Practice Tip of the Week: Why can’t I just be me?

John Oeffinger
Director, eLearning and Training, Texas Health Institute
Co-Director, TransFORWARD: Texas Transgender Health
Member, WPATH (World Professional Association for Transgender Health)

Amy Daly, MBA, BSN, RN, CCRN
Transgender Health Community Advocate
DNP Student
Member, WPATH (World Professional Association for Transgender Health)
Member, Texas Nurses Association

Lou Weaver
Transgender Programs Coordinator, Equality Texas Foundation
Co-Director, TransFORWARD: Texas Transgender Health

“I was consistently misnamed and misgendered throughout my hospital stay. I passed a kidney stone during that visit. On the standard 1–10 pain scale, that’s somewhere around a 9. But not having my identity respected, that hurt far more.”

- 2015 U.S. Transgender Survey

Background

Experiences of stigma, discrimination and marginalization have long been linked with poor physical and mental health outcomes. As a minority, transgender people are no exception. Previous research shows that substantial health disparities affect transgender people and are influenced by discrimination.

Transgender people — whose assigned birth sex is incongruent with their gender identity — are at heightened risk for many behavioral health issues due to the social and emotional challenges associated with being transgender. This includes people who are gender non-conforming or intersex.

As July is Minority Mental Health month, it might be useful to consider transgender Texans, especially their mental health experience. An estimated 124,350 adult Texans identify as transgender with another 13,800 Texas transgender youth between 13 and 17. In this same survey, approximately 39 percent of transgender people said they were currently experiencing serious psychological distress, a rate about 13 times higher than the general population (3 percent).

Effects of Discrimination

Fear of being mistreated as a transgender person is one of the largest barriers to getting health care. One survey showed 22 percent of transgender Texans didn’t see a doctor when they needed to. Transgender people want to be treated the same as everyone else: free to be themselves, and not someone others want them to be. Societal stigma, marginalization, discrimination, and in many cases “hate” is directed to trans people who just want to be themselves.

This marginalization of trans people contributes to suicidality, which includes suicidal thoughts (or ideation) and suicide attempts. Suicide ideation and attempts are a major mental health concern among the transgender population. Evidence shows rates of suicide attempts are substantially higher among transgender people than the U.S. population, across all age groups, races and ethnicities, and levels of educational attainment. One in 25 suicide attempts is fatal. Forty percent of transgender adults have attempted suicide in their lifetime, nearly nine times the rate in the U.S. population (4.6 percent).  Of transgender people who have attempted suicide, over two-thirds (71 percent) did so more than once, including 46 percent who reported three or more attempts.

The 2015 US Transgender Survey used the Kessler Psychological Distress Scale (K6) to ask respondents about their level of psychological distress in the past 30 days and if the feelings interfered in their life or activities. Only 10 percent of respondents reported that their psychological distress did not interfere with their lives. This stands in contrast to the 35 percent in the U.S. general population who reported no interference with their lives. Twenty-seven percent reported a lot of interference, and 58 percent indicated some or a little interference.

“I had suffered from anxiety and depression as a direct result of gender dysphoria. This caused me to become more and more unable to function in society as time went on. Only when my state expanded Medicaid was I finally able to start dealing with all of these issues so I could become a productive member of society.”

- 2015 U.S. Transgender Survey

The Role of Nurses

Respectful and equitable care for all people is a foundational value of the nursing profession. To reduce the high rate of discrimination against transgender people in health care, nurses must understand how to provide inclusive and equitable health care experiences.  In practice, nurses often express anxiety about “saying the wrong thing” to a transgender person, not knowing what name or pronouns to use, or being unfamiliar with what transgender means. When nurses become comfortable caring for this population, they will help reduce the significant barriers to care transgender people face.

Remember that transgender patients are fellow human beings. Each transgender patient has a unique lived experience, which unfortunately often includes discrimination from health care providers. This can create a fear of entering the health care environment, causing delays in treatment or non-participation in health screenings which creates vast health care disparities in the transgender community.

To get started, implement some best practice questions that validate a patient’s identity:

• “What is your gender identity?” Do not assume you know which patients are transgender or cisgender (not transgender). People choose to express gender in a variety of ways, some of which may not fit neatly into traditional male or female categories. Gender identity is personal and is different from assigned birth gender.
• “What is your chosen name?” It is imperative that correct names are used. Do not assume the name on a person’s legal identification matches the name they choose to be called. Before addressing any patient, ask what name they use. This should be documented in the health record, often in the “preferred name” field.
• “What pronouns do you use?” Common pronouns are he/his, her/hers, they/theirs. Do not assume that because a person physically appears more feminine or more masculine they use traditionally assigned pronouns.

As leaders in health care settings, nurses have the opportunity to role model trans inclusive behaviors. Maintain privacy at all levels. Sixty-two percent of transgender people live full time in a gender different from the one on their original birth certificate. Only eight percent of respondents were out to all the people in their lives. Focus on the primary reason the patient is in the health care setting. For example, A patient with a respiratory infection does not need to be asked if they have had “the surgery.” Respect the trans person’s privacy and remember HIPAA and Electronic Health Record implications.  

With these few simple things in mind, nurses can create an inclusive, welcoming health care environment to reduce some of the barriers that transgender and gender nonconforming people face.

Resources:

Cultural Humility: LGBTQ – Stories of Transition on Each Side of Nursing

Transgender Health 101: A Foundation Course on Transgender People and Public Health

Transgender Health 104: Psychological Distress

Transgender Wellness: Trans Resource Guide Austin and Central Texas