An experienced operating room nurse shared an incident involving the care of a transgender patient who appeared masculine. The nurse assumed the responsibility of speaking with him after other members of the healthcare team expressed discomfort about conveying the need for a clinically relevant pregnancy test. According to facility policy, pregnancy tests are to be performed on patients of a certain age who still have their uterus prior to surgery.
Another patient reported seeing a covering provider for continued symptoms of a recent COVID-19 illness only to be repeatedly misgendered and asked unrelated invasive questions about distant gender-affirming surgery. This left the patient uncomfortable, unseen, and unlikely to follow up with this provider again.
These are both snapshots of some of the challenges transgender or gender-diverse patients experience in their care. These types of experiences add to the hesitancies of the patients to seek medical care, which further complicates the healthcare disparities within the community, including mental health disorders, eating disorders, and sexually transmitted infections (Sherman et al., 2018). There is still a lot of work to be done for healthcare professionals to gain transgender or gender-diverse patients' trust in their care.
As nursing professional development (NPD) practitioners, we are positioned to equip staff with clinical skills and empower them to offer care that respects all patients' identities. As we celebrate LGBTQ+ History Month, we will briefly examine the history of gender-affirming care, explore the role of NPD specialists in addressing knowledge gaps, and discover how our education, mentorship, and leadership skills can foster a more inclusive healthcare environment and better patient outcomes.
Brief Evolution of Gender-Affirming Care in the United States
In the United States, the first gender-affirming surgery was in 1917 (Horton, 2022). The United States' first gender-affirming surgery clinic was opened in 1966 but then later closed in 1979 in response to the claim that gender-affirming medicine was ineffective. Politics, transphobia, and poor surgical outcomes due to early surgical techniques were also noted as contributors to its closure (Magrath, 2022).
The Diagnostic and Statistical Manual of Mental Disorders (DSM-III), the standard for mental health diagnostics, included the new diagnosis of gender identity disorder in 1980 (AMA, 2023). Eventually, in 2013, this was replaced with "gender dysphoria," which shifted the focus on individuals or identities to that of gender identity-related distress (APA, 2024). Gender dysphoria is defined as a "marked incongruence between experienced or expressed gender and the one assigned at birth" (Garg et al., 2023).
In 1999, the World Professional Association for Transgender Health (WPATH) issued its Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People. This resource outlined the "professional consensus about the psychiatric, psychological, medical, and surgical management of gender dysphoria" (Knudson et al., 2016). WPATH is currently on its eighth edition of its standards of care, now named Standards of Care for the Health of Transgender and Gender Diverse People and serves as the most widely used clinical guidance for gender-affirming care.
Today, with updated evidence-based interventions, there are several healthcare facilities and clinics that are available to support gender-affirming care for the 1.6 million people who identify as transgender in the United States. Gender-affirming care is linked to lower psychological distress and suicidal ideation (Almazan & Keuroghlian, 2021). Nurses and, subsequently, NPDs play a crucial role in ensuring safe, respectful, and affirming care.
Environmental Scanning: Identifying Practice Gaps and Learning Needs
There are significant gaps in knowledge and practice regarding gender-affirming care. Nurses report lacking familiarity with clinical protocols, such as hormone therapy or post-operative care for transgender patients. They may also feel unsure about appropriate nursing interventions that align with gender-affirming treatment, how their treatment intersects with other aspects of their care, how to ask questions, as applicable, about their gender and sexual health, or simply how to navigate the use of correct pronouns. (Carmichael et al., 2024).
Data from patient feedback, clinical performance reviews, and healthcare outcomes also provide insights into where additional training is required. By identifying these gaps, NPD specialists can design targeted interventions that directly address the learning needs of nursing staff, ensuring that education is relevant and impactful.
Transgender and gender-diverse patients experience health inequities, including higher rates of stress, depression, suicidal ideation, substance use, and sexually transmitted infections when compared to the general population. For us to successfully partner for better outcomes with our patients, we in healthcare will need to have more familiarity with the needs of our transgender and nonbinary patients (Carmichael et al., 2024).
