A Nurse’s Comprehensive Guide to Gender-Affirming Care

Transgender individuals and gender-nonconforming (GNC)/gender-diverse (GD) patients face a lot of challenges in life, especially when it comes to healthcare. They are often subject to misgendering, harassment, and microaggressions, which often lead to a delay in seeking care and treatment. According to a study by Bhatt et al, these populations experience higher rates of suicides, substance abuse, depression, and sexually transmitted diseases, among many other illnesses. 

With nurses being on the frontline, they play a big role in providing transgenders and GNCs with the medical, psychological, and emotional care they need. However, many may not have the experience or access to proper resources to render the necessary services. 

Here, we’ll explore the concepts and care recommendations for delivering gender-affirming nursing care.

Terminologies and Definitions

First, let’s define the common terms that nurses will encounter:

• Gender identity. A person’s internal sense of gender, which can be male, female, neither, both, or somewhere in between the spectrum.
• Transgender. A person whose gender identity differs from the sex they were assigned at birth. 
• Cisgender. An individual whose gender identity matches the sex they were assigned at birth. 
• Non-binary. A gender identity that does not follow traditional, exclusive male or female gender beliefs. 
• Gender expression. The way a person expresses their gender, either through appearance, clothing, or behavior. 
• Gender dysphoria. The distress an individual feels due to the difference between their gender and gender identity. 
• Gender affirmation. The recognition of someone’s gender identity; may be used interchangeably with the term ‘transition’. The process may include name or pronoun changes, clothing and hairstyle changes, gender-affirming surgery, etc.

Transgender and GNC/GD Healthcare Issues

As mentioned, transgender and gender-nonconforming individuals face a lot of inequalities when seeking healthcare services. According to a study by Justin Schneider, DNP, these often stem from the provider’s lack of knowledge, refusal of care due to one’s gender identity, and harassment or abuse in healthcare settings. 

Furthermore, transgender and GD individuals face more financial barriers when accessing care. According to the Center for American Progress (CAP), they have higher rates of poverty and unemployment. They also face higher rates of insurance denials or limited access to gender-affirming care. These economic issues, together with discrimination in healthcare settings, have prodded many transgender and gender-nonconforming people to avoid necessary medical care and preventive screenings. 

Sadly, this avoidance has resulted in higher rates of healthcare disparities. Compared to only 37% of cisgender adults, 60% of transgender adults report having poor mental health. About 81% of transgender individuals have contemplated suicide, in contrast to only 30% of cisgender adults. 

Another CAP article has noted the increased likelihood of HIV, cardiovascular disease, and asthma in the transgender population. 

During the Covid-19 pandemic, the above mentioned risk factors put transgender individuals at a higher risk of developing a severe course of the disease. Their access to gender-affirming care was severely limited as well, leading to the development of mental health issues (or worsening of preexisting ones).

An Overview of Gender-Affirming Treatments

As care providers, nurses need to be well-versed with the gender-affirming treatments and the care responsibilities that come with them:

Hormone Therapy

Hormone therapy helps transgender patients transition with the use of steroids or gonadotropins. According to a report, this mainstay treatment has positive physical and psychological effects on the transitioning individual. 

Testosterone helps suppress female secondary sex characteristics in transgender men. In the US, this hormone is given intramuscularly or subcutaneously. 

Estrogen, meanwhile, suppresses male secondary sex characteristics in transgender women. Estradiol is the drug of choice, and it is given orally or parenterally.

Those who take hormone therapy should have the following blood works checked:

• Hematocrit and lipid profile
• Bone mineral density (if at risk for osteoporosis)
• Serum testosterone and estradiol
• Prolactin (for those undergoing estrogen therapy) 

Nurses play a huge role in monitoring patients who undergo hormone therapy, which should be done every three months in the first year and every 6-12 months thereafter.

Gender Affirmation Surgery

Transgender patients may opt to undergo any of the following gender-affirming surgeries: 

• Penile construction, which involves vaginal removal and urethral reconstruction
• Vaginal construction, which involves penis and testes removal and the creation of other parts, such as the labia and clitoris
• Top surgery, which may involve the removal or augmentation of breast tissue
• Facial gender surgery, which can create more masculine or feminine features 
• Hysterectomy, which removes the uterus and ovaries
• Orchiectomy, which removes one or both testicles

According to Bhatt et al, gender affirmation surgery has helped increase quality of life — especially in transgender women. It has also helped reduce rates of gender dysphoria, depression, and suicide in transitioning patients. 

True enough, nurses play a crucial role in preventing complications and promoting a speedy recovery following gender-affirming surgery.

