Perspectives from Nurses and Physicians on Training Needs and Comfort Working with Transgender and Gender Diverse Youth

Abstract

Introduction:

Nurses and physicians receive minimal training about providing competent care to transgender and gender diverse (TGD) patients, and training specific to TGD youth is particularly lacking. This qualitative study examined healthcare providers’ experiences and attitudes about working with TGD youth to identify specific training needs.

Method:

Semi-structured interviews were conducted with 14 nurses and physicians who work with adolescents. Thematic analysis was used to characterize participants’ responses.

Results:

Five themes summarized participants’ responses to interview questions: 1) training regarding gender diversity, 2) discomfort with gender-related topics, 3) reasons for not asking about gender, 4) talking about gender with patients, and 5) need for resources.

Discussion:

Findings highlight multiple opportunities to improve provider education and care experiences of TGD youth. Specific training is needed to assist providers with managing discomfort with gender-related topics while simultaneously developing their knowledge and skills to discuss gender issues.

Significant disparities in health, health-risk behaviors, and healthcare access and utilization exist between transgender and gender diverse (TGD)¹ and cisgender² youth (Rider et al., 2018; Vance, Halpern-Felsher, & Rosenthal, 2015). Compared to cisgender peers, TGD youth report higher rates of substance use, emotional distress, longer-term health problems, and risky sexual behaviors, which are likely outcomes resulting from minority stressors including stigma, harassment, and violence (Eisenberg et al., 2017; Perez-Brumer, Day, Russell, & Hatzenbuehler, 2017; Rider et al., 2018; Veale, Watson, Peter, & Saewyc, 2017). TGD youth also report using preventive care at lower rates than cisgender peers but visit school nurses more frequently (Rider et al., 2018). Thus, in the context of increased need for healthcare, preventive screening, and anticipatory guidance, TGD youth underutilize traditional venues for care.

TGD people continue to confront challenges to care. For example, TGD patients experience discrimination and reluctance to disclose gender identities due to concern of negative consequences, lack of knowledgeable providers, and other structural barriers (e.g., being addressed by the wrong name due to limited data in electronic health records) (Corliss, Belzer, Forbes, & Wilson, 2007; Lerner & Robles, 2017; Roberts & Fantz, 2014; Safer et al., 2016; Sperber, Landers, & Lawrence, 2005; Stoddard, Leibowitz, Ton, & Snowdon, 2011). Furthermore, TGD individuals are often obliged to serve as educators due to providers’ limited knowledge about gender identity and expression as well as transgender health topics (Bauer et al., 2009).

Transgender health is not a required topic in medical provider education, contributing to gaps in knowledge of evidence-based standards and barriers to care (Paradiso & Lally, 2018). U.S. and Canadian medical education programs only allocate a median of five hours of LGBT-related content for entire curricula, and seven out of 10 medical school deans endorsed that their LGBT-related course content was fair-to-very poor (Obedin-Maliver et al., 2015). Nursing education spends even less time; about 2 hours is devoted to LGBT healthcare, according to a national nursing faculty survey (Kellett & Fitton, 2017). A recent qualitative study suggests education for nurse practitioners may address transgender issues as a generalized diversity topic but not a curriculum requirement (Paradiso & Lally, 2018).

Notably, Vance and colleagues (2015) indicated 86% of adolescent and pediatric specialists in their study desired training in transgender health. Gender is considered a core diversity issue in medical and nursing schools; however, it is unclear how much time is dedicated to TGD health when it is collapsed into LGBT-related content (e.g., Bayer et al., 2017; Shindel, Baazeem, Eardley & Coleman, 2016; Smith & Fitzwater, 2017). Training specific to TGD youth is particularly lacking, which is critical considering the unique needs that emerge with the intersection of adolescence and gender identity/expression. Without training specific to TGD youth, healthcare providers are less likely to be able to provide competent care to meet the needs of this underserved community.

The broad goal of this qualitative study was to describe healthcare providers’ training regarding TGD youth, needed resources, and their comfort and confidence with this topic. The overarching study question was: What do healthcare providers need to work more effectively with TGD adolescents? This information is crucial to improving healthcare access for TGD youth and may decrease the likelihood of TGD youth forgoing or delaying care because of negative experiences in healthcare settings.

