NursePractitionerKnowledgeAttitudesandBeliefsWhenCaringforTransgenderPeople.pdf

Nurse Practitioner Knowledge, Attitudes, and Beliefs When Caring for Transgender People Catherine Paradiso1,* and Robin M. Lally2

Abstract

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

transgender people.

Keywords: attitudes; beliefs; knowledge; nurse practitioners; transgender

Introduction

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

healthcare.1

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

Understanding’’

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.

47

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,

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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

individuals?

Project Design

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

Review Board.

Sample/participants

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

Subject

Years in nursing

practice Nurse practitioner

licensure Nurse practitioner years

Education

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

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Data collection

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

professionally transcribed.

Analysis

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

Rigor

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.

Results

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.

Knowledge gaps

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

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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

continuing education.

‘‘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

people.

‘‘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

#5)

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.’’

(Subject #5)

Another NP experienced in reproductive care

describes uncertainty and fear over providing

appropriate care.

‘‘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

#11)

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.’’

(Subject #4)

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 that he did not

misgender the patient when talking with him.

Growing pride and confidence in care

Acceptance, nonjudgmental attitude, and self-

education contributed to the NPs’ pride in personal

growth and confidence that allowed them to deliver

quality care to their transgender patients.

When possible, filling knowledge gaps and gaining

experience in caring for transgender patients boosted

NPs’ confidence, discussing important but very

sensitive subjects with patients, as in this example from

an NP, experienced in caring for transgender patients.

‘‘So I’ll say to my transgender females, I need to do a rectal

exam because I need to do prostate. For my transgender

males I’ll say, ‘I do need you to see gynecology because I do

need them to do a pelvic.’ So, it’s important to lay those lines

out, and they understand.’’ (Subject #5)

Creating an accepting environment

NPs in this study felt compassion, acceptance, and a

desire to show respect in caring for transgender

patients. One mainstay of nursing is the keen awareness

of how the environment sends loud messages, and how

all nurses should work to assure that the environment

sends messages that communicate acceptance, and

respect to all patients. NPs recognized that provider

offices and other places in the system may

unintentionally communicate exclusion and offend

transgender people.

NPs must meet people where they are

All the NPs described their wish to see transgender

patients treated the same as all people. ‘‘I think that we

should be open and listen to patients and investigate

certain things, so that we can help them through it.’’

(Subject #1) Another added, ‘‘I think that’s the most

important part., that we need to be able to accept those

patients and listen to them as they have some

concerns.’’ (Subject #7) Meeting people where they are

may be the goal, but at times NPs with limited

experience may create the uncertainty described in

preceding sections, and unintentionally be unable to

meet people where they are by misgendering. One NP

was enlightened by a patient’s experience during

transition, illustrating the patient’s personal struggle,

and the NPs not knowing where the patient was; so hard

to meet these patients where they are:

‘‘. a female who was transitioning to male and complaining

about what the testosterone was doing to her . how she was

feeling bossy and kind of, not nasty, ‘I feel very male, like

not happy male,’ and she didn’t know if she could because

what she thought of as nice behavior to people wasn’t

coming up in her brain and in her behaviors, .. That was very

mind opening and eye opening also. I never thought about it

that way.’’ (Subject #3)

In this example, the patient identifies as male, but the

NP is referring to the patient as female. While

misgendering may have no ill intention, when done

during an encounter creates stress for the patient. This

is an example of how lack of experience and knowledge

may impede good intentions.

The environment sends messages One mainstay of

nursing is the keen awareness of how the environment

sends loud messages, and how all nurses should work

to assure messages sent by the environment

communicate acceptance, and respect to all. NPs

recognized that provider offices and other places in the

system may unintentionally communicate exclusion

and offend transgender people. ‘‘The forms, all the

forms and the data that we enter do not give a choice;

it’s male or female, which is non-inclusive’’ (Subject

#5).

