When dealing with any patients, nurses want to be respectful. But there may be some confusion as to what they should do or say when treating patients who are transgender or genderqueer. Jennifer Flynn, CPHRM, Risk Manager with the Nurses Service Organization (NSO), answered our questions on this topic. Following is an edited version of our interview.
How should a nurse find out if a patient is transgender? How should the discussion begin?
A nurse may or may not know whether a patient is transgender or genderqueer, and depending on their role, a nurse may not need to know a patient’s gender identity. For example, if a patient is presenting with an upper respiratory issue, there is no medical need to find out a person’s gender status or to perform a genital exam.
The patient’s health care record may indicate their gender status and preferred name, or the information in the health care record may be out of date or incomplete. If a nurse is unsure about a person’s gender identity, or how they wish to be addressed, ask politely for clarification. You can ask “How do you prefer to be addressed?” or “What is your preferred name?” In the interest of facilitating a good provider-patient relationship, with any patient, it is important not to make assumptions about patients’ identity, beliefs, concerns, or sexual orientation.
How should a nurse approach the subject of which gender the patient identifies as and which pronoun to use? When the nurse finds out, should s/he be the one to tell every other health care worker who will see the patient? Or will it go in the patient’s chart? Or should the nurse do both? Why?
Ideally, a two-step question would be included on patient intake and registration forms that asks patients to indicate their current gender identity as well as the sex they were assigned at birth.
Patients may have a variety of responses to these questions. The most important thing for patients to know is that these questions are designed to ensure that every patient is able to get the health care they need. Asking questions about sexual orientation and gender identity in the demographics section of registration forms communicates to patients that the health center recognizes them and understands their health care needs. It is best practice to document each patient’s name used and pronouns.
This information will be included in that patient’s health care record, which is protected under HIPAA privacy laws. Never disclose a person’s gender status to anyone who does not explicitly need the information for care. If disclosure is relevant to the patient’s care, use discretion and inform the patient whenever possible.
Suppose a transgender person prefers to use “they”? How should a nurse approach that?
Use the patient’s preferred pronoun, even if they prefer the non-gender-specific “they.”
What are some of the care challenges for transgender patients?
- Many transgender and gender nonconforming people delay or avoid seeking medical treatment because they fear they will be discriminated against, humiliated, or misunderstood.
- Mental health concerns (depression, anxiety, substance abuse, gender dysphoria, which represents the distress that being transgender causes, etc.)
- Sexual health history (do not assume heterosexual relationships or that every sexually active person requires contraception) – focus on behavior and associated risks such as STI’s and HIV
- Transgender and genderqueer individuals experience a higher rate of violence and victimization – health providers should screen patients
- Appropriate health screenings (mammograms, Pap smears, prostate cancer screenings, etc.)
What are the legal and regulatory requirements?
Under the Affordable Care Act, it is illegal for any health program, provider, or organization that gets any federal funding (including accepting Medicare or Medicaid payments for any patients) or is administered by a federal agency to discriminate against transgender or gender nonconforming patients. For example, it is illegal for a health care provider to force a patient to have an intrusive and unnecessary examination because of their gender identity.
The Health Insurance Portability and Accountability Act (HIPAA) requires health care providers to protect patients’ privacy. Information about gender status, including diagnosis, medical history, sex assigned at birth, or anatomy, can be considered protected health information. Such information should not be disclosed to anyone without the patient’s consent. This information should also not be disclosed to other medical staff members unless there is a medically relevant reason to do so. If this information is shared for purposes of gossip or harassment, it is a violation of HIPAA and could lead to serious legal consequences.
What does is mean for a nurse to be culturally competent regarding transgender patients?
As nurses, it is important to be culturally sensitive to all patients, respective of diversity, and appropriate with care. When caring for patients who are transgender, the first step is for the nurse to be aware of any potential bias which may create or contribute to providing quality care.
Steps to take about caring for these patients in an appropriate, culturally-sensitive manner, include, but are not limited to, these recommendations on creating a welcoming environment:
- Expand your knowledge about sexual orientation and gender identity
- Communicating with transgender patients: Know what the terms mean
- Create a welcoming environment for transgender patients
- Use inclusive, gender-neutral language
- Convey respect
Having as positive and affirming an experience as possible will make it more likely the individual will seek future care. The quality of a nurse’s interaction can truly make a difference in your patient’s health.
What else should nurses know—overall—about treating transgender patients?
Standards of care can help ensure your practice is evidence-based, an important consideration both for optimal patient outcomes and for protection in the case of legal action. For instance, not understanding the risks associated with hormone therapy could result in patient harm and subsequent court case.
If your patient has an issue with you or another provider or staff member, be sure to address it promptly, before it escalates. Document the issue and its resolution in the patient’s health record.
Whether it’s intentional or inadvertent, discrimination against transgender patients happens too often in health care settings. We encourage nurses to ensure that transgender patients receive the care they deserve by being knowledgeable about their needs, treating them with respect, and advocating that all staff treat them with respect as well. Doing so improves care, helps avoid legal action, and promotes ethical behavior.