Methods

Recruitment and Sample Characteristics

Purposive recruitment strategies, relying upon the team’s professional networks, were employed to invite participation, including emailing physicians and nurses who completed the interdisciplinary Leadership for Education in Adolescent Health post-graduate training program at the [university]. As a secondary strategy, healthcare providers identified as competent and knowledgeable in transgender health by community partners as well as contacts in school-based clinics were invited to participate. Participants were also asked to share study information with colleagues. Potential interviewees were screened to determine whether they provided services to adolescents. After providers were consented, a video conference, phone, or in person interview was scheduled. The Institutional Review Board at the [university] approved all study protocols.

Eight nurses and six physicians who work with adolescents participated. Providers completed a brief survey detailing gender identity, personal pronouns, race/ethnicity, specialty (e.g., nurse practitioner, family medicine physician), healthcare setting, and years of practice. Characteristics are reported in Table 1.

Table 1.

Characteristics of Providers

	Profession	Years in Practice	Practice Setting(s)	Gender	Pronouns	Race/ethnicity	Location
Participant 1	Advanced Practice Nurse	5–9	Academic med. Center; hospital; outpatient practice	Female	she/her/hers	White, NH	City
Participant 2	Physician	10+	School-based health center; univ.-based clinic	Female	she/her/hers	White, NH	Large City
Participant 3	Advanced Practice Nurse	< 5	Community clinic; school	Female	she/her/hers	White, NH	Large City
Participant 4	Advanced Practice Nurse	10+	Hospital	Female	Ms., Dr.a	White, NH	City
Participant 5	Advanced Practice Nurse	10+	Community clinic; school	Female	she/her/hers	White, NH	Suburban Town
Participant 6	Physician	10+	Hospital	Male	he/him/his	White, NH	Large City
Participant 7	Physician	10+	Private practice	Female	she/her/hers	White, NH	Large City
Participant 8	Physician	5–9	Private practice	Female	she/her/hers	White, NH	Large Town
Participant 9	Advanced Practice Nurse	5–9	Community clinic	Female	she/her/hers	White, NH	Large Town
Participant 10	Physician	10+	Private practice	Male	Name	Asian & White, NH	Suburban Town
Participant 11	Advanced Practice Nurse	< 5	Family planning clinic	Female	she/her/hers	White, NH	Town
Participant 12	Registered Nurse	10+	Family planning clinic	Female	she/her/hers	White, NH	Large Town
Participant 13	Physician	10+	Community clinic; hospital	Female	her-hers	White, Hispanic	Large City
Participant 14	Advanced Practice Nurse	5–9	Family planning clinic	Female	she/her/hers	White, NH	Large Town

Note. NH = non-Hispanic.

^aThese are the terms volunteered by this respondent when asked for personal pronouns.

Interviews

Table 2 lists the semi-structured, open-ended questions used to elicit information about patient encounters, experiences discussing gender-related concerns, training received regarding gender identity and expression, and desired resources. Data collection spanned from November 2016-February 2017. Interviews were audio recorded, lasted 42 minutes, on average (range=28–56 minutes), and were professionally transcribed. Participants received a $150 gift card.

Table 2.

Main Semi-Structured Interview Questions

	Interview Question
Question 1	Please tell me generally about the clinic population you serve.
Question 2	When I say “transgender,” what does that term mean to you? What about “gender nonconforming” “genderqueer” “non-binary” or “cisgender”?
Question 3	Do you ever see patients who you would characterize as gender nonconforming, genderqueer, non-binary, or transgender?
Question 4	How do you talk with your patients about gender identity and expression? Can you give an example? How comfortable are you having these conversations with your patients?
Question 5	How do you talk with parents of adolescent patients about their child’s gender identity and expression? Can you give an example? How comfortable are you having these conversation with parents?
Question 6	Thinking about your clinic’s forms, online medical records and things like that, how do you note gender identity if it’s not strictly male or female? Do you have a way to note preferred names and pronouns? If so, how?
Question 7	Thinking back to your [medical/nursing] school days, your residency, continuing education, or other professional training, what, if anything, did you learn about gender identity and expression, or how to talk about it with your adolescent patients and/or their parents? What kinds of resources or materials did you receive (or hear about)?
Question 8	Thinking about continuing education, professional conferences you attend, or other ongoing training opportunities, what kinds of materials, resources, or training would increase your comfort in talking about gender with your patients? [Note: specify type of patient, if appropriate]
Question 9	Are there other things related to your work with adolescents or thoughts on gender identity issues that you’d like to bring up today?

