There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in introduction of a new order of things. - Niccolo Machiavelli (The Prince, 1513)
When healthcare providers (HCPs) think of vulnerable populations, children, prisoners, adults with limited capacity to consent, and non-English speaking patients immediately come to mind. Missing from this list is the individual with gender identity issues. Generally, HCPs know little about caring for individuals in this group, including the transgendered population.
Although HCPs don't actually know how many transgendered individuals there are because they must self-identify, they do know that across cultures people have different beliefs about gender-related issues. Cultures differ in their definitions of words such as masculine, feminine, male and female.
Some cultures provide specific ways in which people learn to live in roles that are different from those assigned at birth. In some cultures, men are expected to be strong and stoic, and in other cultures gentle and nurturing. The cultural lens provides the basis through which HCPs view individuals' gender, identity role and support systems.
There are theories about why people become transgendered.
HCPs can look through the lens of culture and medicine and believe a baby is exposed to fluctuations or imbalances in hormones while in utero. Through the cultural lens of psychology, it is believed children know at an early age they are transgendered. Through the cultural lens of freedom, people must be respected and allowed to choose whatever gender presentation "feels right" for them regardless of their physical appearance.
Importance to Healthcare Providers
"Ideally, gender expression and identity should not make a difference in health providers' care delivery. In reality, negative attitudes and lack of knowledge can compromise the care of the transgendered (TG) patient" (Schaffer, 2005, Journal of Emergency Nursing, 31(4), 405-407).
Establishing a safe haven for exploring the needs of the transgendered patients has its own challenges for the nurse. It may be a lack of knowledge about specific health concerns or checking a box that says "male" or "female" that may cause anxiety for both the patient and the nurse.
Through education, support, and an opportunity for the nurse to dispel myths and biases about transgendered patients, their unique needs can be better addressed in the healthcare setting. This is critical for exploring the unspoken needs of this vulnerable population.
Isolated Patient Population
Healthcare providers and society have victimized the community of transgendered patients in many ways. Often, these patients are experiencing multiple losses and are surrounded by their own veil of isolation from their families, friends and co-workers.
In addition, they may not seek preventative healthcare or care for acute illness, as it will reinforce their negative experiences or perceptions of how they were treated in the past by healthcare providers. A patient could be bullied, teased or ostracized by members of the behavioral health milieu, including staff, and experience the victim role once again.
Often these patients find themselves without healthcare insurance because of unemployment, homelessness and difficulty obtaining access and insurance coverage for medically-desired procedures and for follow-up once the insurer learns they are transgendered. In some states, if insured, gender reassignment surgery is not covered.
HCPs need to care for patients in a holistic manner, individualize the care, and give the transgendered person the chance to heal from whatever brings them to any healthcare facility.
Prompted by a staff request, our facility decided to look at this subset of vulnerable patients and provide education to the staff so the clinical team could deliver the quality focused care these patients desperately need (see Table 1). While we have no formal program at this time, the sensitivity tips learned through research have helped in the care of this patient population.