Caring for a Transgender or Gender Nonconforming Patient


Caring for a Transgender or Gender Nonconforming Patient

A practical guide for nurses

By By R. David Rice, RN, Ph.D., NP, NEA-BC and Stephanie Smith
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One-third of all transgender people report having been harassed, denied medical treatment or otherwise discriminated against in a healthcare setting in the past year. As nurses, we have an ethical responsibility to treat all our patients equally. Read on to learn what it means to be transgender in America, and what we can do to provide appropriate care to this at-risk population.

 Health Disparities

Nurses see each patient as a person, as an individual. The ANA’s Code of Ethics for Nurses with Interpretive Statements states, “The nurse practices with compassion and respect for the inherent dignity, worth and unique attributes of every person.”

We are also reminded that we have an ethical duty to “reduce health disparities.” Our patients are situated within specific populations, which may include age, ethnicity, socioeconomic status and so on. We know that some populations enjoy health advantages while others suffer substantial disparities.

In 2016, the National Institute on Minority Health and Health Disparities (NIMHD) formally recognized lesbian, gay, bisexual and transgender (LGBT) Americans as a healthcare disparity population — meaning they face a higher incidence of disease, poorer daily functioning and earlier deaths.

Among LGBT Americans, transgender (trans) and gender nonconforming (GNC) people are uniquely marginalized and stigmatized in society. This stigma — homophobia and transphobia — extends to the healthcare setting, often with serious consequences.

In this article, we’ll take a look at how discrimination and stigma affect our trans patients and what we as nurses can do to create a welcoming, inclusive healthcare environment.


Trans and GNC Defined

“Transgender” is an umbrella term for people whose gender identity — their internal sense of their own gender — differs from the gender they were assigned at birth. Being trans is distinct and separate from sexual orientation. A transgender person may be gay, straight, bisexual or asexual, and in some cases, an individual’s sexual identification may shift over the course of their transition.

Some, though not all, trans people undergo medical or surgical intervention to align their bodies with their gender identity. This process is broadly known as “transition” and may include hormone therapy, surgical procedures or both.

Gender nonconforming (or “gender variant”) refers to people who do not follow society’s precepts of gender based on binary concepts of “male” and “female ” or stereotypes about how they should look, dress, or act based on their gender. Although some transgender people are gender nonconforming, many GNC people are not trans and vice versa.


Disparities by the Numbers

In 2015, 27,715 Americans completed the National Center for Transgender Equality’s U.S. Transgender Survey. The data from the survey shows a pattern of pervasive mistreatment and violence against transgender individuals by their families, in schools, in places of work and worship, from police, in prisons, in public places and within healthcare settings.

Following are some shocking findings from that survey:

• Psychological Distress. Thirty-nine percent experienced serious psychological distress in the month prior to completing the survey (compared to 5 percent of the U.S. population). 

• Harassment. In the year prior to the survey, 46 percent of respondents were verbally harassed, 9 percent were physically assaulted and 10 percent were sexually assaulted.

• Unemployment. The unemployment rate is triple the U.S. average (15 percent compared to 5 percent).  

• Poverty. Almost one-third (29 percent) live in poverty (compared to 14 percent of the U.S. population).  

• Homelessness. Almost one-third (30 percent) have experienced homelessness at some point in their lives.  

• Home Ownership. Home ownership was substantially less common — 16 percent owned homes, compared to 63 percent of the U.S. population.  

• Suicide. Forty percent have attempted suicide in their lifetime — nearly nine times the attempted suicide rate of the entire U.S. population (4.6 percent).


Medical Mistreatment 

In healthcare, one-third (33 percent) of transgender respondents had at least one negative experience in the past year with a healthcare provider, such as verbal harassment or refusal of treatment because of their gender identity. 

Almost one-quarter (24 percent) reported not seeing a healthcare provider in the previous year due to fear of being mistreated. Respondents’ overall health was poorer than that of the general U.S. population and their incidence of substance abuse was significantly greater (29 percent compared to 10 percent for the U.S.).


A Practical Guide for Nurses 

What can we as nurses do to more effectively care for our trans and GNC patients?  

