A Nurse’s Guide in Caring for Transgender and Gender-Variant Youth

Abstract

With the increasing number of transgender youth and families seeking medical care, they often turn initially to their primary care provider, pediatrician, or nurse practitioner for guidance. Creating and maintaining a positive identity is a developmental step for all adolescents; however, trans youth have the additional challenge and pressure of integrating a non-conforming gender identity with their cultural and ethnic backgrounds, personal characteristics, and family circumstances. This places pediatric healthcare providers in a unique position to guide and support gender-variant children in discovering their authentic self, which requires critical thinking pertinent to all the multidimensional and multicontextual factors that contribute to one’s well-being.

However, there is a limited number of knowledgeable and competent healthcare providers who can adequately meet the needs of this vulnerable pediatric population. Significantly, providers' lack of awareness regarding gender development and trans healthcare is one of the most significant and life-threatening barriers that perpetuate existing health disparities. By improving trans-health competency and practice, providers have the ability, knowledge, and power to help address these health disparities and close the gap.

In exploring the different perspectives of patients, caregivers, and health professionals regarding gender development and gender-affirming care, this article utilizes research with a multidisciplinary approach to guide nurses and other providers on how to deliver competent transgender healthcare. Introduction: It is estimated that 1 to 2% of the United States population identifies as transgender, or gender nonconforming. These statistics could be higher, given the increasing population of transgender youth and underreporting of trans individuals (GLAAD, 2017). A 2016 Harris Poll conducted by GLAAD found that the millennial generation (ages 18-34) is more likely to identify as transgender or gender nonconforming than previous generations are. Prior studies estimate the prevalence of transgender youth varying from 1 to 3.5% within the general population (Torres et al., 2015). This increase has led to the expansion of gender transition clinics for children and endocrinologists delving into the practice of transition medicine for children. The first people transgender youth and their families turn to when seeking guidance related to transition needs, or simply reaching out for more information related to gender nonconformity, are their primary care providers, pediatricians or nurse practitioners.

Unfortunately, many providers report a lack of knowledge or do not feel competent to adequately meet the needs of these pediatric patients (Gridley et al., 2016; McDowell & Bower, 2016; Paradisio & Lally, 2018; Torres et al., 2015). Considering the different perspectives of patients, caregivers, and health professionals regarding healthcare barriers, this article utilizes research with a multidisciplinary approach to guide nurses and other providers on how to deliver competent transgender healthcare. By providing foundation and context, we aim to enlighten pediatric nurses and other pediatric providers to join the discussion, advocate for equitable and inclusive healthcare atmospheres, and render gender-affirming care for gender nonconforming patients. In improving trans-health competency and practice, providers will have the ability and power to help address health disparities and improve health outcomes. As affirming a child’s gender identity is paramount for healthy growth and development, pediatric nurses and other providers are in the unique and important position to provide gender-affirming care. In providing trans-competent care, nurses and other providers must first and foremost recognize their biases and assumptions about gender (i.e., gender as fixed and binary vs. fluid on a continuum and the degree to which gender identity is malleable by external factors vs. something that can only be realized by the individual), and strive to stay current with the evolving science of gender identity and development (Edwards-Leeper, Leibowitz, & Sangganjanavanich, 2013).