An experienced NP gave practical advice on sending

inclusionary messages in the clinical environment,

‘‘.. look at something as simple as your office. Are you

identifying your environment that you’re inclusive to

everybody, that you have two men, two women, a man and a

woman, this, that and the other, as simple as the picture, as

simple as the signage, as simple as education and looking at

the forms. NIH puts it well. I think they have male, female,

male to female and female to male on all the actual forms, or

you could just leave it blank and let them identify

themselves.’’ (Subject #5)

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Discussion

This study explored the knowledge, attitudes, and

beliefs of eleven NPs with varying degrees of

experience caring for transgender individuals. It

revealed NPs’ knowledge gaps that resulted in

uncertainty and fear while rendering care, an overall

caring attitude, knowing that the environment must be

inclusive, and a belief that NPs can and wish to render

quality care, but lack necessary tools. It also revealed

lack of education and availability of resources related

to transgender health. While some NPs had more

knowledge than others, most lacked comprehensive

knowledge and a full understanding of transgender

health issues. For example, some NPs in this study were

confused about anatomical changes, and several

confuse gender identity with sexual orientation. All

identified receiving no formal education or continuing

education and lacking awareness about what resources

are available for self-directed learning. All NPs found

the profession lacking a meaningful body of knowledge

or clinical experts readily accessible and available.

They were unaware of existing work and protocols by

The World Professional Association for Transgender

Health (WPATH) and other groups. All NPs in this

study described that personal and professional

knowledge deficits affected patient care, and that

improvements in graduate NP curriculum pertaining to

transgender health are necessary, as are continuing

education opportunities.

These results are consistent with and findings from

other studies.31 A recent publication22 found uncertainty

among physician providers, while another32 found

uncertainty among RNs caring for transgender patients.

These studies also revealed a lack of provider education

and experience in providing respectful care to

transgender people, which are barriers that perpetuate

existing disparities. Also, in accord with these studies,

was our study’s finding that NPs were aware that

patients felt discrimination in their previous

experiences with providers and had a desire to be

respectful in their practices.

NPs in this study were aware of the importance of

accepting of a person’s identity, feel compassion for

transgender individuals’ social plight, and possessed a

desire to understand the complexities involved in these

patients’ care. It was noted that even with NP growing

knowledge and experiences with transgender patients,

their use of language, such as, ‘‘[sexual] preference’’

as opposed to ‘‘orientation’’ and referring to a

transitioned person as an ‘‘it’’ revealed unconscious

biases. Some identified awareness of their own

potential to misgender or insult a patient. Subjects

wanted to convey respect, felt no bias in their heart, but

were aware that they could portray themselves

otherwise. This emphasizes the serious need for

training. According to the Association of American

Medical Colleges, education of students can work to

overcome these biases.33 Bias originates from

assumptions that are not accurate and are often

unconscious.33 While NPs in this study perceived

themselves as unbiased, not knowing that anatomical

changes or proper communication takes the form of

bias. Finding these biases among NPs who volunteered

for this study and who expressed interest in improving

their knowledge and welcoming transgender patients

leads to questions about biases held by NPs who may

be even less aware and committed to transgender care.

Lack of knowledge required delivering care with

more intention. The need for constant awareness of

their deficiencies was described by most of the NPs and

is present because they were aware that their lack of

experience could result in offending the patient.

Ultimately, the NPs described an environment in which

transgender patients and healthcare providers are not

always comfortable with each other. Patients sense a

lack of provider competence, and providers experience

discomfort with their own lack of knowledge. These

findings are consistent with patient experiences

identified by in the literature.21–23

This study offered the participants the opportunity to

self-reflect on the care they render. In doing so, they

identified that knowledge deficits and uncertainty

inhibit shared decision-making and full actualization of

NPs’ potential. The partnership between NP and patient

is fundamental to providing quality care and is

weakened if the NP partner is not prepared to inform,

educate, guide, and instill confidence. The partnership

is only strong when the NP recognizes the autonomy of

the patient, and the patient feels respected and

empowered with information and support to make their

own decisions. Even if the provider is knowledgeable,

an authoritarian approach will always weaken the

partnership.

Intention and desire to render inclusive care was a

strength held by these providers, but without education

and resources to develop clinical competence,

Paradiso and Lally; Transgender Health 2018, 3.1 55http://online.liebertpub.com/doi/11.1089/trgh.2017.0048

uncertainty, and fear resulted. The NPs worked to

create an accepting environment as best as possible

during encounters. However, they all identified that

more must be done to reduce invisibility of the

transgender patient. For example, some NPs worked in

environments that routinely cared for transgender

patients, so their knowledge included the need to have

inclusive signage, forms, pictures, and subordinate staff

who are properly trained. Other NPs worked in settings

where transgender patient encounters were rare, and

thus there were no system efforts toward inclusion.

Thus, there existed room for improvement.

