Chapter Eleven – Section 3: Gender-Affirming Care
Practical Application: Book Activity
Practical Application
Setting the Scene
The City of San Francisco has distinguished itself as a national leader in addressing the needs of the transgender community. Under the leadership of executive director Theresa Sparks, who is transgender, The San Francisco Human Rights Commission has led various groundbreaking efforts to prevent anti-transgender violence and reduce the vast disparities faced by members of the transgender community.
One of the city’s flagship initiatives has been trans-inclusive universal healthcare for all residents of San Francisco, which includes all medically necessary transition-related care free of cost to transgender people, care that has a limited-to-no impact on the city’s budget but would be prohibitively expensive for many individuals.
In the last year alone, San Francisco has also allocated $2 million in funding to local service providers for programs working specifically with transgender residents. These programs include an employment program that has provided training and job placement for 200 transgender people in the last couple of years, the creation of a Trans Advisory Council for the city, and an HIV prevention program aimed at eliminating HIV transmission in the transgender community by the year 2020.
The city also has programs to support transgender women of color in prison and help facilitate their reentry into society following incarceration, which, according to Sparks, has cut the recidivism rate among those who have participated in the program to about 20%, compared to a statewide average of more than 50%. San Francisco is also taking direct aim at the issues of anti-transgender street violence and domestic violence. Earlier this year, the Human Rights Commission published an LGBTQIA+ Community Violence Assessment report along with 15 other community organizations and has allocated funding for implementing and tracking the report’s recommendations. The city has also started a violence prevention program for transgender Latinas, one of the city’s most marginalized groups (Human Rights Campaign, 2015).
Think About It
- Does your area offer similar programs to support the health and well-being of trans people in employment, healthcare, or safety? How did you locate these programs?
- As a nurse, what actions can you take to ensure you provide safe and supportive care for trans patients?
- In your health care practice, you have a colleague misgendering a patient. How do you react?
Practical Application: Additional Guidance
Exercise Title
Exploring Local and Personal Strategies for Supporting Transgender Patients
Objectives
- Compare local transgender support programs with those in San Francisco.
- Develop strategies to ensure safe and supportive care for transgender patients.
- Learn how to address and correct misgendering in a professional setting.
Preparing for the Exercise
- Review the Chapter Material:
- Review the case study on San Francisco’s support programs.
- Gather Resources:
- Ensure students have access to research tools for locating local transgender support programs.
- Familiarize yourself with best practices in transgender healthcare.
- Preparing materials:
- Prepare role-playing scenarios and handouts.
Exercise Components
- Research and Discussion (30 minutes)
- Activity: Research Local Programs
- Have students research and identify any similar programs in their area that support the health and well-being of transgender people. This can include employment support, healthcare, or safety initiatives.
- Provide guidance on how to locate these programs (e.g., local LGBTQIA+ organizations, health departments, online resources).
- Activity: Class Discussion
- Discuss findings as a class. Ask students to present examples of local programs, how they compare to those in San Francisco, and what gaps might exist in their own communities.
- Activity: Research Local Programs
- Conclusion (5 minutes)
- Summarize the key points discussed during the activity.
Evaluation and Assessment
- Student Participation:
- Assess students’ participation in discussions and role-playing activities.
- Review their ability to identify and compare local transgender support programs.
- NCLEX Questions: Review responses to NCLEX-style questions to assess understanding of key concepts.
Integration into Curriculum
- Alignment with Course Objectives: Integrate evidence-based strategies to address gender-affirming care into nursing courses.
- Sequencing: Incorporate this activity into a broader unit on cultural competency and LGBTQIA+ healthcare.
- Integration of Theory and Practice: Use the role-playing exercise as part of training modules on communication skills and patient advocacy.
Resources and Support
- Learning Resources:
- Provide students with access to resources on best practices for transgender healthcare.
- Share links to local LGBTQIA+ organizations and support networks.
- Recommend additional readings on cultural competency and inclusivity in healthcare.
- Faculty Support: Offer guidance, feedback, and support to students as they engage in the exercise, addressing any questions or concerns they may have about the scenario or related topics.
