Nurses are responsible for creating a nonjudgmental, welcoming environment for all patients. Still, transgender and gender-nonconforming patients continue to face healthcare prejudices and feel unwelcome in healthcare environments. To provide gender-affirming holistic nursing care requires a paradigm shift from a gender-binary to a gender-inclusive world view with continual ongoing self-assessment for bias. Nurses must learn more about gender transition and gender-affirming care to engage in therapeutic gender-affirming care.
How Is Gender Identity Different Than Gender Expression?
Nurses need to understand the differences between these two key concepts: gender identity and gender expression.
Gender identity is a person’s internal sense of being male, female, or something else such as agender, binary, gender fluid, gender non-conforming, genderqueer, or nonbinary. Gender identity is internal (not always visible) and intrinsic to all people.
Gender expression is how a person represents or expresses one’s gender identity to others, often through behavior, clothing, hairstyles, voice, or body characteristics, which can be masculine, feminine, neutral, or other.
Gender identity and gender expression are essential parts of who a person is and how they present themselves. However, a person’s gender expression may not correlate to their gender identity or match traditional masculine and feminine norms. Therefore, nurses cannot assume a person’s gender identity based on their gender expression. Likewise, when working with patients to provide gender-affirming care, nurses should not assume their gender identity based on how they dress, speak, or act.
What Is Gender Dysphoria?
One of the significant barriers to gender-affirming care is not understanding gender dysphoria. Patients experience gender dysphoria when there is a mismatch between their gender identity and their assigned sex at birth. As a result, there is a feeling of dissonance between one’s internal sense of self and the external presentation to others. This dissonance can cause distress and impact a patient’s physical and mental well-being.
Addressing gender dysphoria is often a lifelong endeavor with a team of providers from various specialties, including endocrinology, social work, psychology, psychiatry, voice therapy, gynecology, and plastic surgery. Unfortunately, a significant barrier to care is that not all patients experiencing gender dysphoria have access to comprehensive multidisciplinary care. Often, this requires traveling to a facility for expertise in the care of gender-diverse people.
Gender-affirming care can explore options to change their external self (body and gender expression) to match their internal sense of self (gender identity). Some patients prefer only to explore avenues to improve their mental health through non-medical methods such as therapy, counseling, and social support groups. Other patients may choose to use hormone therapy and surgical procedures to decrease their feelings of gender dysphoria. Regardless of patient choice, nurses can create a supportive environment.
What Is Gender-Affirming Care?
Gender-affirming nursing care is “the practice of nursing care without the impact of uninformed bias, especially in regard to gender where the nurse embodies acceptance and affirmation of the patient’s chosen gender, which may include the transformative process of negating prior societal or personal beliefs about gender.”
Examples of gender-affirming care can include:
- surgical procedures (mastectomy, phalloplasty, orchiectomy, facial feminization, filler injections)
- laser hair removal
- hormone therapy
- therapy or counseling
- social networking and support groups
- social transition
- legal transition
What Are Two Simple Best Practices for Gender-Affirming Care?
Not all nurses will work in a specialty clinic such as transgender and intersex care. Still, all nurses can follow two simple strategies with all patients to provide gender-affirming care.
- Never assume a patient’s gender identity.
One example of how nurses can build rapport with a patient is for nurses to provide their pronouns first, then ask for theirs. For example, “Hi, my name is Jill. I’ll be your nurse today. My pronouns are she/hers; how may I address you?” Leaving the question open-ended allows the patient to describe their gender identity in their own words. Even when working with trans youth, nurses must ask the patient (not the parent) about their gender identity.
- Ask patients about how they share their gender identity with others in their social circle.
“Do you want me to use a different set of pronouns/different name with any members of your support team?” can help prevent an accidental “outing” of the patient. Unfortunately, not all members of a patient’s family or community may support their gender identity, so listening to how the patient refers to themselves is essential.
Patients seeking gender-affirming care may not know what avenues they want to pursue or eligible routes or paths. Nurses can guide the patient through the process. There are many benefits for patients who receive gender-affirming care, including improved mental health and a better quality of life. Patients who receive gender-affirming care may also find it easier to socially transition and receive less resistance from systemic barriers in their everyday lives.