IN TRANSITION: BREAKING THE BARRIERS BETWEEN NURSES AND TRANSGENDER PATIENTS
Kara Aguilar
October 22, 2019
NASHVILLE, Tenn.- Efforts to roll back protections for transgender Americans continue, as U.S. District Judge Reed O’Connor of the Northern District of Texas abandoned an Obama-era healthcare rule banning healthcare providers from discriminating on the basis of sex, including gender identity.
The federal judge ruled on Oct. 15 that the 2016 policy put in place by the Obama administration violated the religious freedom of Christian providers, who argue that the rule forces doctors to perform gender transition services even if they morally or medically object to those services.
This is not the first time that the government has moved towards eliminating protections for transgender citizens. In May, the Trump administration proposed to no longer recognize gender identity as a basis for sex discrimination, which would allow insurers and providers to deny transgender people treatment or coverage.
Aside from government regulations, transgender people face a multitude of barriers when it comes to healthcare. This includes lack of proper insurance coverage, mistreatment by healthcare providers and their discomfort or inexperience with treating transgender people.
A study done in 2015 by the National Center for Transgender Equality found that over 30 percent of respondent reported having a negative experience related to their gender identity. Such experiences included verbal harassment, refusal of treatment or having to educate their provider about transgender people in order to receive appropriate care.
The same study also found that over 20 percent of respondents did not seek the health care that they needed over the previous year due to fear of being disrespected or mistreated as a transgender person.
The Attitude Three Decades Ago
The Post-Anesthesia Care Unit is located on the third floor of the Vanderbilt University Medical Center. Nurses working in this area are responsible for monitoring and caring for patients who have just undergone surgery.
Pam Jones is the Traffic Flow Nursing for the Holding Area. Since she was a teenager, Pam was always interested in medicine and in 1980 she started her nursing career.
She estimated that she has taken care of about five transgender patients in her 39 years as a nurse. The one that had the greatest impact on her was her first, she said.
“The first one was actually in transition back in the late 80s, early 90s,” Jones recalled fondly. “I was his nurse the whole time he was at the hospital.”
According to Jones, the patient was in the process of transitioning from female to male at the time. He had changed his name from Judie to Jude and had already undergone a mastectomy. He already had a flat chest and facial hair when Jones met him.
“She… or he… had already been through hormone therapy and was having a penis constructed out of abdominal tissue and he looked every bit a man except that he still had a vagina,” Jones said.
She said that the culture of the hospital at the time was not accepting of transgender patients at all. This was reflected by the way some of the staff talked about her patient.
“I guess it made a lot of people uncomfortable,” Jones said. “You know, like ‘I don't want to be that nurse’ [or] ‘don’t assign me in there’. That kind of thing.”
As a Christian woman, Jones says that even though she personally doesn’t agree with what her patients are doing, she still tries to provide them with the same amount of compassion and care as any other patient without casting judgement.
“What I learned from that very first patient I had 30 years ago is that they are just people,” she said. “They deserve respect and they deserve compassion and they don't need our ridicule. I think it's a pretty brave thing for them to do what they are doing. Whether I agree or not, it is still a brave thing.”
Transgender patients that pass-through Vanderbilt’s holding area are not always admitted for surgeries related to transition. Some are also there for surgeries related to other health issues.
“The few that we have had here in the holding area they seem to be kind of guarded when they come in. They don't know how they are going to be perceived. You can tell and you just kind of have to break that ice,” Jones said.
Pam says that she tries to be conscious of the proper pronouns she uses when addressing her transgender patients but it can be difficult to do at times without prior notification.
“I have made the mistake before of using the wrong pronoun and been corrected,” she said. “They aren't generally hostile or mean about it but they are sensitive about it.”
Through her mistakes, Pam says she tries to be as respectful as possible to not offend anyone. She accredits Jude for opening her eyes to understanding her transgender patients.
“He's the one that helped me the most to understand that it’s a hard choice when they make that choice,” Pam said. “That first patient that I took care of was the one that helped me the most to be accepting and try to find their heart.”
Today's Attitude
Down the hall in a dimly lit area of the hospital is Abbie Martin, a 22-year-old nurse resident. She recently moved to Nashville from Atlanta in July to begin her residency.
Her first experience with a transgender patient happened during one of her first shifts. According to Martin, the patient had been born female but identified as a male and was pregnant.
“That was really confusing for a lot of people as far as what to address him as,” Martin said. “A lot of people would say she, especially being pregnant, she would go by she, her and all those female pronouns but she actually identified as male and preferred he, him or they. And so it was just an added obstacle being in the medical field and having to catch yourself before addressing them as a certain pronoun.”
Martin said she noticed that a lot of people had to either ask beforehand which pronouns the patient preferred. She also added that some of her colleagues didn’t have any regard for the patient’s pronoun preferences and would go off of the gender that he was born with.
“It seemed that they just kind of accepted it and dealt with it but you could just tell it was a lack of respect and that they felt a disrespect from it,” she said.
From her perspective, this disregard was mainly common with professionals who were in and out of the room, such as physicians, doctors and anesthesiologists. Nurses on the other hand had more time to look at the bigger picture, she said.
“I think nurses are more holistic in the sense that they know the chart in and out as far as preferences of care and those are the first kinds of questions we ask a patient before giving any care,” Martin said.
As a young nurse, she says that the situation was a helpful experience for taking care of future patients. But she also acknowledged some of the challenges medical professionals face when trying to take care of transgender patients.
“I think a lot of people don't mean to be disrespectful but in an environment like this where something like biological gender can affect your care and your treatment,” Martin said. “For example him being pregnant, those two words are difficult for anyone to put together in a sentence and it be like the norm. So I think a lot of people struggle with it just not out of intentional disrespect but it's just not the norm that they are used to.”
Through interviews and paying attention to personal requests regarding care is what Martin believes to be important for future medical professionals to better care for transgender patients. As well as, making it known that the patient is in an accepting environment.
“If [it] is an important thing to them being addressed by certain pronouns that are different from what is assumed, that is welcomed here,” she said. “We accept them and we prioritize that here at Vanderbilt and that the care that we want to give is like making you feel included and feel very present in your care and that it's not looked over or assumed.”
Vanderbilt established the Clinic for Transgender Health last year in August. The clinic provides services such as hormone therapy, consultations for transitioning surgeries, and coordination with other medical specialists for primary care and behavioral health services.
Moving Forward
While the struggle to minimize friction between medical professionals and transgender patients is still a work in progress, there are steps that can be made to break down some of those barriers.
According to research released by the Department of Health and Human Services in 2016, lack of providers with expertise in transgender medicine was the largest component inhibiting transgender patients from accessing care.
The study was not able to identify any reliable prior attempts to determine specific workforce needs in providing care for transgender patients or to determine the current status of care.
The report suggests that more intensive research needs to be done to review the ability of the country’s health care system to provide transgender patients with proper care. It also calls for a careful assessment of the causes behind industry’s shortcomings.
“There is a specific need to determine if providers receive adequate care training in transgender medicine and if not, to determine the gap,” the report stated.