One responsibility of healthcare providers involves creating a welcoming and nonjudgmental environment for every patient. Still, transgender individuals — people whose gender is different than the one assigned at birth — and gender nonconforming (GNC) patients continue to face challenges and prejudice in healthcare settings.

Nurses have an especially important role in providing an affirming space for transgender people. Many patients confide in nurses, sometimes finding them more trustworthy than physicians. In fact, nursing has consistently ranked as the most honest and ethical profession for the past two decades, according to Gallup polls.

More and more nurses wish to provide a comfortable environment for all their patients, including those who are transgender or GNC. However, this can feel challenging for nurses without a great deal of experience caring for this community, especially because they have not had adequate or appropriate educational resources.

This guide aims to help nurses better understand the transgender and GNC community, the hurdles they might face in healthcare, and helpful steps on working with transgender and GNC patients.

Healthcare Barriers to Transgender Patients

For many transgender patients, healthcare can be an intimidating — and often inaccessible — environment.

Transgender people are more likely to be uninsured than cisgender patients, those who are gendered correctly at birth or those who are not transgender. This can restrict their access to healthcare with high costs. According to an analysis by the Kaiser Family Fund, 19% of transgender adults reported not possessing health insurance compared to 12% of the cisgender population. Another 19% reported encountering cost-related barriers to receiving care. Only 13% of cisgender adults encountered these barriers.

[them and misusing] their pronouns, [or] misnaming them if they are referred by a name different than their legal name."

For instance, without the sensitivity and consideration needed to communicate concerns relating to transgender patients, some healthcare providers may accidentally out transgender patients to their families and friends, risking the patient's health and safety.

In addition to emotional and financial barriers, transgender people also face outdated polices and processes modeled for heterosexual and cisgender patients.

According to Desiree Díaz, Ph.D., associate professor at University of Central Florida's College of Nursing, these distressing experiences can lead to transgender people avoiding necessary appointments and procedures.

"Transgender patients often delay care due to past experiences when attempting to access care," Díaz says.

Healthcare Biases and Discrimination

Often healthcare providers do not intentionally or maliciously misgender patients or make them feel alienated. The problem roots from broader systemic issues, meaning, among many things, that some nurses and other healthcare professionals have been socialized or taught to believe that being transgender or GNC is wrong so they might not want to treat or support trans and GNC patients.

Another systemic issue is that the healthcare system can disproportionately harm trans and GNC patients due to biases, stigmatization, and outdated policies. Even those who do wish to provide competent care do not necessarily have the training to adequately care for transgender patients.

Additionally, broad-based hostility and discrimination can limit the number of transgender and GNC people who pursue a nursing career which would bring lived experience to the field. Systemic issues have also resulted in a lack of research on transgender patients in healthcare.

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"I believe that there are many nurses and providers who want to do the right thing and provide affirming care, but don't have the support of their organization for training," says Kristie Overstreet, Ph.D., who works as a clinical sexologist, psychotherapist, and LGBTQIA+ healthcare expert.

Greater education and training for working with transgender and GNC people is one solution to this problem. Another is acknowledging biases, then taking action to eliminate or lessen the potential harm those biases can cause.

For example, healthcare providers may make assumptions because of internal biases that can lead to mistakes about medical transitioning or taking sex and gender as the same. Some transgender people face more direct discrimination, such as providers refusing to treat them or calling them by a legal name they do not use because of the providers' personal beliefs.

Considerations for Creating a More Supportive Environment

Once nurses understand their own biases and learn more about transgender and GNC individuals, they can take steps to provide affirming healthcare spaces for people in these communities. Remember: Each person and their individual situation is unique, so consider these considerations as general guidelines.

"In general, it is not acceptable to ask about people's genitals or gender-affirming surgeries or hormone therapy or other details about medical or nonmedical transition, or lack of transition," explains Dasuqi.

If these details are directly relevant to a patient's care, ask in a careful and sensitive manner. Do not share this information with other healthcare staff unless it is medically necessary.

"Healthcare staff should assume this information is very personal and should inform patients ahead of time when it will be necessary to share information about their body to other healthcare providers for the purpose of medical treatment," Dasqui says.

Ask open-ended questions, but make sure you do so in a direct but sensitive way. You can ask about a person's gender, but be mindful how you ask about their sex.

"More direct questions that are relevant are often more appropriate," Dasuqi advises, "such as 'can you tell me more about what kind of genitalia you have and the symptoms you are experiencing there.'"

If you are unsure about something regarding a person's gender, seek clarification instead of making assumptions.

Make note of your patient's pronouns.

Use the terms your patient uses when referring to themselves and their partner(s). Your patient may use he/him/his, she/her/hers, they/them/theirs — even if they present more stereotypically feminine or masculine. Others may use less common pronouns like ze/hir/hirs or ze/zir/zirs, so always ask before addressing them.

You can also make transgender and GNC patients feel more comfortable by introducing yourself with your own pronouns.

"Because most forms still require healthcare workers to fill out the sex of an individual, they should know that this question can be painful or triggering for transgender and gender nonconforming individuals to answer," says Dasuqi, adding that nurses and healthcare workers should be ready to offer support and understanding in these situations.

Sometimes, a patient's name and gender may not match what is listed on their insurance or medical records. Should you need to cross-check a patient's identification information, never ask what their "real" or given name is. Instead, the LGBT National Health Education Center recommends asking the patient what the name on their insurance is and confirming their date of birth and address, then continuing to address them by the name they originally provided.

You can find a guide on how to do so here, and templates here from the National LGBT Health Education Center.

As Overstreet says, "A patient's gender identity is one part of them, so be sure to care for them as a whole person and not inflate or narrow their identity."

In other words, consider a patient's transgender or GNC identity within their larger cultural, emotional, physical, and psychological being.

"Cultural congruence is important when caring for all people but specifically the LGBTQ+ population," Díaz adds. "This means understanding how culture pertains to … respecting the intersection."

If you hear your coworkers misgendering patients or making transphobic comments, do not be afraid to speak up. You can also be a patient advocate on issues like gender confirmation surgery and fertility treatments.

Creating More Equitable and Gender-Affirming Care in Nursing

"Health equity is the most important concept. It is about providing safe care to all people regardless of sexual preference, orientation, or identity," Díaz says.

Equity within the healthcare space requires buidling a safe, nonthreatening environment for all patients, including those who are transgender. The ultimate goal, according to Dasuqi, is creating a healthcare system in which transgender patients would not have to worry about being treated like special cases.

"It is about shifting the systems and social conditioning on wider levels to include the trans and GNC experience as part of what is normal, rather than always an exception," Dasuqi concludes.

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