Data Analysis

Thematic analysis was used to characterize participants’ responses (Braun & Clarke, 2006). Two coders independently reviewed transcriptions, grouped responses by interview questions, and assigned a theme to text portions that illustrated relevant points. Within themes, quotes were reviewed for subthemes, with discussion between coders to resolve discrepancies. The research team discussed the coding to increase validity of analysis and findings.

Results

Five themes characterized responses to interview questions: 1) training regarding gender diversity, 2) discomfort with gender-related topics, 3) reasons for not asking about gender, 4) talking about gender with patients, and 5) need for resources. Themes and subthemes are elaborated below, illustrated by representative quotes (refer to Table 1 for speaker details).

Theme 1: Training Regarding Gender Diversity

Little to no training.

Most interviewees, including those practicing for years and early career professionals, described receiving no training in academic programs regarding transgender health. Although many lacked training on gender identity and expression, a few received education on sexual orientation and sexuality. For example, Participant 8 shared, “In medical school…we were told to take a sexual history, but it was more number of partners and sexual preferences…not a huge emphasis placed on gender identity.”

Some participants independently sought educational opportunities, indicating that providers supplement training once in practice and want to learn more about gender issues in order to provide competent care. Participant 1 shared, “I’ve got a lot of experience, but none of it came from formalized academic setting; it was all on my own personal initiative.” Several providers reported attending continuing education trainings.

Some training.

Providers who received some training described two content areas: training that 1) focused on defining some identity terminology only or (2) went beyond definitions. Participants felt they received important knowledge but missed practical information necessary to provide competent care. In their experiences, relevant training was typically embedded in a brief presentation or one-hour group discussion.

…it was a one-page handout and it was the instructor in class…no guest speaker…no representation from anybody in the LGBTQ community… It was more like, ‘Hey, this exists, but we’ll just wait until you see it in your own practice to actually learn about it.’

(Participant 14)

Variation in reactions to such trainings was conveyed during interviews. While some expressed surprise that transgender health was not emphasized more in their programs, others were surprised to be discussing gender and sexuality at all. Participant 4 stated, “I remember just feeling in awe learning all these things…It was just like…I can’t believe that we’re actually hearing this in public, because it seemed like kind of a private thing.”

Theme 2: Discomfort with Gender-Related Topics

Providers expressed marked discomfort and hesitation about making mistakes during interactions with patients, due to a lack of training. Stating that while they do not have personal issues with TGD youth, they felt their inexperience with asking about pronouns and transgender issues would result in missteps with patient care. Participant 7 shared “…I’m comfortable talking about it; I just don’t feel like I have the tools to talk about it…Yeah, I don’t think it’s a personal issue. I think it’s more of a training issue.”

Acknowledging the ever-evolving language within this community, providers struggled with keeping up-to-date with terminology. Participant 4 described that gender can be a topic youth initiate but that she would make mistakes with terms: “…if one of the kids was comfortable explaining to me what their thoughts and feelings were around their gender identity, I would be fine talking with them about it. But I don’t think I could use the correct terms…” These concerns were echoed by a provider well-experienced in providing care to TGD youth who stated, “…we’re still developing the language in gender expression, so, even though I’ve been doing it for a long time, I find…community words have changed, or things that we use to describe something have changed” (Participant 6).

Theme 3: Reasons for Not Asking about Gender

Information available on forms.

Some providers do not ask about gender when meeting with TGD youth patients, instead rely on standard forms patients complete to gather information about gender identity, pronouns, or preferred names. For example, Participant 12 explained, “I have a demographic sheet…and it does give them an option to put born gender, and…their preferred pronouns, so I don’t diverge into too much personally with them about it. I just will try to use their preferred pronouns.”

Fear of offending or losing trust.

During patient encounters, some participants attributed hesitation or reluctance to discuss gender to concerns of being offensive or losing patient trust, instead expressing desires to be sensitive and nonjudgmental. For example, providers were concerned about misgendering (e.g., using incorrect pronouns) or not having the skills to approach a conversation about gender expression. These contributed to providers’ discomfort and possible avoidance of gender discussions.

… I don’t want to pass judgment on anybody. And again, it’s the uncomfortable; I don’t know what to say or how to say it without other people taking offense to it. I don’t want to offend anyone. I’m here to treat everybody as equals, and I don’t want them to feel uncomfortable coming to my clinic.