• As with all patients, be respectful, be compassionate, be genuine, be open. Create a safe space.

• Don’t assume that you can tell if someone is transgender or not. Many trans people are not “out” to their healthcare providers.

• Don’t make assumptions about a patient’s sexual orientation. Also, remember that identity does not always align with behaviors. For example, a man may describe himself as heterosexual (identity), but he may have sex with male partners (behaviors).

• If you’re not sure which name or pronouns to use, ask the patient which they prefer and then use those consistently. However, keep in mind that asking these questions unnecessarily can itself be stigmatizing. If the patient corrects you, simply apologize and move on.

• In any event, do not ask a trans person what their “real” name is. Birth names are a source of anxiety for many transgender people. Respect the name the trans person currently uses, even if it differs from their ID or records.

• Use inclusive and gender-neutral language. Ask open-ended questions that avoid making assumptions about patients’ identities or lifestyles. 

• Be mindful of your patient’s confidentiality. It is not our place to “out” patients. Some trans patients will be comfortable disclosing their status and others will not. During a healthcare encounter, a patient may come in contact with many care and service providers beyond the RN and physician. Each time, it is the patient’s choice whether to disclose or not.

• Unless clinically indicated, do not ask invasive questions about the patient’s genitalia, transition-related care (such as hormones or surgery), sexual orientation or sexual practices. Do not examine a patient’s genitals unless you have a specific clinical reason to do so.

• The best way to ally with your trans patients is to listen to them with an open mind and express no judgments. Many trans patients are accustomed to having to teach healthcare and service providers about trans people in order to receive appropriate care, which can be burdensome and stressful.  

• Familiarize yourself with the Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People, Version 7, published by the World Professional Association for Transgender Health (WPATH). The WPATH SOC v7 reflects the most current, evidence-based clinical consensus on treating trans patients. You can find these standards (in several languages) at 

• Stand up for your patients. Don’t be silent if your colleagues or other patients create an uncomfortable situation or hostile environment for your trans or GNC patients. However, be cautious about compounding patients’ discomfort or subjecting them to further stigma. 

• Know your facility’s nondiscrimination policy and the applicable state and local laws protecting LGBT people and make sure that you and your fellow nurses follow them. 

• Educate yourself and keep in mind the mental and physical stressors trans people face, some of which are noted in the paragraphs above. These include increased incidence of depression, anxiety, substance abuse and suicidality. 

• Create a welcoming environment.  Is the nondiscrimination policy visible in the workplace?  Are there symbols of inclusion (e.g., rainbow flags, safe zone indicators)? Are there gender-neutral restrooms?  Is there educational literature about LGBT health in your waiting room?

In the sidebar, you’ll find additional resources you can use to educate yourself, your colleagues and your communities as well as your patients and family caregivers. 



WPATH Standards of Care

National Center for Transgender Equality (NCTE)


University of California, San Francisco (UCSF) – Center of Excellence for Transgender Health

Human Rights Campaign – Healthcare Equality Index

(Note: the HEI also offers excellent training resources for healthcare professionals and patient-facing care providers.)

The Williams Institute / UCLA School of Law – Best Practices for Asking Questions to Identify Transgender and Other Gender Minority Respondents on Population-Based Surveys

National LGBT Cancer Network – Best Practices in Creating and Delivering LGBTQ Cultural Competency Trainings for Health and Social Service Agencies

U.S. Department of Health and Human Services – LGBT Health and Well-Being

The Joint Commission – Advancing Effective Communication, Cultural Competence and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual and Transgender (LGBT) Community — A Field Guide

National LGBT Health Education Center (a program of The Fenway Institute)

Association of American Medical Colleges – Diversity and Inclusion Learning Series

New York State Department of Health AIDS Institute – HIV Clinical Resource: Care of the Transgender Patient with HIV Infection Guideline


Robert David Rice, RN, Ph.D., NP, NEA-BC, is director of professional practice and education at City of Hope National Medical Center in Duarte, Calif. Stephanie Smith is a writer, producer and multimedia manager at City of Hope. 


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