has supported holistically the transgender person, further enhancing their overall health and trust in the medical community. 

Physical Assessment Considerations 

Many transgender persons find the healthcare arena to be overwhelming, causing high levels of anxiety, and distrust. The goal of any physical assessment; therefore, is to make the patient comfortable by providing a safe, calming, and supportive environment. 

Maintaining patient privacy and confidentiality are paramount during a physical assessment. This assessment should be related to patient complaints and not done out of curiosity. Patients should be informed of all procedures done (internal examinations, blood levels, x-rays and more) and how they relate to overall health.  

Depending on whether the patient has had gender affirming surgery, additional procedures may be required. For example, a (pre-op) transgender male may need a vaginal examination; a transgender female may need a prostate examination. As with all patients, informed consent and a focus on patient comfort and safety are the goals of treatment (10). 

Hormone Treatment and Monitoring 

Gender affirming hormone therapy (GAHT) is the primary medical treatment sought by persons included in the trans umbrella. This treatment allows the secondary sex characteristics to be more aligned with the persons gender identity. In addition, GAHT can be used as a stand-alone treatment for persons not interested in pursuing gender affirming surgery; it may also be used prior to surgery to improve surgical outcomes. 

While GAHT is generally welcomed in the trans community, it is not without risk. Studies have shown that GAHT has been linked to changes in lipid metabolism and insulin resistance, two factors that heighten the risk for chronic disease development.  

Thus, ongoing medical surveillance must occur with this treatment plan and should include preventive health care screenings, routine vital sign checks, hormone level checks and weight monitoring (11). 

Transgender youths who have not completed puberty can receive a class of medication called “puberty blockers” which suppress the release of sex hormones (testosterone and estrogen).  These medications would suppress the growth facial and body hair, as well as prevent the usual voice deepening associated with male puberty. 

For females, puberty blockers would stop normal breast development and interrupt the normal menstruation. If the puberty blockers are stopped during any point in the puberty growth cycle, normal hormone function returns.  

 After puberty blocker therapy, adults usually go on to receive hormone therapy aimed at increasing levels of either estrogen or testosterone to aid in the development of sex characteristics more aligned with their chosen gender identity (12). According to the National Transgender Discrimination Survey, 95% of transgender people and 49% of nonbinary people were interested in hormone therapy (13).  

For an in-depth look at monitoring guidelines related to hormone therapy, check out the algorithm link-> https://arupconsult.com/algorithm/gender-affirming-hormone-therapy  

Mental Health Issues 

Depression 

Transgender persons report higher levels of depression, often related to their experiences in the daily life. They often experience prejudice and discrimination in their personal and professional life, and many report being the victim of violence.  

In addition, external factors such as financial instability and various health challenges also impact feelings of depression.  Left untreated, these feelings often manifest into thoughts of suicide (14). 

Suicide 

According to the American Foundation for Suicide Prevention about 0.5% (or 1 in 200) adults have made at least one suicide attempt (15). By comparison, the rates for transgendered youth who considered suicide in 2021 was closer to 50 percent and nearly 1 in 5 have attempted suicide according to the Trevor Project Survey (16). 

Gender-Dysphoria 

Gender dysphoria is defined, by the American Psychiatric Society, as the “distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity”. Synonyms for incongruence include disagreement, conflict, disharmony, and discord. (17) 

This distress may appear in many different time periods of a transgender person and be highly influenced by external factors such as (lack of) strong support symptoms, lack of appropriate medical care, and perceived biases in areas such as gainful employment and community involvement.  

In addition, the age of the transgendered person, and where they are in the transition process (hormonal therapies, and surgical intervention) also directly influence the level of distress. 

Gender dysphoria is also further delineated into adult and adolescent groups, versus children. The marked incongruence timeline of 6-month duration must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning (18). 

For children, symptoms may manifest in some of the following ways: 

• A strong preference for playmates of the other gender 

• A strong dislike of one’s own sexual anatomy 

• A strong preference for cross gender roles in fantasy play 

• A strong preference for toys and games typically used by the other gender 

For adults and adolescents, symptoms may manifest in some of the following ways: 

• A strong desire for secondary sex characteristics of the other gender 

• A strong desire to be treated as the other gender/ alternative gender 

• A strong desire to be rid of one’s primary/secondary sex characteristics 

• A strong desire to be the other/alternative gender 

Treatment may include multiple interventions, including but not limited to mental health evaluation and psychological counselling, family therapy, support groups, and medical and/or surgical intervention (age appropriate). 

Conclusion

Nurses have a duty to ensure that all patients receive holistic care in a supportive and knowledgeable care setting. In doing so, we build trust between provider and patient, positively impacting patient satisfaction and health outcomes. The transgendered community, over 1 million strong, is dependent on us to advocate for their health needs, ensuring that they receive healthcare that is patient centered, quality driven, and all inclusive.  

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