Nurse Practitioner Knowledge, Attitudes, and Beliefs When Caring for Transgender People Catherine Paradiso1,* and Robin M. Lally2
Purpose: The aim of this study was to explore Nurse Practitioner (NP) knowledge, attitudes, and beliefs when
working with transgender people and to inform about Practitioner education needs.
Methods: A qualitative descriptive design was used to explore (NP) experiences. Focused semistructured
interviews were conducted in 2016 with 11 (N= 11) NPs in the northeastern United States who represent
various years of experience and encounters with transgender patients. The interviews explored NP knowledge
attitudes and beliefs when caring for transgender patients and described their overall experiences in rendering
care in the clinical setting. The interviews were professionally transcribed and analyzed independently and
jointly by two investigators using conventional content analysis.
Results: Four main themes and six subthemes were identified: Main themes include personal and professional
knowledge gaps, fear and uncertainty, caring with intention and pride, and creating an accepting environment.
Conclusions: NPs in this study perceive gaps in their knowledge that threaten their ability to deliver quality,
patient-centered care to transgender patients, despite their best intentions. These findings have implications
for changes in nursing practice, education, and research needed to address vital gaps in the healthcare of
Keywords: attitudes; beliefs; knowledge; nurse practitioners; transgender
After years of discrimination in all areas of life,
transgender people are now prominently included in
the country’s civil rights agenda. Healthcare
discrimination is especially appalling. The National
Transgender Discrimination Survey (NTDS) identified
denial of healthcare, issues with provider ignorance of
transgender and gender nonconforming health needs in
preventative medicine, routine and emergency care,
and transgender-related services in 2011 and again in
2016.1,2 Such discrimination reduces access and deters
transgender people from seeking and receiving quality
In 2011, the Institute of Medicine (IOM) addressed
health needs of transgender persons in their document
‘‘The Health of Lesbian, Gay, Bisexual, Transgender
People: Building a Foundation for Better
describing stigma, discrimination, and lack of provider
knowledge and training as barriers to transgender
healthcare leading to significant health disparities.3
The need for transgender health research, although
included under the umbrella of lesbian, gay, bisexual,
transgender, and queer (LGBTQ), is receiving more
prominence in the public and in academia. Improving
the health, safety, and well-being of LGBTQ
individuals is a Healthy People 20/20 objective.4 Also,
sexual and gender minorities were officially
designated as a health disparity for National Institute
of Health research in 2015, raising consciousness in the
research community and making funding available.5
Transgender care should, then, be an education and
research priority for nursing.
Transgender healthcare is currently not required in
medical provider education.6,7 Gaps in medical
1Department of Nursing, The College of Staten Island, The City University of New York, Staten Island, New York. 2College of Nursing, University of Nebraska Medical Center, Omaha, Nebraska.
*Address correspondence to: Catherine Paradiso, DNP, ANP-BC, PSYMHNP-BC, College of Staten Island, School of Health Sciences, Building 5 S, 2800 Victory Boulevard, Staten Island, NY 10314, E-mail: [email protected]
Paradiso and Lally; Transgender Health 2018, 3.1 48http://online.liebertpub.com/doi/11.1089/trgh.2017.0048
ª Catherine Paradiso and Robin M. Lally 2018; Published by Mary Ann Liebert, Inc. This Open Access article is distributed under the terms of the Creative Commons License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
curriculum leave providers (Physicians, Physicians
Assistants, NPs) unaware of evidence based
standards,8,9 making access to care a barrier to basic
health services.10 Nurse Practitioners (NPs) are
prepared with 2–3 years of graduate education. There is
no curriculum requirement to specifically include
transgender health, but rather address any transgender
issues as diversity in general.11 Moreover, most general
nursing education programs have not included
transgender issues at all into their curriculum and spend
a short amount of time on the topic, about 2 h.12 To the
best of our knowledge, there is only one published
article on integrating LGBTQ content into a NP
program.13 NPs increasingly provide primary and
specialty care for a variety of populations and could
improve access to and quality of care for transgender
patients. There are no published studies that have
explored the attitudes, beliefs, or educational needs of
NPs when providing transgender care.
Background Lack of data
Attempts have been made to estimate the population of
transgender persons in the United States. The Williams
Institute has estimated that 0.6% of adults, about 1.4
million, identify as transgender in the United States.
They provide the first state-level estimates of the
percentage of adults who identify as transgender.14
Research on transgender health is scant due to
limited epidemiologic data.8,15 Academic researchers
agree that the lack of epidemiologic data and an absent
standard lexicon of definitions obstruct research.
Larger studies to acquire evidence-based prevention
data and plan care for the transgender population are
needed, including a dedicated, national research
infrastructure. Nationally, studies are needed that
identify health promotion needs of this special
population, training needs of providers, and strategies
to achieve safe effective care for transgender people at
all staged of transition.15,16
Complexity of needs
Transgender healthcare needs are complex. As
individuals transition into their identified gender and as
they move through life, they may seek care from
specialty providers such as urology, surgery, or
gynecology. In addition to transgender-related services,
primary prevention, routine, and emergency care are
needed by all people, so provider understanding of how
to care for transgender people is always necessary in
healthcare settings. Healthcare provider competence is
especially important in transgender reproductive health
because of unique needs. For example, health
promotion includes cancer screening for retained birth
organs. Another example is that of breast cancer risk.