- Summarize key learnings from the research and role-playing activities.
- Emphasize the importance of creating an inclusive and supportive environment for transgender patients.
- Encourage students to continue exploring ways to improve care for all patients, with a focus on marginalized communities.
Conclusion
This exercise provides a structured approach to understanding and supporting transgender patients, with activities designed to engage students in meaningful discussions and practical exercises.
Additional Activities
Role-playing/Communication Exercise
Scenario Title
Responding to Misgendering in the Healthcare Setting
Objectives
- Practice appropriate responses to misgendering.
- Develop skills in advocating for and supporting transgender patients.
Roles
- Nurse
- Colleague (misgendering the patient)
- Transgender patient
- Observer (to provide feedback)
Scenario Setting
A nurse is in a healthcare setting where a colleague repeatedly misgenders a transgender patient. The role-playing exercise will involve the nurse addressing the situation tactfully and supporting the patient.
Scenario Setup
- Review the scenario details and key points on addressing misgendering.
- Prepare a list of guiding questions for the debriefing session.
Role-Playing Activity
- Introduction (5 minutes):
- Introduce the scenario and objectives of the role-playing exercise.
- Explain the importance of addressing misgendering and supporting transgender patients.
- Role-Playing (15 minutes):
- Conduct the role-playing exercise with participants assuming their roles.
- Observe interactions and provide guidance as needed.
- Debriefing and Feedback (10 minutes):
- Discuss the experience with participants.
- Reflect on what went well and what could be improved.
- Provide feedback on effective strategies for addressing misgendering and supporting transgender patients
Interactive Module
Create an interactive escape room using Google Forms that challenges students to solve puzzles related to the chapter topic. These NCLEX-style questions can be a starting point.
- What is the most effective initial response when a colleague is misgendering a transgender patient?
- Ignore the situation to avoid conflict.
- Correct the colleague in a public setting to make a point.
- Politely and privately correct the colleague and ensure the patient’s preferred pronouns are used.
- Discuss the issue with the patient to seek their input.
- Which of the following initiatives is likely to improve healthcare access for transgender individuals in a community?
- Providing trans-inclusive universal healthcare coverage.
- Offering general healthcare services without specific considerations for transgender needs.
- Restricting access to transition-related care to reduce costs.
- Restricting access to transition-related care to reduce costs.
- A nurse is caring for a transgender male client (assigned female at birth) who is starting testosterone therapy. Which of the following side effects should the nurse include when educating the client about testosterone therapy?
- Decreased body hair
- Breast enlargement
- Increased muscle mass
- Decreased libido
- A nurse is providing care to a client who identifies as nonbinary. The nurse should:
- Ask the client what their preferred name and pronouns are
- Avoid using any pronouns to prevent offending the client
- Use “he/him” pronouns unless the client states otherwise
- Default to using “they/them” pronouns for all nonbinary clients
- A nurse is assessing a transgender client who reports experiencing gender dysphoria. Which statement by the client reflects a need for immediate mental health intervention?
- “I feel like my body doesn’t match who I am.”
- “I’ve been isolating myself because I feel uncomfortable in public.”
- “I’m frustrated because people don’t understand my gender identity.”
- “Sometimes I feel like hurting myself because of how I look.”
- A nurse is preparing a transgender female client (assigned male at birth) for gender-affirming surgery (vaginoplasty). Which preoperative teaching point is most important to include?
- “You will need to avoid any hormone therapy after surgery.”
- “It’s normal to have a period after surgery, so use sanitary pads.”
- “You will need to dilate the neovagina regularly to prevent closure.”
- “Your ability to conceive will improve after surgery.”
- A transgender woman (assigned male at birth) reports feeling uncomfortable seeking healthcare due to past negative experiences with medical providers. Which response by the nurse is most appropriate?
- “I understand why you feel that way, but you need to trust us to help you.”
- “You should always report any provider that makes you uncomfortable.”
- “I’m sorry you’ve had those experiences. How can we make you feel more comfortable here?”
- “Healthcare providers aren’t supposed to treat people differently based on gender.”