How to Provide Gender-Affirming Nursing Care

Providing gender-affirming care starts during the first encounter with the patient, be it in the waiting room, through phone calls, or through website access. And, throughout the pipeline, nurses can continue to provide such care by doing the following:

Assess Gender Identity

Nurses should inquire about the patient’s gender identity and sexual orientation when taking a health history or assessing them. It is not recommended to make an assumption simply based on the patient’s appearance. Of course, this should be done with respect and tact.

Use Inclusive Communication Techniques

According to the WPATH Standards of Care, which aims to help nurses and other healthcare professionals provide care that helps transgender and GD patients achieve “lasting personal comfort with their gendered selves,” nurses should use culturally relevant language that promotes dignity, respect, and safety.

Nurses should also discuss with the client the language or terminology they prefer. They should ask the client what name or pronoun they wish to use. Likewise, telling the patient what pronouns the nurse uses will make the procedure or treatment more comfortable for both parties. 

Inclusive communication should also be utilized in the forms patients need to fill up. Schneider and Bhatt et al’s studies recommend using documents that:

• Include the option for preferred name alongside the legal name
• Ask “What is your gender identity?” and “What sex were you assigned at birth?”
• Use inclusive and non-gender specific terms, such as spouse/partner, parents, or blood relative
• Use gender-neutral images that depict body areas or quadrants

If such forms are still not being used in their respective institutions, nurses can take the role of advocates by championing the use of such documents with their administrators.

Educate Oneself

Knowledge is power. While hospitals and health systems provide gender sensitivity training, proactive learning about transgender health issues and needs, including the risks and benefits of gender-affirming care, can help improve the nurse’s delivery of gender-affirming care.

For one, nurses should update themselves with the newest treatments and standards of care that come due to advancements in gender-affirming medicine. 

In addition, knowing about the local laws and regulations that govern gender-affirming procedures, such as the requirements for updating IDs and documents, will help nurses fulfill their advocacy role to a newly transitioned patient. The Transequality ID Documents Center is a good resource for such information.

Provide Appropriate Care

The nurse plays a big role in monitoring the course of gender-affirming treatments, preventing possible complications, and making sure that everything goes accordingly.  For example, the pre- and post-operative care that the nurse provides helps eliminate surgical complications following gender-affirming surgery. The follow-up and education that the nurse provides, meanwhile, help prevent the onset of possible adverse events during hormone therapy. 

On top of delivering appropriate nursing care, nurses can promote better health outcomes by upholding the WPATH recommendations for delivering transgender health services. These include:

• Matching the treatment approach to the client’s specific needs
• Focusing on health promotion
• Instituting approaches that reduce harm
• Enabling informed participation throughout the health decision-making process
• Putting patients in touch with supportive communities and peer networks
• Advocating for clients within their families and respective communities

Bhatt et al’s study also recommends advocating for HPV vaccination, pre- and post-exposure HIV prophylaxis, and hepatitis A/B assessments for transgender patients, as they are at high risk of contracting sexually transmitted diseases.

Promote an Inclusive Environment

Placing welcoming posters or printed material in waiting areas and other sections can help promote inclusion. The text and images used, however, should be reviewed and chosen carefully so that they represent all types of patients.

Advocating for the construction of gender-neutral restrooms can also help promote inclusion in the institution. It could also benefit the caregivers who have to assist their patients with personal care.

Nurses can also advocate for the change of gender-specific institutional names to more inclusive ones, such as “Women’s health centers” to “Ob-Gyn centers” and “Mother and Child Units” to “Labor and Delivery Units.”

Again, educating oneself about the tenets of gender-affirming care can help create a more inclusive environment. If a nurse knows what to say and do when providing gender-affirming care, their patients won’t feel the discrimination and prejudice that would otherwise drive them away from seeking treatment.

Follow-Up Cancer Screenings

Transgender individuals may forego certain cancer screenings as they may feel that they are not aligned with their gender identity. Although this is the case, nurses should advocate for cancer screenings that fit the transgender patient’s profile. As per Schneider’s study, nurses should remind the following patients to undergo:

• Prostate cancer screening for any trans women with a remaining prostate
• Pap smear and pelvic exams for any patient with a cervix
• Routine mammography for:
  • Trans Women who have developed breast tissue after undergoing at least 5 years of feminizing treatment
  • Transmen who have not undergone chest surgery

Resources for US Nurses and Patients

If you are a nurse who wishes to educate yourself regarding transgender health and issues, or if you have a patient in need of resources and support, here are some websites to consider:

Resources for UK Nurses and Patients

Here are some resources for UK-based nurses and individuals seeking gender-affirming care:

Final Thoughts

The nurse plays a crucial role in providing gender-affirming care to transgender and GNC/GD patients, as they face quite a lot of health inequities.

This can be done by properly assessing each patient’s gender identity, using inclusive communication techniques, promoting an inclusive environment, providing appropriate care, and following up on cancer screenings. Likewise, nurses can provide better care by educating themselves on the unique needs of transgender and GNC/GD patients.