Bazzi et al., (2015) found transgender patients were less
likely than cisgender patients to adhere to screening
guidelines.17 Screening guidelines for transwomen who
are exposed to extended hormone use is not yet
determined, so screening must be emphasized.
Barriers to care
Barriers to quality care include the following: (1)
reluctance of transgender patients to disclose gender
identity when receiving medical care, (2) insufficient
numbers of competent providers to care for LGBTQ
issues, (3) insurance and policy barriers, (4) lack of
culturally appropriate prevention services, and (5)
discrimination.3,8,18 The importance of a competent
provider and access to healthcare includes a greater
likelihood of a medical evaluation before starting
hormone therapy, obtaining hormone therapies from a
medical provider, and a greater adherence to risk-
reduction behaviors.19 Educating providers and creating
a welcoming environment to remove feelings of stigma
and discrimination are recommended to reduce barriers
to care; however, one study found that as few as 20%
of providers in OB/GYN receive formal training in
transgender care and do not know clinical requirements
following gender reassignment or routine health
maintenance.7,20 Another study found that 79% of
providers studied had never considered that their
patient may identify as LGBTQ. In that study, all
healthcare providers, except for nurses, demonstrated
low levels of tolerance and respect. Nurses
demonstrated the highest levels of tolerance and respect
for transgender people.6
Providers lack comfort caring for this population
compared to caring for lesbian and bisexual patients,
Paradiso and Lally; Transgender Health 2018, 3.1 49http://online.liebertpub.com/doi/11.1089/trgh.2017.0048
regardless of years of experience.20 For example,
discomfort in communication during transgender
health encounters has been identified by Lurie (2005)
who found that physician providers desired to treat
transgender patients respectfully but admitted
discomfort and lack of tools for asking specific
questions during assessments.21 One specific area of
discomfort is in meeting the psychological support
needs of transgender patients, especially when
behavioral healthcare is necessary. Providers describe
patients with many behavioral health needs, some of
which they are not prepared to meet because of a lack
of understanding.22,23 Transgender people describe
anticipating that providers will not know how to meet
their needs and therefore avoid medical encounters.22
NP, nurse practitioner.
Education can remove barriers
Healthcare provider education can remove barriers for
transgender individuals. Lelutiu-Weinberger et al.
found improvement in licensed and unlicensed medical
staffs’ knowledge and attitudes and a more welcoming
clinic physical environment after training.19,24 Exposure
to transgender individuals, whether in person or
through videotape training, increased confidence levels
and established a more positive attitude and
performance of more comprehensive physical
examinations when compared to medical staff and
students who had no exposure.6,25
Guided by this evidence, this study aimed to answer
the following research questions: What are NPs’
attitudes, beliefs, and level of knowledge regarding the
care of transgender individuals? and What do NPs
describe as current gaps in Advanced Practice
education pertaining to the care of transgender
A qualitative descriptive design was used. Focused
semistructured interviews about the NP experiences
were conducted in 2016. Semistructured interviewing
allowed subjects to express openly, deeply, and in
detail their experiences and feelings, when working
with transgender patients.26 This study was approved by
the Primary Investigators’s university Institutional
Purposive sampling was used to identify NPs with
maximum variation in their clinical encounters with
transgender patients. Maximum variation allows
exploration of similar and unique experience across a
broad range of individuals and was thus deemed the
best method to answer the research questions.26,27
Participants were recruited from clinical practices and
Universities in the Northeastern United States through
the lead author’s faculty and clinical contacts informing
colleagues about the study. Criteria for inclusion were
that NPs must have cared for at least one transgender
patient. Table 1 describes the sample demographics
A final sample of 11 NPs participated in this study.
After, it was believed that data saturation had been
reached (e.g., subsequent interviews were not
providing additional data). The lead author
purposefully sought out NPs with similar and dissimilar
experiences to the first seven participants to confirm
and/or disconfirm the initial data,22 thus adding to the
credibility of the findings.26,30
Table 1. Subject Demographics
Years in nursing
practice Nurse practitioner
licensure Nurse practitioner years
Estimate number of
transgender patients Recent care 1 31 Family NP 7 MSN 5 Currently
2 12 Adult NP 4 MSN 10 Currently 3 40 Women’s Health NP 24 PhD 3 6 years ago 4 8 Adult NP 5 MSN 100 Currently 5 18 Adult NP 8 DNP 15 Currently 6 14 Psyche.MH NP 3 MSN 6+ Currently 7 35 Family NP 16 MSN 3 6 months 8 6 Family NP 2 MSN 2 1 year ago 9 30 Nurse Midwife 21 DNP >10 Currently
10 30 Family NP 20 MSN 100 6 months 11 25 Women’s Health NP 8 DNP 4 1 year ago
Paradiso and Lally; Transgender Health 2018, 3.1 50http://online.liebertpub.com/doi/11.1089/trgh.2017.0048
Data were collected over a 4 month period. Following
informed consent, focused, semistructured interviews
were conducted in person (n = 5) or via video
conferencing (n = 6) and digitally recorded.