While creating and maintaining a positive identity is a developmental step for all adolescents, trans youth, however, have the additional challenge and pressure of integrating a non-conforming gender identity with their cultural and ethnic backgrounds, personal characteristics, and family circumstances (Grossman & D’Augelli, 2006). Facing levels of stigma, social ostracizing, and abuse, transgender children and adolescents represent a particularly vulnerable population, the health of which is at stake. In a Canadian study examining transphobia in the education system, 90% of transgender students heard transphobic comments on a daily or weekly basis from classmates and 78% of transgender students indicated feeling unsafe at school (Bonifacio, 2015). Experiences of bullying, stigma, and social ostracization correlate with negative health outcomes, leaving trans youth at much higher risk for developing depression, anxiety, substance abuse, self-harm behaviors, and suicidal ideation (Bonifacio, 2015; Cierco & Wesp, 2018; Olsen et al., 2015). Similarly, the 2015 U.S. Transgender Survey (USTS) indicates that while the suicide attempt rate for the general population is 4.6%, of the 27,715 transgender people surveyed, 40% have attempted suicide. Furthermore, 39% of the sample reported that their first attempt occurred between the ages of 14 and 17 (James et al., 2016). The fact that suicidal ideation increases as youth reach adulthood indicates that there is a significant health disparity among transgender youth and throughout their lifespan.

In a study (2006) exploring factors that affect experiences of transgender youth, researchers Grossman & D’Augelli identified four key issues related to their vulnerability within the healthcare system: (1) the lack of safe environments, (2) poor access to physical health services, (3) inadequate resources to address their mental health concerns, and (4) a lack of support from their families and communities. Similarly, in a more recent study revealing transgender youth and caregiver perspectives on barriers to gender-affirming care, researchers identified similar barriers as those found in the 2006 study, with exceptions regarding inconsistent use of name/pronouns and insurance exclusions (Gridley et al., 2015). Evidence shows these barriers continue to exist throughout the decade, indicating that our healthcare system has yet to effectively close this critical gap. In fact, the 2011 National Transgender Discrimination Survey (NTDS) reported that 19% of transgender adults were refused medical care, 28% experienced harassment or violence in medical settings, 28% delayed medical care due to discrimination, and 50% had to teach their medical provider about transgender care (Grant et al., 2011). Findings also indicate that instances of discrimination occur more frequently when providers are aware of their patients’ transgender identity (Grant et al., 2011).

Furthermore, when healthcare providers refuse to care for transgender adults, suicide attempt rates significantly increase from 40% to over 60% (Haas, Rogers, & Herman, 2014; Cierco & Wesp, 2018). Although there are limited comparative studies regarding the trans youth population, research reveals that many trans youth who would benefit from gender-affirming care — including mental health referrals and medical interventions (i.e., puberty blockers and cross-sex hormones) — rarely receive them (Gridley et al., 2016; Grossman & D’Augelli, 2006). The Institute of Medicine (IOM) identifies stigma, discrimination, and lack of provider knowledge as key barriers contributing to health disparities among the trans population. Therefore, it is our responsibility as nurses to expand our understanding and to reflect on our own biases in order to competently meet the physical, psychological, and psychosocial needs of our transgender patients (Paradiso & Lally, 2018). In a qualitative study researching nurse practitioners' knowledge, attitudes, and beliefs when caring for transgender people, Paradiso and Lally (2018) revealed that although NPs have an overall caring attitude and wish to provide quality care, they lack the education and knowledge related to transgender health.

As a result, the child and their families often have the burden of educating their provider about "what it means to be transgender" (Torres et al., 2015; Paradisio & Lally, 2018). Similarly, in another study on healthcare providers' comfort towards trans-care barriers (Vance, Halpern-Fisher, & Rosenthal, 2014), researchers found that despite increased awareness for the need for comprehensive medical and mental healthcare, pediatric and adolescent providers report a lack of confidence in their ability to care for this population. Both studies support the claim that knowledge deficits, lack of resources, and lack of experience contribute to providers' lack of confidence, discomfort, uncertainty, and bias, even if unintentional. Consequently, this lack of awareness regarding transgender individuals and transgender healthcare is evidently one of the most significant and threatening barriers that actually perpetuate existing health disparities. Considering the different perspectives of patients, caregivers, and health professionals in regard to healthcare barriers, we aim to utilize the research with a multidisciplinary approach to guide nurses and other primary care providers on how to break down these barriers and deliver competent trans-care. Table 1 illustrates how unhealthy environments impact well-being — a key aspect of trans-competent care.

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