Journal of Nursing and Practice

Barriers to Health Care for Transgender Individuals; Lisa A. Nelson, Kathleen Shurpin Stony Brook University

Abstract

Introduction: The transgender non-conforming (TGNC) clients experience provider bias, erasure, refusal to treat and, violence.

Aim: The purpose of this article is to identify barriers to health care for TGNC Individuals and discuss recommendations for Nurse Practitioner practice treating this population.

Method: Literature review of prime research was conducted.

Results: Evidence suggests barriers to TGNC health care, include lack of provider transgender knowledge and transgender sensitivity, lack of provider communication, lack of emotional and physical safe health care environments.

Discussion: TGNC clients face barriers to accessing health care and specific recommendations to improve NP practice will decrease these barriers.

Implications for practice: Lack of provider education affects transgender individuals accessing quality health care. Recommendations to improve NP practice are essential to improve care.

Keywords

Transgender, Transgendr*; (women OR female); (breast exam OR mammogr*), LGBTQ

Introduction

The purpose of this article is to identify recommendations for Nurse Practitioners to improve practice and treatment of the Transgender (TG) population. Implementing these recommendations will enable improvement in provider care to this population and ultimate improvement in TG clients' health outcomes, mortality and morbidity. This improvement will also decrease cost to the health care system, since TG clients will be able to receive timely medical treatment, receive preventative treatment, adhere to health care guidelines and communicate openly to their provider about their medical needs.

Transgender individuals (TG) are people who identify as a different gender then the gender they were assigned at birth. Cisgender are individuals that identify as the gender they were assigned at birth. It is estimated that one million people in the U.S. are transgender non-conforming individuals (TGNC) [1]. This estimate is considered low because most National Surveys have not included identifiers to register as a TG individual [1].

TGNC individuals face barriers to health care. It is estimated that health care barriers and substandard care continues for transgender clients [2]. In addition to health care barriers, transgender individuals experience societal discrimination, decrease family support, decrease rate of college attendance and completion, low paying jobs, hazardous jobs and lack of insurance [3]. The 2008 National Transgender Discrimination Survey on health and health care addressed the barriers to health care for TG individuals. This survey has not been repeated since 2008. The survey described how this population experienced discrimination from health care professionals ranging from disrespect, trans-ignorance, violence, and refusal to treat. These discriminations occurred in doctors' offices, emergency rooms, mental health clinics, and drug treatment programs [2].

Barriers to health care affect TGNC individuals' access to quality health care, increasing their mortality and morbidity [3]. According to the World Health Organization (WHO) and the U.S. program on HIV/AIDS, transgender individuals' HIV infection rate is 4X more than the general population [3]. TG individuals reported higher rates of smoking and much higher suicide rates then the general population [2].

Provider ignorance, bias, and refusal to treat causes TGNC individuals to postpone essential medical care and not attend preventative care [2]. Transgender women were less likely to adhere to mammography guidelines [4]. A decrease in provider transgender knowledge and trans-sensitivity decrease patient provider communication, negatively affecting the TG clients' health care outcomes [5]. However, TGNC individuals adhere to sexual health guidelines when attending a clinic that is trans-sensitive and the providers are trans-educated [6]. A repetitive theme in the literature, was lack of provider transgender education. TGNC individuals accessed care when they knew their provider was knowledgeable about their treatment needs. Providers were able to provide quality of care when they had this knowledge.

The literature identifies five themes related to barriers to health care for the transgender individuals. The five themes identified include health screening, delay in health care access, provider communication, provider knowledge of transgender issues, and negative health care experience. Transgender men and transgender females differ in their access to mammography screening [4,7]. Transgender men are more compliant with screening than transgender women or cisgender women [4,7]. Transgender individuals delay health care services due experiences of providers' transphobia, and abuses toward TG clients [2,6,8]. The TG individuals attend health care appointments when the providers are educated in TG issues, with that knowledge, the providers are able to effectively communicate and treat TG clients [9].

Health care screening was a major theme of four studies with a focus on mammogram Screenings [4,7,8,10]. Multiple studies reported differences in mammogram screening practices in the LGBTQ community [7,8,10]. A study by Barefoot, et al., suggested that rural lesbians were less likely than urban lesbians to have mammography screening [8]. In 2015, Bazzi's, et al. study showed that transgender clients were less likely than cisgender women to adhere to mammogram guidelines [4]. A study that evaluated mammogram screening based on gender: male to female (MtF), female to male (FtM), concurred that transwomen compared with cisgender women were less likely to adhere to mammogram screening. However, this study also differed in its findings stating transmen were more likely than cisgender women to adhere to mammogram guidelines [10]. Additionally, a study by Narayan, et al, (2017) differed from any other study in its' findings that transgender individuals and cisgender women were equally participating in mammogram screening [7].