An interview guide was used to maintain consistency
in initial open-ended questions. These questions were
followed by probing questions to obtain detail about the
experience. All interviews were conducted by the lead
author who maintained a journal of thoughts
immediately following each interview. Key words were
highlighted in the journal for analysis. Interviews were
Conventional content analysis was chosen for analyses
of these data since this method is best used when a
study design seeks to describe experiences with limited
existing theory and research and to provide knowledge
and understanding of the phenomenon under study.26
Analysis was ongoing throughout data collection. The
first author read each transcript thoroughly to acquire
the essence of each interview, then reread each
interview multiple times to derive codes that captured
the key concepts. Notes were taken of first impressions
associated with quotes that exemplified key concepts.
As analysis progressed, themes were identified that
reflected associated concepts. Coded data were
continuously compared with new data and themes.27
The second author coded the interviews independently
and then reviewed the codes, themes, and subthemes
developed by the first author identifying similarities
and differences. An ongoing discussion between the
authors resolved differences and resulted in collapsing
and expanding subthemes throughout the analysis and
development of the final article.28,29
This work was conducted with attention to credibility
and dependability of the study data.30 An audit trail of
the transcripts, coding, and decisions on themes and
subthemes was maintained. The lead author also
maintained a reflective journal containing her
impressions throughout data collection. Credibility of
this work is supported by independent and joint coding
and theme development by the two authors; one
(second author) experienced in qualitative research
method and acting as a method and analysis coach to
the lead author. The lead author is a NP with 15 of years
of experience and a nurse educator, for whom this
research is her Doctor of Nursing Practice scholarly
work. Her professional background provided the lens
through which these data were interpreted. Additional
processes to support credibility included constant
comparison of developing coding and themes and
selecting interviewees later in the data collection
process who represented varied experiences and
professional backgrounds whose data could challenge
initial data. All interviews were conducted one-on-one
by the lead author, who does not have experience with
care of transgender patients.
Interviews were conducted in a location chosen by
the NPs to support interviewee privacy and comfort in
sharing opinions on this sensitive subject matter.
Finally, rigor was supported through sharing the article
with an experienced DNP practicing in transgender
health, to obtain input of the congruence of the work
with current practice as the article was finalized.
Four predominant themes and six subthemes were
identified. Themes included knowledge gaps,
uncertainty and fear, caring with intention and pride,
and creating an accepting environment.
Personal and professional knowledge deficits were
described by all NPs, as experienced by themselves and
their colleagues. NPs described transgender
individuals’ needs as very complex, involving
behavioral health, gender, and transition care needs
superimposed upon the usual care required by all
people. Opportunities to provide care for transgender
patients both highlighted NP knowledge deficit and
provided chances to learn from their patients as well.
Personal knowledge gaps
Patients have to teach providers. NPs’ personal gaps in
knowledge, resulting from a lack of resources and a
minimal evidence base to guide practice, caused
patients to have to teach their NPs about transgender
care. Teaching from patients included making NPs
aware that they still retained their birth organs, or that
hormones may increase health risks of certain
conditions. An NP described an example of her
encounter with a female patient who informed the NP
that she had a penis ‘‘I said to her ‘Would you be
Paradiso and Lally; Transgender Health 2018, 3.1 51http://online.liebertpub.com/doi/11.1089/trgh.2017.0048
willing to educate me’ because better I should learn
from a patient than reading a book.’’ (Subject #2). An
experienced NP shared that learning from patients is
ongoing and enhanced by asking questions.
‘‘So stating to the patient, ‘if I misstep and I misspeak and I
refer to you as something that makes you uncomfortable, if I
say something or ask you something that makes you
uncomfortable, it’s not my intention to do that, but please
stop me and correct me.’’ (Subject #9)
Lacking resources. Knowledge of transgender care had
to be acquired, but NPs experienced frustration over the
lack of available published evidence about transgender
care. One NP described her efforts, including turning to
the media for information, ‘‘I did some reading ., but
there wasn’t a lot to read. It was only after meeting
transgender people like that I ever did anything to read
up on it and try to watch it on TV if there was
something’’ (Subject #3).
NPs also did not know where to obtain knowledge on
terminology to support their communication with
transgender patients. These nurses found that variations
in terminology for describing individuals and
anatomical changes exist within the transgender
community, but are not necessarily known by
providers. NPs described their dilemmas when even
words that are automatic, such as ‘‘Mr.’’ or ‘‘Ms.,’’
may be incorrect or clinical requirements, such as
cancer screenings protocols, are not clear for a
transgender individual who may have internal organs of
the opposite gender. NPs’ insecurity with basic
communication created awkwardness and caused them
to be hesitant to speak and treat their transgender
patients, despite the desire to provide quality care.
‘‘I started self-teaching, what would help me would be to
know a little bit more about the resources that are out there,
because I don’t even really know where my lapses of
knowledge are. But every year I learn something new. I
suppose I’m selfmotivated because I care about the
population.’’ (Subject #2)
Professional gaps in knowledge
Regardless of how recent their education, all the NPs in
this study expressed that transgender care had not been
part of their graduate curriculum. The absence of
education in transgender care was seen as a flaw.
‘‘There was nothing from the faculty. I would say that
the training is minimal to nonexistent’’ (Subject #4).
