Transgender Health Care for Nurses: An Innovative Approach to Diversifying Nursing Curricula to Address Health Inequities

Abstract

Background

Transgender people experience high rates of discrimination in health care settings, which is linked to decreases in physical and mental wellness. By increasing the number of nurses who are trained to deliver high-quality care to transgender patients, health inequities associated with provider discrimination can be mitigated. At present, baccalaureate nursing curricula do not adequately prepare nurses to care for transgender people, which is a shortcoming that has been attributed to limited teaching time and lack of guidance regarding new topics.

Method

We developed transgender health content for students in a baccalaureate nursing program and used a student–faculty partnership model to integrate new content into the curriculum.

Results

We incorporated new transgender health content into five required courses over three semesters.

Conclusion

We mitigated common barriers to developing and integrating new, diversity-related topics into a baccalaureate nursing curriculum. Added transgender health content was well received by students and faculty.

The Institute of Medicine (2011) and the U.S. Department of Health and Human Services (2014) have called for a prioritization of lesbian, gay, bisexual, and trans-gender (LGBT) health and have identified lack of training in LGBT health for providers as a critical barrier to wellness for these populations. This barrier and its resulting health inequities are particularly salient for transgender patients, who experience high rates of discrimination and often have difficulty accessing gender-affirming care (Grant et al., 2011; Khan, 2011). Among a community-based sample of trans-gender adults, 24% reported experiencing discrimination in a health care setting in the past year; those who experienced discrimination were more likely to postpone needed and preventive care, screen positive for depression, and report negative physical symptoms (Reisner et al., 2015).

Schools of nursing are uniquely positioned to address the nationwide need to increase the number of health care providers who are prepared to deliver gender-affirming care to transgender patients. However, findings from a survey of more than 1,000 baccalaureate nursing faculty in the United States indicated that nursing lags behind other health care professions in prioritizing transgender health education: Baccalaureate nursing programs dedicate a median of 2.12 total hours to LGBT-related curricular content, compared with 5 total hours among schools of medicine (Lim, Johnson, & Eliason, 2015; Obedin-Maliver et al., 2011). The majority of baccalaureate nursing faculty believe that LGBT issues are important to nursing but attribute the lack of LGBT curricular content in their programs to limited space in existing curricula and limited guidance on how to integrate topics (Lim et al., 2015).

The Transgender Health Curriculum Integration Project

Through the Transgender Health Curriculum Integration Project at the Johns Hopkins University School of Nursing, we used student–faculty partnerships to make feasible and well-integrated additions of transgender health content to the existing curriculum. We leveraged one graduate student’s expertise in transgender health and faculty members’ expertise in nursing education to develop and strategically integrate content aimed to prepare nursing students to provide gender-affirming care to transgender patients.

Curriculum Integration Process

The Transgender Curriculum Integration Project, initiated in response to the lack of LGBT-specific curricular content identified by students and faculty in a school-wide diversity survey, was actualized through four main steps. First, we presented a preliminary outline of potential curricular changes to the Baccalaureate Curriculum Committee and received approval to weave new transgender health content into courses throughout the curriculum. Second, we conducted a literature review and spoke with key informants in the medical and lay communities to identify priority transgender health topics that could be addressed within the context of the existing curriculum. These topics were (a) health inequities, (b) gender-affirming language and best practices, (c) preventive health, (d) mental health, (e) gender-affirming interventions, and (f) prenatal care. Third, we identified and reached out to faculty members leading courses with content that paralleled these topics. These courses were Professional Role Development in Nursing, Health Assessment, Pharmacology, Psychiatric-Mental Health Nursing, and Nursing in the Childbearing Family. All contacted faculty members agreed to integrate transgender content into their courses. Fourth, we had one to two meetings with each of the faculty members in the months leading up to the start of each course. We shared key points relevant to the faculty members’ courses and worked with them to identify the most effective and feasible way to deliver this new content to their student audience. Methods for integrating content differed across courses due to variations in syllabi structure, as well as faculty members’ availability and baseline knowledge of transgender health topics. We followed up with faculty members to confirm they had delivered the new transgender health content as planned.