NPs advocate for patients in systems where they

work, as members of professional associations, and in

communities where they live. Advocacy for

transgender people can be strengthened by knowledge

about and exposure to the population. Results of this

study point to a potential need to assist operational

leaders with resolving challenges, for example, are the

nondiscrimination policies strong and sufficiently

inclusive? Do we hold staff accountable for adhering to

them? How can we include nonbinary gender

identification in our Electronic Medical Records? How

can we participate in training ancillary staff? How do

we direct staff when identified gender or name and

existing demographic forms do not match? What public

policies need changes and how can NPs become

involved? Based on this study’s findings, addressing

such questions holds the potential to positively impact

the care of transgender people through increasing the

knowledge and ease with which NPs engage with

transgender patients.

This study is important, as it revealed the need for

more education and research in this field. Some

elements are very basic, such as knowing to

acknowledge, apologize, and correct mistakes in

communication when they occur. As NPs’ practice

scope expands and the openness of the transgender

community increases, more NP interaction with

transgender patients will result. Due to a sparse

evidence base, little is known about how NPs perceive

experiences with transgender patients and whether NPs

are able to provide quality, patient-centered care for

these individuals. It is important to know about NP

practice with this population so that NPs can

understand the transgender community, and provide

clinically competent care without judgmental attitude.

Also important are studies that investigate the

transgender patients’ experience with NP providers.

Best practices for health promotion and shared

decisionmaking strategies for this population should

also be researched.

Inexperience and unawareness weaken the role that

NPs play in the broader role of health promotion and

advocacy. NPs should lead the work of developing

national health promotion goals for transgender people.

Comfort with the population and evidence makes

robust health promotion and prevention plans possible.

Further implications of this study are not only for

NPs but also for nursing education as a whole. Based

on our findings, nursing curriculum should more

thoroughly prepare NPs to care for the transgender

population. Improvements in training for new NPs

about to enter practice and in continuing education for

practicing NPs is a necessity and must detail needs of

transgender people specifically, not be simply

addressed as diversity training for LGBTQ issues. Most

important is for NPs to reach understanding and

accepting of the many ways that people may identify

gender, and how to engage in respectful

communication to establish trust. Health risks of the

transgender community and where NP can find the

latest evidence-based resources should be part of each

NP’s lexicon. Education of all nurses presently in

practice, administration, education, and research are

essential to improve transgender care throughout

nursing and is the only way to change the culture of

healthcare now experienced by transgender people

from a place where they feel disregarded to one where

they are comfortable. Strategies to provide education

that is more inclusive has been identified,13,34 but more

is needed. NP programs need to include and test on best

practices from protocols, such as WPATH, with the

same approach as used with other clinical guidelines

and assure that all teaching materials are gender

inclusive.

Limitations

One limitation is that subjects were recruited from the

North East, with nine from NYC. Most subjects had

significant amounts of experience, so it was assumed

that their knowledge, attitudes, and beliefs had evolved

over time and were influenced by past experiences or

lack of experiences. Another limitation is that subjects

might have been hesitant to disclose negative attitudes

because of the public attention toward the community

Paradiso and Lally; Transgender Health 2018, 3.1 56http://online.liebertpub.com/doi/11.1089/trgh.2017.0048

and because these attitudes are counter-instinctual and

not acceptable for nurses.

Conclusion

Discrimination toward transgender people continues to

be widespread. Discrimination and bias in healthcare

delivery, even if unintentional, contributes to and

supports the disparity in care. Findings in this study

show that despite a desire to provide care, lack of

experience with and education about transgender

healthcare limit NPs in their role, potentially causing

them to be among the group of providers who

unintentionally support existing disparities. There is a

dearth of evidence in peer-reviewed nursing literature

for NPs to use when caring for transgender people.

Knowing what is important to patients, how to properly

communicate, and knowing what health conditions

people are most at risk for are basics in the provision of

care for all people. Ultimately, nursing must begin to

research transgender issues and teach all levels of

nurses, through graduate nursing education on quality

care for transgender people to eliminate current

disparities in care.

Acknowledgments

The author acknowledges the contributions by Justin

M. Waryold, DNP, RN, ANP-C, ACNP-BC, CCRN,

CNE, Clinical Assistant Professor, Director of the

Advanced Practice Nursing Program in Adult Health

Department of Graduate Studies, Adult Health Stony

Brook University School of Nursing for his review of

and contributions to the final article.

Author Disclosure Statement No

competing financial interest exists.

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