Nursing faculty confirmed the perceptions of these
NPs. A NP faculty member with many years of
transgender care experience stated,
‘‘I can tell you it’s not something I teach in my curriculum. I
could also tell from sitting on the board for the [NP exam]
writing. We don’t test on it. There’s so much to teach that we
don’t teach them [NPs] about it [transgender care]. But there
are certain webinars and education programs that you can tap
into, if you can find them.’’ (Subject #5)
More experienced NPs describe the lack of
transgender health education available through
‘‘I have not received any other training. There’s no in-
services or CE credits that are required by the places I’ve
been employed. You have to do everything about infection
control and other things every single year, but there’s not
much. There really is very limited promotion of the
information of transgender treatment.’’ (Subject #6)
They further identify the need for efforts to provide
continuing education to practicing NPs.
‘‘I think it should be an automatic put in place, that maybe
there is a speaker one night that’s transgender. Maybe have
a speaker the following week that is not just transgender–I
know that’s what we’re talking about–but maybe have a gay
or a lesbian couple or person come in and speak about some
needs or feelings that they have that we’re not Addressing.’’ (Subject #7)
Uncertainty and fear
The complexity of transgender care coupled with NPs’
knowledge deficits caused NPs to experience
uncertainty and in some cases fear of making errors
during clinical encounters. Knowledge gaps resulted in
awkward encounters, which in some cases made the NP
appear transphobic and ignorant. ‘‘I said, ‘really,
there’s a penis in that underwear? You’re the most
beautiful woman I’ve ever seen. What the heck is the
story here?’’ (Subject #3).
Fear of making a mistake in clinical judgment,
embarrassment and awkwardness from unknowing, and
worry about making patients feel disrespected were
described as objectifying.
‘‘There were two others (I cared for) and they were both born
females who were in their hearts and their heads really male.
They looked feminine to me and I had to keep saying to
myself, that’s a he, you idiot; don’t call it a she. That would
be an insult; don’t do that.’’ (Subject #3)
An experienced NP described the fear he observed in
nurses around him,
‘‘Some Nurse Practitioners are afraid and they’re afraid
because they don’t know. Some of them don’t understand;
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they can’t wrap their heads around it; they don’t conceptually
understand it [transgender]. They don’t understand how to
treat them. They are afraid to treat them; they are afraid to
misstep.’’ (Subject #5)
NPs’ responses demonstrated acknowledgment of
uncertainty, differing degrees of knowledge deficit, and
levels of confidence in care provision associated with
gender affirming hormone therapy. ‘‘Their medications
are administered differently, and I’ve tried to research
why.’’ (Subject #1). Another NP clarified the need to
remember that transgender patients are the same as all
‘‘They have the same healthcare needs that everyone else
does and I think that is what we all forget. We all look at it
like, oh, you must see this and you must see that, but they all
have hypertension, they all have diabetes, they all have
dyslipidemia. We still need to treat them as people. We still
treat the diagnoses, the illnesses, and their disease processes.
If he’s a transgender male, he can still get sinusitis.’’ (Subject
Reproductive care presents additional complexity in
care and an especially sensitive topic that could create
animosity between the patient and NP. Transgender
patients may have two sets of anatomy, and an
inexperienced NP may not realize all of the nuances
with regard to genital structure and associated medical
needs, for example, a trans male will have a cervix and
require cancer screening, leading to uncertainty and
fear of making a mistake or insulting the patient. These
are extremely sensitive issues to all people, and in a
transgender person the NP must understand these
differences, the care required, and how to communicate
this understanding. Without knowing, an NP could
misgender a patient during the encounter, reducing trust
and rendering the encounter nonproductive for the
patient. Empowering a patient with knowledge,
supporting them in their decisions, informing, and
guiding are more likely to have a good outcome, but
hard for an NP with limited experience and skill to
achieve. Below is an example of an NP thinking he was
doing so, but the patient did not accept the information,
most likely because the NPs approach was authoritarian
instead of collaborative.
‘‘I said, ‘well, when was your last pelvic exam?’ He only
slept with HIV positive men, orally, anally, and vaginally, so
there was a lot of opportunity for counseling. I said, ‘you
really do need to have a pelvic exam,’ he pretty much thought
I was the worst person in the world because I told him that.’’
Another NP experienced in reproductive care
describes uncertainty and fear over providing
‘‘Not awkward because of their life choice, awkward because
I am not sure I am doing the right thing and I want to do right
by the patient. I just felt woefully inadequate. I do not know
what I am supposed to be looking for, specifically or per se,
for each of these clients. It’s not that I felt uncomfortable
personally. It was just more I felt inadequate as a healthcare
provider. That was the daunting part of it for me.’’ (Subject
Caring with intention and pride
This theme illustrates that NPs worked to overcome
their fears by putting extra effort into the intentional
care of each transgender individual and filling their
own knowledge gaps. By intentional, the NP is
referring to ‘‘constant awareness’’ Over time, NPs
experienced increased pride over their personal and
professional growth. The following two subthemes
reflect this further.
Intentional care balances complexity Knowledge gaps
and patient complexity required NPs to take more time
to think critically.
‘‘There’s always an awareness that this patient in front of me
is transgender, versus if the person in front of me is gay, or
black, or purple. I might not even think about it.. if it [the
encounter] is transgender I will always remember. There’s a
difference. It’s intentional in the way I have to interact with
a transgender person.’’ (Subject #2)
Behavioral health comorbidities within the
transgender population were also identified as an area
requiring NPs to focus intentional care. ‘‘There’s a lot
of psych hospitalizations for this population; there’s a
lot of suicidal ideation and attempts.’’ (Subject #6);
another said ‘‘.. higher levels of depression, higher
levels of substance abuse in the population. Did I say
domestic abuse?’’ (Subject #2). One NP described
psychological issues experienced by transgender
persons in more depth.