New Content Added to the Curriculum

New transgender health material was added to five required courses over three semesters: three introductory core classes and two clinical specialty classes (Table 1). In each of the three introductory courses, we included key points on the following topics: health inequities, gender-affirming language and best practices, preventive health, and hormone use. In the Professional Role Development course, we developed a 20-minute introductory webinar that addressed discrimination against transgender patients in health care settings; introductory terminology; asking about name and pronoun preferences; best practices for conducting a physical assessment in a respectful and comfortable manner; and an overview of gender-affirming interventions (e.g., hormones, surgery). This webinar was included as a required component of an online learning module on social determinants of health. In the Health Assessment course, we added to previous content on gender-affirming language and best practices by including key points on taking a sexual history in a gender-affirming manner. We also included key points on cancer screening recommendations for transgender patients. In the Pharmacology course, we added three slides on hormone use for transgender individuals to an online lecture on drugs affecting sexuality. Key points highlighted in these slides were goals of hormone therapy, hormone administration methods, and hormone monitoring.

TABLE 1.

Transgender Health Content Integrated into Five Baccalaureate Courses

Course	Topic	Key Points	Method of Content Integration
Professional Role Development in Nursing	Health inequities Gender-affirming language and best practices Gender-affirming interventions	Rates of discrimination in health care settings Introductory terminology Asking about name and pronoun preferences Physical assessment best practices Overview of gender-affirming hormones	Topics were incorporated into a 20-minute introductory webinar. The webinar was included in an online learning module on social determinants of health.
Health Assessment	Gender-affirming language and best practices Preventive health	Taking a sexual history in a gender-affirming manner Cancer screening recommendations for transgender patients	Topics were incorporated into in-class lectures on taking a sexual history and cancer screening.
Pharmacology	Hormone use	Goals of hormone therapy Hormone administration methods Hormone monitoring	Topics were addressed on three slides, which were incorporated into an online lecture on drugs affecting sexuality.
Psychiatric-Mental Health Nursing	Mental health	Stigma Suicide Gender dysphoria and the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (American Psychiatric Association, 2013)	Topics were addressed on four slides, which were posted to the online course site to accompany materials on suicide.
Nursing in the Childbearing Family	Prenatal care	Gender-affirming language and best practices Gender-affirming antepartum care	Topics were incorporated into existing slides and discussed during an in-class lecture on antepartum nursing assessment.

In the two clinical specialty courses, we briefly reviewed gender-affirming language and best practices and provided key points on specific topic areas. In the Psychiatric-Mental Health Nursing course, we integrated four new slides on transgender mental health into an online module about suicide. Key points discussed on these slides were transgender stigma, increased rates of suicidal ideation and suicide attempt, and the role of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (American Psychiatric Association, 2013), in transgender health. In the Nursing in the Childbearing Family course, we added key points about prenatal care for transgender patients into the existing slide set for an in-class lecture on antepartum nursing assessment. We revisited best practices for taking an initial patient history and conducting a physical assessment in a respectful and comfortable manner in the context of a prenatal visit. We also edited slides to make language and content more inclusive (e.g., changing “mom” to “parent”).

We drew new content from evidence-based interdisciplinary guidelines on transgender health, peer-reviewed literature, and grey literature (Table 2). We consulted transgender health experts and community members to validate our findings and to inform content development in subject areas for which evidence-based nursing guidelines do not yet exist. We applied the nursing process framework to the interdisciplinary guidelines to select content that was relevant to nursing care of transgender patients in our identified topic areas. We then matched selected content with students’ nursing knowledge level as they progressed through the program. For example, transgender content presented in the introductory-level Professional Role Development in Nursing course used students’ early knowledge of the nursing process (e.g., physical assessment). Advanced concepts related to implementation and evaluation of hormone therapy for transgender patients were covered in Principles of Pharmacology, a second-semester course. We leveled transgender health concepts such that students’ knowledge of effective gender-affirming care would strengthen and expand as they progressed from core to specialty courses.