Facilitating Learning and Leading Change
Effective education on gender-affirming care involves creating content and an environment that examines the physiological, social, and emotional aspects of patient care. Nurses need to feel confident in addressing the holistic needs of transgender patients, which requires a combination of evidence-based clinical knowledge and cultural humility.
Training programs should be tailored to the organization's needs. Content could include the latest gender-affirming care options and appropriate nursing interventions. Strategies such as simulation can help nurses practice inclusive language and avoid misgendering. Using well-designed patient panels can also enhance understanding of the patient's lived experience. Following guidelines from reputable organizations—such as the WPATH and the University of California San Francisco Center of Excellence for Transgender Health—in creating these courses ensures that programs are based on current clinical standards.
Mentorship and Advocacy
Nurses benefit from ongoing support as they navigate the complexities of gender-affirming care. NPD specialists can serve as mentors, offering guidance and encouraging reflection on how nurses can examine their biases, engage in self-awareness, and practice cultural humility.
As NPD practitioners, we can also serve as advocates. We are well-equipped to develop partnerships that foster inclusive and affirming care environments. One example of how we can do this is by working with our leadership to implement policies and practices promoting inclusivity, such as ensuring that patient intake forms allow for accurate gender identification and inclusive reproductive assessments. Once processes are developed, we can support clinical staff using these new tools to promote inclusive care. Such systemic changes help create a culture of respect and inclusivity, directly improving patient outcomes.
Measuring Impact and Outcomes
Healthcare provider confidence, positive patient feedback, and improved clinical outcomes are all indicators of the effectiveness of the educational programs and systemic changes implemented. Transgender patients who feel respected and supported by their healthcare providers are likelier to engage in regular care, leading to better health outcomes and a stronger patient-provider relationship (Kcomt et al., 2020).
The Road Ahead: Overcoming Challenges and Seizing Opportunities
While progress has been made, challenges remain. Resistance to gender-affirming care from within healthcare systems, whether due to bias or a lack of understanding, can slow the pace of change. A nurse leader recently reported that during an initial presentation to hospital personnel about the concepts and principles of gender-affirming care, some of the staff expressed strong feelings of discomfort about the topic, even saying that they do not need to talk about it since everyone should be "treated the same." Another person remarked on the increasing number of choices regarding gender, from the previous choices of only male or female.
NPD practitioners can support learning by discussing the importance of individualized care to better patient outcomes. Continued advocacy and education are essential to overcoming these obstacles, as is addressing implicit biases among healthcare providers. Introductory and ongoing education on the care of transgender and nonbinary patients should explore implicit and explicit biases and how they are manifested in the way that these individuals experience healthcare. There are several ways to achieve this, such as presenting statistics that focus on the healthcare experiences of gender-diverse patients, reading letters from transgender or gender-diverse patients about their experiences, and creating a safe environment for a patient or patient panel to share their experiences with the help of an experienced facilitator.
Additional areas to consider for continued education include gender diversity, communication, and a review of available gender-affirming care.
Conclusion: Leading the Future of Inclusive Nursing Practice
NPD specialists have a unique role in shaping the future of gender-affirming care by identifying practice gaps, facilitating meaningful learning, mentoring nurses, and advocating for systemic change. This will lead to patients receiving evidence-based, respectful, and affirming care. Ultimately, it is about creating a healthcare environment where patients feel valued, respected, and seen.
Resources for NPD Specialists on Gender-Affirming Care
World Professional Association for Transgender Health
Resources: Standards of Care, International Journal for Transgender Health, Scientific Symposiums, and the Global Education Institute
Website: https://www.wpath.org/
National LGBTQIA Health Education Center
Resources: Distance Learning, Conferences (Transgender Health and Gender Minority Health), toolkits, and CMEs available
Website: https://www.lgbtqiahealtheducation.org/
References
- Almazan, A., & Keuroghlian, A. (2021, July 1). Association between gender-affirming surgeries and mental health outcomes. JAMA Surgery. https://doi.org/10.1001/jamasurg.2021.0952
- AMA J Ethics. 2023;25(6):E383-385. doi: 10.1001/amajethics.2023.383.