(Participant 11)

Theme 4: Talking about Gender

Participants with some expertise or experience working with TGD youth offered a range of possibilities for how and when to talk about gender with patients. Some providers only asked about gender identity of patients who presented to the appointment for a gender-related reason and shared that they do not initiate discussions about gender if it does not seem relevant to the presenting issue. For instance, Participant 14 stated, “Unless they are seeing me for transgender hormone therapy, it [gender] doesn’t come up [randomly like] ‘Now let’s take a moment and talk about [your gender]…’ It doesn’t necessarily come up like that.”

Some providers expressed desires to address patient health concerns while also incorporating educational gender discussions. Participant 6 described gender to patients as “being a spectrum, and that not everybody fits at one end of the spectrum, and that you could be anywhere in-between, and that’s normal.” Others asked about patients’ preferred language for body parts incorporate terminology of the patients’ choice while discussing exams or other medical information. Prior to conducting a physical examination, Participant 5 finds it important to ask “… specifically about how they want me to refer to their body parts, and [use] the language that is most comfortable to them.”

Furthermore, many providers stressed the importance of talking about gender identity and expression with all patients. Participant 6 shared that he talks about gender “…not as much as I’d like to, but certainly it’s part of my general intake with patients when I’m asking my broader range of questions.” Similarly, another said, “[asking about gender] is for everyone because they might be identifying themselves as cisgender right now, but…sometimes you have someone who is at that age of wondering…” (Participant 13).

Theme 5: Need for Resources

Training strategies for talking with TGD patients.

Participants expressed a desire for support regarding their discomfort in order to improve confidence and patient care. For example, Participant 7 recommended discussing cases because they are “…really important in terms of how they have an impact on me…[W]atch a provider pretend to have or a videotape of a provider having an interview with a patient and how they bring up issues.” Participant 2 described wanting an “exploration of clumsier conversations” and having “a small group or one-on-one where people practice talking about cases and how one should approach [gender discussions].” Other providers described needing specific examples of phrasing and language to use when initiating gender discussions. For example, Participant 9 shared, “I’m not going to just assume that the female has male partners, so why should I assume that because the chart says female, the person identifies as female? So having language to use. How do you even bring it up? What is an okay question?”

Hormone therapy/puberty suppression.

Even if they do not offer particular services, providers wanted foundational knowledge about hormone therapy and puberty suppression to be able to talk with TGD youth who might be interested in these gender-affirming interventions. Many noted lacking education to have even basic discussions about such services.

It would be helpful to have…very basic knowledge on hormone therapies and puberty suppression, because…I have no clue what that looks like, what that means, what that does to a person’s body…I wouldn’t even be able to broadly explain it to somebody who wanted more information.

(Participant 3)

…even though I’m not a provider that offers it, I feel like I would love to have the repertoire so that I could be like, ‘This is what’s available to you if you decide that’s the path you want to go. This is what you could expect.’ Risks, benefits, a full conversation about that would be helpful.

(Participant 5)

Professional network/consultation.

Providers shared an interest in developing a professional network for case consultation, calling for a multidisciplinary network to discuss the various concerns that arise when working with TGD youth. Participant 10 noted it would be helpful to ask “a therapist or a person that works in depth [with TGD youth]…can you help me understand what role I should be playing here and what referral patterns I can be looking at to try to help get this person whatever help they might need?” Participant 6 elaborated that a professional connection can be important “even if they’re not in the same field, they often will have a perspective that’s helpful.” Finally, another described the importance of expanding professional networks for wrap-around care:

“… not necessarily just clinic healthcare providers that are also providing hormone therapy, but also services for if you have a patient who’s trying to change their name on their ID or passport. Or what’s the process of going to court and trying to change their name without doing the IDs…I wish there was more than necessarily the clinics,…I want to be able to send them somewhere and know that they’re going to be taken care of.”

(Participant 14)

Hearing from TGD youth themselves.

Hearing first-hand from TGD patients about barriers, challenges, and successes is key to helping providers become allies. Although reading literature and doing research was a critical step to learning facts and becoming more informed, opportunities for patient-led, experiential learning were considered extremely important. In particular, Participant 11 noted the impact of hearing first-hand experiences and reflected on that impact:

For me, it’s hearing personal stories. That really sticks with me, hearing…real life experiences. It just breaks my heart when I hear people that have gone to a clinic and they’re being judged the whole time…I look at myself and maybe I’m being judgmental because I’m not even able to talk about it.