TABLE 2.

Guidelines and Resources for Transgender Health Care Delivery

Name	Source	Description
Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (World Professional Association for Transgender Health)	http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351&pk_association_webpage=4655	Provides professional guidelines for transgender health care based on available science and expert professional concensus Free PDF version includes information on primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments
Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People (University of California, San Francisco, Center of Excellence for Transgender Health)	http://transhealth.ucsf.edu/trans?page=protocol-00-00	Provides peer-reviewed medical guidance on a range of transgender health topics Free and easy-to-use online tool that is updated and validated as new evidence becomes available
National LGBT Health Education Center (The Fenway Institute)	http://www.lgbthealtheducation.org/	Provides free on-demand webinars and learning modules on a wide range of LGBT health topics for health care providers Webinar topics range from “Understanding and Assessing the Sexual Health of Transgender Patients” to “Providing Care and Support for Transgender Rural Latino/as and Migrant Farmworkers”
Lavender Health Education for Health Care Providers (Lavender Health LGBTQ Resource Center)	https://lavenderhealth.org/education/	Nursing-centered Web site and resource center for educating health care providers about LGBTQ health Provides free information that can be used across education programs and levels to introduce basic LGBTQ care concepts to students and practitioners
LGBTQ Cultures: What Health Care Professionals Need to Know About Sexual and Gender Diversity, 2nd edition (Eliason & Chinn, 2015)	https://www.amazon.com/LGBTQ-Cultures-Healthcare-Professionals-Diversity-ebook/dp/B01ACDU6HQ/185-1613892-6973602?ie=UTF8&keywords=lgbtq%20cultures&qid=1452484030&ref_=sr_1_2&sr=8-2#navbar	E-book that provides an introduction to LGBTQ health for health care professionals and includes materials for teaching Discusses important topics in LGBTQ health and health care disparities, including the impact of stigma on health and older LGBTQ adults.
Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, or Born with DSD (American Association of Medical Colleges)	http://offers.aamc.org/lgbt-dsd-health	Publication designed to support medical schools in integrating LGBT health content into their curricula Provides an outline for integrating key concepts into curricula and offers clinical scenarios and discussion points for teaching

Note. LGBT = lesbian, gay, bisexual, and transgender; LGBTQ = lesbian, gay, bisexual, transgender, and queer.

Conclusion

The Transgender Health Curriculum Integration Project was well received by the Baccalaureate Curriculum Committee, faculty, and students. The curriculum committee welcomed the integration of diversity-related curricular content and supported the use of a student–faculty partnership model. Faculty members affirmed that transgender health was an important and relevant topic and welcomed collaborative integration of content into their courses. Students expressed interest in the explicit discussion of and instruction regarding caring for transgender populations.

Feedback from both faculty and students highlighted the potential value of faculty development on transgender health topics, which were not formally included in our work. This feedback reflected recent findings from a national survey of baccalaureate nursing faculty, the majority of whom expressed a need for faculty development in LGBT health to increase readiness to teach LGBT health topics (Lim et al., 2015). While the student–faculty partnership fostered informal transgender health training at this School of Nursing, more formal and sustainable faculty training programs on transgender health topics will be integral to the success of ongoing efforts at the of Nursing and other programs nationwide (Lim et al., 2015).

We have established a framework for increasing the number of nurses who are prepared to deliver gender-affirming and effective care to transgender patients by making small, well-integrated additions of transgender health content to existing baccalaureate curricula. We mitigated common barriers to developing and integrating new, diversity-related topics into a baccalaureate nursing curriculum (e.g., limited classroom time and space in curriculum, limited guidance on how to integrate topics, limited knowledge of topics) by using a student–faculty partnership model and making meaningful and feasible content additions (e.g., two to five key points per course) in five required courses.