‘‘Mental health effects that are related to facing a lifetime of
discrimination, which for a lot of transgender people starts in
childhood, so that’s pretty deep and formative. Parental
rejection, homelessness, or being cut off from the central
family at some point, sometimes rejection from a partner,
boyfriend, or girlfriend during transition or thereafter.’’
An experienced NP described high-level
intentionality in care and gave an example of the care
he provided to a patient who was a female transitioned
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to male. He advises NPs when delivering care,
requiring this level of intention, to be humble and ask
the patient what is not clear. He makes a point to the
listener that as a clinician he must think careful of what
anatomy is present, so that misgendering does not occur
and the patient can be advised appropriately.
‘‘Do not be afraid to ask your patient about what pronoun
they want used. Consider the anatomy.. When I said that [you
need to have a pelvic exam] to him, he was like, ‘of course
that makes sense.’ [He understood that] of course.., In
describing his thinking ‘I would have to think about his
anatomy, her anatomy, her male anatomy’.’’ (Subject #5)
Describing the NPs thoughts as he went through
them in his head shows the level of concentration and
deliberate thinking to make sure …
Delivering Culturally Sensitive Care to LGBTQI Patients Jessica Landry, DNP, FNP-BC
American Assoc receive 1.0 cont reading this artic aanp.inreachce.c
ABSTRACT Many health care providers are uncomfortable having conversations with patients about their sexual identity or sexual behaviors. Avoiding this discomfort is causing a serious threat to the mental and physical health of Americans, particularly those in the lesbian, gay, bisexual, transgender, questioning, or intersex (LGBTQI) community. The health-related disparities among LGBTQI patients range from bullying and physical assault to refusal of health care and housing. Many individuals choose not to seek health care due of fear of being judged, marginalized, or abused. This article focuses on the many disparities faced by the LGBTQI community and describes how simple changes in the practices of health care providers can potentially improve their health outcomes.
Keywords: care of LGBTQI patient, cultural sensitivity, gender fluidity, gender identity, LGBTQI health disparities � 2016 Elsevier Inc. All rights reserved.
THE STAGGERING STATISTICSealth care professionals strive to provide culturally sensitive and high-quality mental
Hand physical health care to children and
adult patients, regardless of their age, race, religion, sexual practices, or personal belief system. Conveying a sense of understanding of a patient’s culture and a nonjudgmental attitude toward their behaviors may be a means to “meet patients where they are,” and lay a foundation for a trusting relationship that can lead to improved health outcomes. According to the Gay Lesbian Straight Educational Network, 74.1% of lesbian, gay, bisexual, transgender, questioning, or intersex (LGBTQI) students are harassed or threat- ened in American schools.1 Of the 7,898 LGBTQI students involved in the study, 5,852 were subjected to derogatory remarks referencing their sexuality. Ninety percent of these students indicated feelings of distress during their time on campus, and 30.3% missed at least 1 day of school due to harassment or bullying.1
iation of Nurse Practitioners (AANP) members may inuing education contact hours, approved by AANP, by le and completing the online posttest and evaluation at om.
urnal for Nurse Practitioners - JNP
Grant and colleagues2 studied 6,400 transgender and gender nonconforming people in kindergarten through grade 12 and found that 78% experienced harassment, 35% suffered physical assault, 12% were victimized by sexual violence, and 15% discerned a sense of threat severe enough to quit school completely. The discrimination of transgender persons continued into the workplace, with 90% of those surveyed reporting incidents of harassment and mistreatment. Nineteen percent of the economically disadvantaged and less educated individuals in this group reported being refused home rental or apartment leasing contracts, found themselves homeless at some point during their life, or experienced outright refusal of health care due to their sexual orientation.2 Of this disadvantaged population, 55% of those who sought asylum in homeless shelters reported being harassed by shelter employees, 29% were outright refused entry, and 22% were sexually assaulted by either shelter residents or staff.
The United States Centers for Disease Control and Prevention (CDC) named suicide as the second leading cause of death among people between age 10-24 years in the United States between 1994 and
Volume 13, Issue 5, May 2017
VIGNETTE A family nurse practitioner (FNP) in a busy emergency
department read the triage note of a 12-year-old boy
that stated he had “tried to tie a belt around his neck to
hang himself.” The medical history exhibited no sig-
nificant findings, as he had no physical or mental ill-
nesses. The FNP introduced herself and began small
talk for a few minutes, but noted only silence from the
young patient. She began asking him questions about
why he had tried to hurt himself, and he refused to
answer. She asked him questions about his school,
grades, did he have “girl trouble,” was his teacher
unkind or unfair? He just shook his head “no,” with his
eyes turned down. She continued gently questioning
him to determine if he was experiencing physical,
sexual abuse, verbal abuse, parental neglect, or
bullying from others. Again, he just shook his head and
avoided eye contact with her consistently.
She proceeded to the examination portion of the visit
and the only abnormal finding was redness around his
neck from the belt. She ordered a soft tissue X-ray of his
neck and left the room to question his parents. They re-
ported that he had many friends, achieved honor roll
several times, and his teacher had positive reports of
behavior and academic performance; yet, in spite of all
the positive aspects of his life, he had begun to express
more sadness overthe last year andthis concerned them.