Case Study: Gender Affirming Care
Objectives
By engaging with this case study, nursing students should:
- Demonstrate how to apply inclusive communication practices and use correct pronouns for transgender clients.
- Provide evidence-based education on hormone therapy, its effects, and management of side effects such as persistent menstruation.
- Counsel transgender clients about surgical transition options, emphasizing patient autonomy and informed decision-making.
- Offer gender-affirming preventive care recommendations, being mindful of the unique needs and concerns of transgender clients.
- Recognize the importance of mental health support and reduce the impact of healthcare discrimination on transgender individuals.
Background
You are a nurse working in a primary care clinic. Your client, Jordan, is a 24-year-old transgender man (assigned female at birth) who has been taking testosterone therapy for 18 months. Jordan presents today for a routine check-up and to discuss some health concerns. He is generally healthy and has no significant past medical history aside from gender dysphoria, which was diagnosed three years ago.
Jordan is employed full-time and has supportive family and friends. However, he reports ongoing stress related to navigating healthcare and fear of discrimination when seeking services. Jordan’s goals include maintaining his health, continuing hormone therapy, and exploring future surgical options (top surgery). He also expresses concerns about the potential side effects of testosterone and whether he should be doing anything different for his health as a transgender man.
Assessment Information
- Vital signs: BP 122/80 mmHg, HR 76 bpm, RR 16 breaths per minute, Temperature 98.6°F
- Medications: Testosterone cypionate 100 mg IM every two weeks
- Current concerns:
- Some anxiety about how long he should continue hormone therapy and possible long-term effects
- Increased facial and body hair growth (expected) but some frustration with persistent menstruation
- Wants to discuss future surgical options (top surgery for chest masculinization)
- Requests advice on general health screening and preventive care
Nursing Considerations
- Communication and Support:
- Use Jordan’s preferred name and pronouns throughout the interaction.
- Assess how comfortable Jordan is in the healthcare setting and address any fears of discrimination he may express.
- Provide a safe, nonjudgmental space to talk about gender identity and future goals.
- Education:
- Testosterone therapy: Review potential side effects and benefits of continued hormone therapy. Provide evidence-based information regarding long-term effects of testosterone on bone health, cardiovascular risk, and reproductive system.
- Persistent menstruation: Explain that while testosterone can suppress menstruation, some individuals may still experience bleeding. Discuss options such as adjusting testosterone dosage or using additional medications like progestins or GnRH agonists to stop menstruation.
- Surgical options: Explore Jordan’s interest in top surgery. Explain the process, including how to get a referral for a consultation with a surgeon, insurance considerations, and the general recovery timeline. Address any questions or concerns about the procedure.
- Preventive care: Provide gender-affirming advice for routine health screenings (e.g., Pap smears, breast cancer screening) and discuss reproductive health, including options if Jordan does not want to pursue hysterectomy. Offer information on maintaining bone health with long-term hormone therapy.
- Mental Health Support:
- Ask Jordan how he is coping with stress and anxiety related to healthcare discrimination and body image. If appropriate, provide resources for mental health support, such as gender-affirming counselors or support groups.
- Screen for signs of depression or anxiety, as transgender individuals may face higher rates of these conditions due to minority stress.
Questions for Reflection and Analysis
- Communication and Cultural Competence:
How can the nurse ensure Jordan feels safe, respected, and supported during the visit? What communication techniques would be appropriate to ensure gender-affirming care? - Testosterone Therapy:
Jordan expresses concerns about the long-term effects of testosterone therapy. What side effects should the nurse discuss, and how can the nurse provide reassurance or additional resources about managing these effects? - Menstrual Suppression:
Jordan is frustrated by persistent menstruation despite being on testosterone therapy. What options can the nurse suggest to help manage this, and how can the nurse help Jordan feel more comfortable discussing reproductive health? - Surgical Transition:
Jordan expresses interest in top surgery. How should the nurse counsel Jordan regarding the next steps, and what should be discussed regarding recovery, risks, and emotional aspects of the surgery? - Preventive Health:
What gender-affirming recommendations should the nurse provide regarding preventive health screenings (such as cervical cancer or breast cancer screening) while being sensitive to Jordan’s needs and concerns?