Barriers to accessing health care was examined in multiple studies [3-6,8]. Findings suggested a delay in health care access by lesbian and transgender individuals [3-6,8]. A study by Bauer, et al., demonstrated that a barrier to health care access for transgender individuals was due to active, passive and institutional erasure [3]. Active erasure included providers' visual discomfort, refusal to treat, and acts of harm to this population. Passive erasure included lack of transgender identification on forms and institutional erasure included lack of transgender information in textbooks. A study addressing health care providers' attitudes to transgender individuals also demonstrated delay in health care for this population was a result of a lack in trans-sensitive training to health care providers and a lack of trans-specific services [6].

Multiple studies identified impaired patient- provider communication as impacting transgender individual's healthcare outcomes [2,6,8]. Transgender individuals were more likely to access health care when they knew the staff was trans-sensitive, the institution was trans-friendly, and providers were knowledgeable about the trans individuals' issue [6]. A case study identified MtF transgender woman developing metastatic breast cancer [5]. The study concurred with other studies, that lack of provider's communication and trans-sensitivity led to lack of knowledge of the client's belief system, at the time of breast cancer diagnosis. This resulted in the client's refusal to excise the tumor and the provider not addressing the breast tumor at follow up appointments [5].

Transgender individuals' negative experiences with health care providers were another barrier to accessing health care [6]. Two studies identified transgender individuals experiencing transphobia by providers and lack of health insurance due to low income [2,6]. According to a study by Bauer, et al., (2009), the health care system and providers operate with the assumption that each individual grows up as their assigned gender at birth [2]. Transgender individuals seeking health care, challenge this reality. A study examining transgender individuals' use of sexual health services also suggested that transgender individuals will access care from a safe trans-sensitive environment that can also facilitate financial assistance for health care [6].

The results of a metanalysis examining provider behaviors found that providers exhibited transphobia to LGBTQ client [9]. The study demonstrated lack of LGBTQ education in nursing and medical schools' curriculum, lack of LGBTQ knowledge of differences and health needs in this population, and lack of health care promotion for this population [9]. The metanalysis suggested that the Health Equity Index, a yearly survey, measures a facilities ability to meet four essential policies: LGBTQ patient non-discrimination, employment non-discrimination, staff training in LGBTQ knowledge, and equal visitation rights [9].

This review identified barriers to health care for transgender and LGBTQ populations, and described how these barriers have affected the health outcomes of these individuals. Identified barriers to health care included lack of provider transgender knowledge and sensitivity, lack of health care facilities providing LGBTQ individuals with physical and emotional safe environments, lack of provider communication with LGBTQ clients. Provider education was identified as an important intervention to remove these barriers to health care for this vulnerable population.

Implications for Practice

Main barriers to health care for transgender individuals included lack of provider knowledge of this population's health needs, and provider bias interfering with patient communication and safe quality care. Additionally, transgender non-conforming individuals experienced low income and lack of health insurance affecting their ability to access needed medical care. This reflected societal bias and discrimination of the transgender community. Transgender individuals are not supported by society and some experience this lack of support from their parents, leading to financial instability. Furthermore, there was a focus on health screening for the transgender community, specifically mammogram screening.

Implication for Education

The literature review suggested and, the additional studies supported, several gaps in providing quality health care to transgender clients and provider education on transgender issues [11,12]. Therefore, it is important to initiate courses in transgender knowledge in nursing and medical school curriculum. In addition, it is essential to make this information available in continuing education.

Recommendations for Practice

General

Providers' offices should add inclusive intake forms to include transgender options of identification, preferred names and pronouns [3]. During the treatment session it is important for the provider to use this information when addressing the client. The providers should foster an office culture of safety for the transgender clients which include a no tolerance policy for abusive treatment toward theses clients with consequences for those staff members who violate this policy [2]. The NP provides' need to be aware of and collaborate with local providers such as endocrinologists, attorneys, surgeons' offices to foster interdisciplinary approach [13]. The providers can include pamphlets for additional resources ie endocrinologists, surgeons, attorneys and support groups. The provider group can identify an individual who will champion these changes and monitor policy implementation.

Education

Nurse Practitioners should have opportunities to attend continuing education programs addressing Transgender Issues. The providers should then share this knowledge with support staff to promote competent care of TG clients throughout the practice setting. Nurse Practitioner educators should facilitate and develop curriculum on TG issues and competent treatment of TG clients. This content should be included in both undergraduate and graduate educational programs in nursing.