The FNP decided she would approach him once
more, this time without his parents, nurse, or social
worker present. She sat on the side of his bed and
touched his arm, she asked him to please make eye
contact with her. He appeared defeated and worn, much
too young to wear such an expression. She asked him
directly again, “Why did you try to hurt yourself? You
have much goodness in your life; you are handsome,
smart, and your friends, teacher, and parents love you
and are concerned about you. I want to understand why
you want to die.” He looked the FNP squarely and stated,
“Because I am a girl and no one understands that.”
When she tried to respond she realized she was afraid
she would use the wrong words and possibly make him
feel worse. She had been preparing to have him
committed to a psychiatric facility, and she was con-
cerned he would assume he was being committed for
his gender identity and not his suicide attempt. The FNP
attempted to explain this, she felt she was unclear. He
was discharged to a psychiatric facility from which he
was shortly discharged. Four months later he attempted
suicide again, this time he was successful.
2012, with 5,178 of these deaths in 2012 alone.3 The CDC also reported that, among students attending American schools and enrolled in grades 9-12, 14.8%
of heterosexual students attempted suicide compared with 42.8% of gay, lesbian, or bisexual students within the 12-month period prior to being sur- veyed.4 The survey further reported that, compared with heterosexual students, nearly twice as many gay, lesbian, and bisexual students were threatened or injured with a weapon, such as a gun, knife, or club, on school grounds at least once.
HEALTH DISPARITIES IN THE LGBTQI COMMUNITY The CDC reported that gay, lesbian, bisexual, and students are 30.5% more likely to feel sad or hope- less, 13.6% are more likely to be victims of sexual violence, 23% are more likely to attempt suicide, 15.4% are more likely to use marijuana, and twice as likely to experiment with hallucinogenic drugs as their heterosexual peers at the same age.5 The survey also revealed that students who questioned their sexual identity were 14.9% more likely to suffer from physical violence during dating and 9.5% more likely to use or abuse cocaine than their heterosexual peers.
The responsibility for the health of sexual mi- nority students has largely been placed on schools, which often play very limited role in educating stu- dents on sexual and mental health. The School Health Policies and Practice Study showed that about half of American high schools discuss sexual identity or orientation as part of the curriculum at any grade level.5 The study further noted that only 34.6% of these high schools provide health care specifically to LGBTQI students. Many psychological textbooks and current literature still refer to those questioning their gender or displaying gender-nonconforming traits as have a gender-identity disorder (International Classification for Disease-10th revision, F-64.9), which causes more confusion for teachers, nurses, and physicians who are trying to advocate in the best interests of their students or patients.
Often, health care providers lack the education, terminology, and basic understanding of LGBTQI culture, and this does not go unnoticed by pediatric or adult patients. The National LGBT Health Education Center: Fenway Institute researched why many people in this group do not seek basic health care. Over- whelmingly, the collective answer was that they felt “invisible” to their provider.6 The “Don’t ask/don’t
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tell” model that has been unintentionally applied in general practice is ineffective and is contributing to the staggering number of health disparities seen in this population. The National LBGT Cancer Network reported that patients often fear the responses from providers. This may, in part, explain some of the cause for health disparities among this group.7
UNDERSTANDING GENDER FLUIDITY Health care professionals cannot change societal norms nor force the majority population to accept any race, religion, culture, or sexual orientation, but we are responsible for their health care collectively. National LGBT Health Education Center: Fenway Institute expressed the importance of understanding gender fluidity, in contrast to traditional binary viewpoints of sexual identity, as a means to grasp the basic understanding of this culture.8 This understanding will allow for the health care provider to appreciate a more comprehensive assessment of the patient’s current and future health needs.
Traditionally, gender has been expressed in a binary view—male and female. Boys and men were expected to behave in a masculine manner as leaders of the home and family, whereas girls and women were expected to respect the male authority and to dress with femininity and modesty. It is not surprising that anyone who chooses to believe or behave outside of what is considered normal by the majority at that given time are discriminated against to varying degrees. Societal norms are expectations of the group’s majority and those desiring acceptance within the group should conform, or suffer potential consequences.
The concept of gender fluidity suggests that gender identity and sexual preference are multidimensional and multifactorial in nature. One may be born male and be attracted sexually to another male, a female, or both. This male may be comfortable (cisgender) or tormented (transgender) in his male body (see Table 1 for glossary). How one identifies their gender does not have to be consistent with the sex to which they are attracted, nor to the gender to which they were assigned at birth. Some are not specifically sexually attracted to any gender, but rather to the person themselves, regardless of their biologic sex.
The expression of “self” may vary greatly among this diverse group. Some simply want to “pass” as their
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gender identity instead of their biologic sex. Some may prefer to dress extravagantly as one gender or another, whereas others are incapable of expressing the gender they identify with, and suffer from isolation, depres- sion, and even attempt or commit suicide.9 Potential warning signs could be recognized and addressed by astute health care providers and the number of suicide successes and attempts could decrease.