Discussion

This study described healthcare providers’ professional training related to working with TGD youth, explored comfort and confidence during patient encounters, and identified specific training needs and resources providers would like in order to work more competently with TGD youth. Providers described a range of comfort levels and a lack of training about gender identity and how to ask about gender issues. During patient encounters, providers expressed a desire to be sensitive and nonjudgmental; however, they expressed concerns with being perceived as offensive and thus tended to avoid gender discussions with adolescent TGD patients. Providers described having difficulty keeping up with changing gender-related terminology, having concerns with using incorrect pronouns, and not having the language to ask questions or start a discussion regarding gender with patients. Many providers wanted more resources and opportunities to network with others who have more experience working with TGD youth.

Findings suggest that healthcare education has inadequately prepared providers for working with TGD youth. These results are consistent with findings from other studies. Recent studies continue to document a lack of training regarding working with TGD individuals in healthcare provider education (Kellett & Fitton, 2017; Obedin-Maliver et al., 2015; Paradiso & Lally, 2018; Vance et al., 2015; Zaccagnini & White, 2011). This limited training creates and maintains barriers to care for TGD youth and may perpetuate health disparities given that providers are not educated on evidence-based practices or culturally competent patient encounters (Paradiso & Lally, 2018).

Furthermore, some providers are missing opportunities to initiate discussions about gender, which may convey caring and assist with building trust with TGD youth. Providers indicated that training significantly lacked content on how to approach conversations about gender, and having few opportunities to discuss their own comfort levels with working with TGD youth. When providers felt ill-equipped to discuss gender with patients, they often avoided the conversations or used their clinic’s standard forms rather than initiating this important discussion. Relying on TGD youth to initiate gender-related conversations places additional emotional burden on them – a community that has been historically discriminated against or treated insensitively in healthcare settings (Corliss et al., 2007; Lerner & Robles, 2017; Roberts & Fantz, 2014; Safer et al., 2016; Sperber, Landers, & Lawrence, 2005; Stoddard et al., 2011). Although it is important to have multiple methods to capture relevant information, solely using clinic forms disregards the fact that some TGD youth may not respond authentically on a form. Some TGD youth may be unwilling to disclose their gender identity, preferred name, or pronouns on forms, particularly if a parent (who is not supportive or the youth is not out to) is present and/or watching them complete the form.

Additionally, providing education to healthcare providers may remove barriers to care for TGD individuals (Paradiso & Lally, 2018). Studies demonstrate that knowledge and attitudes improve following training about TGD health needs (Lelutiu-Weinberger et al., 2016). Further, studies indicate that interacting with TGD individuals or exposure to TGD patients via training videos results in improved confidence, attitude, and performance of comprehensive physical examinations (Burch, 2008; Kelley, Chou, Dibble, & Robertson, 2008). When asked what resources would be helpful, providers shared a broad range of requests including, but not limited to, getting support through professional consultation, identifying a referral network, and having access to trainings on puberty suppression and hormone therapy. Results highlight an important point in provider education that comfort and confidence are not synonymous with knowledge and competence.

Limitations and Strengths

Purposively-recruited participants were volunteers and do not necessarily represent all adolescent health providers. Given the over-representation of white, non-Hispanic females in the sample, findings may best reflect experiences of this provider subgroup. Other limitations include that participants are from Minnesota and mostly from Minneapolis and St. Paul, which is generally more welcoming for LGBTQ+ individuals than other parts of the country. Findings from this group (e.g., general interest in being nonjudgmental and welcoming) may differ in other areas.

Despite these limitations, strengths included a diverse provider sample in terms of years of experience, a variety of specialties, and work in diverse settings. This range of backgrounds and experiences brought a multitude of perspectives into the interviews that added to the nuance and understanding related to training needs.

Conclusion

Results highlight multiple opportunities to improve healthcare education through both primary education (i.e. medical and nursing school) and continuing education, and ultimately, the healthcare experiences of TGD youth. Despite providers’ desire to provide care sensitively and nonjudgmentally, lack of educational opportunities may perpetuate or increase barriers to TGD youth care. Specifically, results suggest training is needed to assist providers with managing discomfort with gender-related topics while simultaneously developing their skills to discuss gender issues. Such efforts may result in increased access to care and improved quality of care for TGD youth.