Communication

NP providers would benefit from attending supervision to explore unconscious biases toward the transgender population, to enable them to facilitate open communication about the clients' emotional, physical needs. If providers erroneously believe that the TG clients' mental health/health issues is linked to their identity, they will miss the actual issue the client is experiencing [3]. The NPs' increased knowledge of transgender issues will enable open communication and the patients' actual health needs will be identified. The Psychiatric Mental Health Nurse Practitioners should allow TG client to collaborate with focus of therapy and assist in enabling the client to increase awareness of their specific needs concerning transitioning [14]. Participation in supervision sessions will also enable them to increase awareness of microaggressions is overt expressions of disapproval, pathologizing of TG identification, invasion of bodily privacy [15]. When the NP providers' increase TG competent treatment, it will increase the outpatient practice setting competency and increase systematic competency [15].

Research and advocacy

The NP providers performing research can focus on transgender specific needs, specific transgender communities, ensure research questions are non-pathologizing, and enable transgender individuals to identify research needs [3]. The knowledge and data obtained from these studies can be published and added to nursing textbooks and continuing edcuation [3]. In addition, the acquired data of transgender health needs and inequities can be used to assist providers to advocate for change in government policy to promote social change to improve health care programs, health care services and insurance reimbursement for the TG clients [2].

Policy

United States government policies need to be developed, to protect the transgender community from discrimination and oppression [1,2,3,6,11,12]. Nurse Practitioners need to promote this effort, since these providers are responsible for providing safe quality care. Without these policy changes, transgender individuals will continue to avoid needed and preventative medical interventions, and continue to suffer increase mortality and morbidity.

Conclusion

Education improves ignorance and bias [5,6,12,15]. In addition, Nurse Practitioner education and continuing education on TG issues needs to implemented and attended to improve quality of their care to the TG population. When providers are adequately educated, they will be able to address gaps in their treatment of the TG population. In addition, NP providers can address the inequities in U. S government policy which will systemically change the lack of quality care to transgender individuals. Furthermore, this change in policy will influence societal treatment of the transgender population improving availability of higher paying jobs and health insurance for this community. Funding for health care research will improve quality of care and quality of life for the transgender non-conforming population.

Acknowledgment

Acknowledgment to Keri Hollander statistics and technology. The author has no conflict of interest. The author did not need or receive any funding.

References

1. Stroumsa D (2014) The state of transgender health care: Policy, law, and medical frameworks. Am J Public Health 104: e31-e38.
2. Grant Jamie M, Mattet Lisa A, Justin T, et al. (2011) National transgender discrimination survey report on health and health care. Findings of a Study by the National Center for Transgender Equality and the National Gay and Lesbian Task Force. National Center for Transgender Equality.
3. Bauer GR, Hammond R, Travers R, et al. (2009) “I don’t think this is theoretical; this is our lives”: How erasure impacts health care for transgender people. J Assoc Nurses AIDS Care 20: 348-361.
4. Bazzi AR, Whorms DS, King DS, et al. (2015) Adherence to mammography screening guidelines among transgender persons and sexual minority women. Am J Public Health 105: 2356-2357.
5. Dhand A, Dhaliwal G (2010) Examining patient conceptions: A case of metastatic breast cancer in an African American male to female transgender patient. J Gen Intern Med 25: 158-161.
6. Porsch LM, Dayananda I, Dean G (2016) An exploratory study of transgender New Yorkers’ use of sexual health services and interest in receiving services at planned parenthood of New York city. Transgender Health 1: 231-237.
7. Narayan A, Lebron-Zapata L, MorrisE (2017) Breast cancer screening in transgender patients: Findings from the 2014 BRFSS survey. Breast Cancer Res Treat 3: 875-879.
8. Barefoot KN, Warren JC, Smalley KB (2017) Women’s health care: The experiences and behaviors of rural and urban lesbians in the USA. Rural Remote Health 17: 1-16.
9. Lim FA, Brown DVJ, Justin Kim SM (2014) CE: Addressing health care disparities in the lesbian, gay, bisexual, and transgender population. Am J Nurs 6: 24.
10. Tabaac AR, Sutter ME, Wall CSJ, et al. (2018) Gender identity disparities in cancer screening behaviors. Am J Prev Med 3: 385-393.
11. Bell SA, Bern-Klug M, Kramer KWO, et al. (2010) Most nursing home social service directors lack training in working with lesbian, gay, and bisexual residents. Soc Work Health Care 9: 814-831.
12. Daley A, MacDonnell JA (2015) ‘That would have been beneficial’: LGBTQ education for home-care service providers. Health Soc Care Community 3: 282.
13. (2019) APA Manual 7th Edition: The 17 most notable changes.
14. Wylie K, Barrett J, Besser M, et al. (2014) Good practice guidelines for the assessment and treatment of adults with gender dysphoria. Sexual Relationship Therapy 29: 154-214.
15. Whitman CN, Han H (2017) Clinician competencies: Strengths and limitations for work with transgender and gender non-conforming (TGNC) clients. International Journal of Transgenderism 18: 154-171.