PROVIDING INCLUSIVE QUALITY CARE Many LGBTQI people have difficulty finding health care where they feel they are accepted, understood, and do not fear discrimination.10 LGBTQI people are extremely diverse and can be of any race, nationality, religion, wealthy, or impoverished, and anything in between.11 It is the role of the health care provider to understand how their identities and experiences with others can potentially affect their health. Barriers to this type of affirmative and inclusive care may be limited access, past negative experiences, and lack of knowledge and experience of the health care professional who is delivering care.10
The National LGBT Health Education Center: Fenway Institute has developed strategies that have been shown to foster an inclusive, safe environment for LGBTQI people.6 The first strategy recommended is that providers keep realistic expectations with communication. Many times, LGBTQI people have experienced discrimination or lack of awareness from previous providers and may come to expect this reaction when they are seeking care. For example, if the health care provider uses the wrong pronoun or makes the verbal assumption that a pediatric patient lives with a mother and father instead of 2 mothers or 2 fathers, the provider can simply apologize, correct the mistake, and try to reestablish constructive dialog while focusing on the reason they are seeking care.
Strategies that can be employed by health care providers include: improving basic communication; avoiding assumptions and stereotypes; and using preferred pronouns and names.12 When a health care provider is unsure of how the patient wishes to be addressed, it is acceptable to politely ask them, and document this information for other coworkers to be aware. Respect, concern, and an inclusive
Volume 13, Issue 5, May 2017
Table 1. Glossary of Terms
Ally A person who does not identify with the LGBTI group but shows support
and advocates for the rights of LGBT people.
Asexual or ACE Has no sexual orientation and exhibits a lack of interest in sex; not
considered in the same domain of celibacy.
Bisexual A person who is attracted to both men and women.
Bottom surgery A means of describing external genitalia reassignment surgery.
Cisgender Comfortable with the external genitalia present at birth; not transgender.
Disorders of Sexual development A congenital condition in which reproductive organs do not develop into a
definite male or female reproductive system.
Drag king/queen The theatrical performance of women dressed as men (drag king) and men
dressed as women (drag queen).
Gender fluid Describes a person whose gender identity is not static, it is a mixture of the
2 traditional genders in which the person may be attracted to males or
females. This group is a attracted to a person’s authenticity and personal
compatibility regardless of the external genitalia.
Gender nonconforming A person whose gender expression does not conform to societal norms
Gender dysphoria Distress by those whose gender identity is not incongruent with birth
gender, presents clinically with signs of mental distress, and has impaired
social and occupational functioning.
Gender expression The person acts, dresses, speaks, and behaves in ways that may or may not
correspond to assigned sex at birth.
Intersex An individual’s biologic anatomy (fetal development of reproductive
system) vary from the expected norm (eg, ambiguous genitalia or those
born with both a penis and vagina or a testicle and ovary).
MSM Men who have sex with men.
Omnigender A person who is sexually attracted to someone regardless of the gender
identity, gender expression, or either biologic sex.
Queer A label that describes those who identify with a sexual orientation outside
the social norms. Some consider this term empowering (younger
generation), whereas others strongly dislike the term.
Transsexual Gender identity is not congruent with their biological external genitalia.
They may or may not desire hormonal or surgical means to feel more
congruency to their perception of self.
Transgender Describes a person whose biologic anatomy does not correspond with their
sexual identity and many have a desire to outwardly express the gender to
which they identify.
Questioning Describes those who are unsure and taking time to determine their gender
identity; searching for their authentic self.
Adapted from the National LGBT Health Education Center: Fenway Institute15 and the Gay Alliance.16
environment is perceived when all hospital/clinic staff are addressing the patient as they express themselves (Table 2).
If the name and gender on records do not match, it is recommended to ask, “Could your
chart be under a different name?” or “What is the name on your insurance card?”8 It is not recommended to refer to their birth name as their “real” name, as this may imply that their wish to be called by their preferred name is not respected.
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Table 2. Communicating Respectfully in Health Care
Best Practices Examples
Addressing a new patient: Do not assume a pronoun
like “sir’ or “ma’am,” but rather keep your remarks
open and general.
“How can I assist you?” or “Welcome, what brings you to
If you unsure of the pronoun a patient wants used,
simply ask politely. If you use the wrong pronoun,
apologize and document the patient’s preferred
name and pronoun so others are aware.
“I am sorry for using the wrong pronoun and I did not
mean any disrespect, I will note this in your chart so
other’s hopefully will not make the same mistake” or
“How would you like to be addressed while you are
staying in the hospital/while you are at the clinic?”
If you cannot find the patient’s preferred name in the
electronic health record, ask about other names they
have used in the past.
“Could your record be under another name, perhaps?” or
“How does your name read on your insurance card?”
In conversation, you should use the terms that the
person uses to describe themselves. Some identify
as queer and it is acceptable to address them this
way, if it is consistent with how they personally
If a person verbalizes that he is “queer,” do not call him
“gay or homosexual.” If a woman refers to her partner as
her “wife,” you should follow suit.
Adapted from the National LGBT Health Education Center: Fenway Institute.8(p21)
Sometimes their name is changed on the driver’s license or other medical documents, but, for legal or safety reasons, their gender is not changed. Consider the negative consequences that could result if a transgender person (female to male) is arrested and placed in a cell with male inmates. Sometimes gender documentation change is not done because specific screening services may be excluded by insurance carriers. An example is the female-to-male transgender patient, whose insur- ance carrier may refuse to pay for a Pap smear if there is a male gender on file. Knowledge of this information can play a role in improving health outcomes, promoting culturally sensitive care, and reducing health disparities.