- American Psychological Association. (n.d.). A guide for working with transgender and gender nonconforming patients. Psychiatry.org - A Guide for Working With Transgender and Gender Nonconforming Patients. https://www.psychiatry.org/psychiatrists/diversity/education/transgender-and-gender-nonconforming-patients
- Carmichael, T. , Copel, L. & McDermott-Levy, R. (2024). Effect of an Education Intervention on Nursing Students' Knowledge of and Attitudes Toward Caring for Transgender and Nonbinary People. Nurse Educator, 49 (5), 268-273. doi: 10.1097/NNE.0000000000001600.
- Kcomt, L., Gorey, K. M., Barrett, B. J., & McCabe, S. E. (2020). Healthcare avoidance due to anticipated discrimination among transgender people: A call to create trans-affirmative environments. SSM - Population Health, 11, 100608. https://doi.org/10.1016/j.ssmph.2020.100608
- Knudson, G., Tangpricha, V., Green, J., Bouman, W. P., Ettner, R., Adrian, T., Allen, L., DeCuypere, G., Hansen, T. M., Karasic, D., Kreukels, B., Rachlin, K., Schechter, L., & Winter, S. (2016, December 21). Position Statement on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A. World Professional Association for Transgender Health- Position Paper. https://wpath.org/media/cms/Documents/Insurance Training/WPATH Position on Medical Necessity 12-2016.pdf
- Harper, M. G., & Maloney, P. L. (2022). Nursing professional development: Scope and Standards of Practice. Association for Nursing Professional Development.
- Horton, K. (2022, June 30). Meet oregonian dr. Alan Hart, who underwent the first documented gender-confirming surgery in the US. opb. https://www.opb.org/article/2022/06/30/oregon-us-gender-affirming-surgery-history-dr-alan-hart-lgbtqia-history/
- Magrath, W. J. (2022). The fall of the nation’s first gender-affirming surgery clinic. Annals of Internal Medicine, 175(10), 1462–1467. https://doi.org/10.7326/m22-1480
- Sherman, A. D. F., McDowell, A., Clark, K. D., Balthazar, M., Klepper, M., & Bower, K. (2021). Transgender and gender diverse health education for future nurses: Students’ knowledge and attitudes. Nurse Education Today, 97, 104690. https://doi.org/10.1016/j.nedt.2020.104690
Disclaimer: The views and opinions expressed in this article are solely those of the contributor and do not necessarily reflect the official policy or position of ANPD.
Jezrel B. Badoy, MSN, RN, NEA-BC
NCAL Clinical Program Manager, Perioperative Services, Kaiser Permanente
Jezrel Badoy was born and raised in the Philippines and relocated to the US in the early 2000’s. She has worked in various fields of nursing, from being a nursing clinical instructor to collaborating with the Philippine government to support directly observed treatment chemotherapy (DOTS), an anti-tuberculosis program which also leveraged community involvement.
Badoy's current primary expertise is perioperative nursing, having been an OR nurse for more than 20 years. At Stanford Hospital, she was formally exposed to improvement work and eventually obtained a certification as Lean Six Sigma Black Belt from Villanova University. Badoy served as operating room manager at a Kaiser Permanente (KP) facility before assuming the current role of clinical program manager, supporting more than twenty KP perioperative facilities in Northern California.
Misty Cahoon, MSN, RN, NPD-BC
Professional Development Specialist, UC Davis Medical Center
Misty Cahoon MSN, RN, NPD-BC, has 21 years of nursing experience, and her journey has taken her to the bedside, leadership, and education. She completed her undergraduate studies in psychology and nursing at the University of Massachusetts Amherst and earned a Master of nursing degree from the University of Texas Arlington.
Cahoon has clinical experience in orthopedics and oncology, as well as experience in quality and safety. She has worked in education for the past 8 years and is currently a program co-coordinator for the Rising Nurse Leaders. Cahoon has a strong passion for promoting diversity, equity, and inclusion. She is actively involved in several initiatives in her workplace, including serving as the education officer for UC Davis Medical Center’s Pride Employee Resource group, being a member of the UC Davis Health Staff Advisory Committee on Equity, Diversity and Inclusion, a member of the Vice Chancellor’s LGBTQ+ Advisory Council, and nationally as a member of the Association for Nursing Professional Development’s Diversity, Equity, and Inclusion Committee.