AFFIRMING CLINICAL ENCOUNTERS Beyond having a welcoming environment for LGTBQI patients, health care providers should be open and nonjudgmental when taking sexual and social history data.13 Best practices include using open-ended and general questions and avoiding asking questions with specific answers that can exclude individuals who are not mainstream. When inquiring about partner/marital status, asking “Who lives at home with you?” or “Who is family to you?” is more inclusive than “Do you have a wife/ husband?” Questions should be worded to initiate
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discussion about their intimate relationship and/or sexual behaviors that may affect their health. An example of an open-ended question is, “What does safe sex mean to you?” Eliciting honest answers allows for the provider to have a better understanding about what screening tests to order, currently relevant patient education to provide, and to anticipate guidance in preventing future possible negative out- comes. Knowledge of this information can play a role in improving health outcomes, promoting culturally sensitive care, and reducing health disparities.
Once a trusting relationship has been established between the patient and the health care provider, a sexual risk assessment should be conducted. This assessment is commonly known as the 5 P’s: partners; practices; past sexually transmitted disease history; protection from sexually transmittable diseases; and pregnancy plans.12 These questions assist the provider in stratifying a patient’s risks for poor health outcomes or diseases. Registered nurses, advanced practice nurses, and physicians are encouraged to become trained in how to provide respectful, quality care to LGTBQI patients.14
CONCLUSION Effective health care is based on the foundation of providing quality care to patients with a holistic approach. Part of giving quality care is for the
Volume 13, Issue 5, May 2017
provider to begin by having an awareness of the cultures of the patients they care for, including the many cultures of the LGBTQI population(s). Having this awareness will allow the health care provider to begin to better meet the mental and physical needs of the population for which they are caring.
1. Kosciw JG, Greytak EA, Palmer NA, Boesen MJ. The 2013 national school
climate survey: the experiences of lesbian, gay, bisexual, and transgender
youth in our nation’s schools. 2013. http://www.glsen.org/sites/default/files/
.pdf/. Accessed November 25, 2016.
2. Grant JM, Mottet LA, Tanis JT. Injustice at every turn: a report of the national
transgender discrimination survey. 2011. http://endtransdiscrimination.org/
PDFs/NTDS_Report.pdf/. Accessed November 25, 2016.
3. US Centers for Disease Control and Prevention. Suicide trends among persons
preview/mmwrhtml/mm6408a1.htm/. Accessed November 25, 2016.
4. US Centers for Disease Control and Prevention. Sexual identity, sex of sexual
contacts, and health-related behaviors among students in grades 9-12 United
States and selected sites. 2015. http://www.cdc.gov/mmwr/volumes/65/ss/
ss6509a1.htm/. Accessed November 25, 2016.
5. School Health Policies and Practice Study. 2014.
6. National LGBT Health Education Center: Fenway Institute. Understanding the
health needs of LGBT people. 2016. http://www.lgbthealtheducation.org/wp
-content/uploads/LGBTHealthDisparitiesMar2016.pdf/. Accessed November
7. National LGBT Cancer Network. Barriers to healthcare. 2016. http://www
barriers_to_lgbt_healthcare.php/. Accessed November 25, 2016.
8. National LGBT Health Education Center: Fenway Institute. Providing inclusive
services and care for LGBT people. 2016. http://www.lgbthealtheducation.org/
Accessed November 25, 2016.
9. National LGBT Health Education Center: Fenway Institute. Ten things:
creating inclusive health care environments for LGBT people. 2015.
Final-WEB.pdf/. Accessed November 25, 2016.
10. National LGBT Health Education Center: Fenway Institute. Building
patient-centered medical homes for lesbian, gay, bisexual, and
transgender patients and families. 2016. http://www.lgbthealtheducation
.pdf/. Accessed November 25, 2016.
11. Healthy People 2020. Healthy People 2020. 2016. https://www.healthypeople
Accessed November 25, 2016.
12. National LGBT Health Education Center: Fenway Institute. Collecting sexual
orientation and gender identity data in electronic health records. 2016.
November 25, 2016.
13. National LGBT Health Education Center: Fenway Institute. 2016. Building
patient-centered medical homes for lesbian, gay, bisexual, and transgender
patients and families. http://www.lgbthealtheducation.org/wp-content/
-2016-pdf/. Accessed November 25, 2016.
14. Healthcare Equality Index. Healthcare Equality Index (HEI). 2016. http://www
.hrc.org/hrc-story/. Accessed November 25, 2016.
15. National LGBT Health Education Center: Fenway Institute. Glossary of
LBGT terms for health care teams. http://www.lgbthealtheducation.org/
wp-content/uploads/LGBT-Glossary_March2016.pdf/. Accessed November
16. Gay Alliance. Safe zone: Train the Trainer Certification Program. 2016. http://
-certification-program/. Accessed November 25, 2016.
Jessica Landry, DNP, FNP-BC, is an Nursing Instructor in the School of Nursing at the Louisiana State University Health Sciences Center in New Orleans. She can be reached at [email protected] lsuhsc.edu. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.
1555-4155/17/$ see front matter
© 2016 Elsevier Inc. All rights reserved.
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- Delivering Culturally Sensitive Care to LGBTQI Patients
- The Staggering Statistics
- Health Disparities In The LGBTQI Community
- Understanding Gender Fluidity
- Providing Inclusive Quality Care
- Affirming Clinical Encounters