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The art and science of nursing are both critical for transgender patients

The magic of nursing makes the difference in improving patient outcomes, says professor Erin Ziegler
By: Bonte Minnema
March 29, 2021

Erin Ziegler, an assistant professor in the Daphne Cockwell School of Nursing, recently published a new study, external link, opens in new window that looks at the various ways nurses play a role in caring for transgender individuals and how nursing care can make an essential difference to these patients. This study is a component of a more extensive study in which Ziegler examines ‘Models of Care’ and how interprofessional teams provide care to transgender individuals. “When I was writing up the Care Team results, there were so many key findings and points of care that related to nurses and care that specifically nurses were, or could be, providing. This data inspired me to do a secondary data analysis specifically looking at nurses and their role in providing care to transgender individuals. In many ways, I wrote this for nurses and nurse leaders to provide some insight into how they can provide care to transgender individuals,” said Ziegler. 

“There are a lot of gaps when it comes providing gender affirmative care to transgender individuals. Nurses can play a key role in bridging those gaps for patients. We can all advocate for training, updating materials like intake forms, say at staff meetings or with our managers, to be more inclusive of gender diversity. Nurses, specifically, have direct and ongoing contact with patients. They are often a patient’s first medical contact at a clinic. When we look to what we call ‘the aesthetic’ or ‘art’ of nursing, as my research shows, nurses have many opportunities to make a meaningful and lasting positive impact on patients, in particular those who are transgender.”  

Ziegler has collaborated with Rainbow Health Ontario , external link, opens in new windowfor her research. She also attends to patients at her clinical practice, the Wise Elephant Family Health Team, external link, opens in new window, in Brampton. She is the clinical lead of their Transgender Care Program, where she receives five to seven referrals a month of patients seeking out her care. It was an early patient of Ziegler’s that inspired her to follow this clinical and research path. “I was in my first year as a nurse practitioner and saw a patient for an acute respiratory infection. This patient came back to me a few weeks later and came out to me as transgender, telling me that no one else in their life knew this, and they had been managing their transition by ordering hormones on the internet. I was honoured that this patient trusted me enough to share what they were going through. I had to admit that I did not know how to best support them at that time, but I knew how brave my patient’s request was and promised to find out and get back to them. I did, and that is how this started,” said Ziegler. In the years since she’s answered that question, she’s seen 300-400 patients on their gender-affirming journey. She also works with primary care providers to build capacity and support for transgender individuals into their clinical practice. 

“I’m glad to be doing this work because it reminds me of the importance of breaking down barriers and building access for patients. Many people don’t know, for example, that nurses can, when working in the full scope of their license, provide many patient services in a primary care setting. Nurse practitioners can offer birth control, the morning-after pill, and transitional hormones,” said Ziegler. “Nurse practitioners can also provide access to medication to delay puberty and the onset of secondary sex characteristics like body hair or breasts. This delay gives a patient more time both in their process and time with their healthcare practitioners. Secondly, it can help reduce the number of surgeries a patient may need further in this process by delaying the onset of secondary sex characteristics. For example, I have a patient who, likely, will not need chest wall surgery, also known as ‘top surgery,’ because we were able to delay puberty and breast development. We can help prevent transgender women from developing their adam’s apple by putting a pause on puberty. So nurses, working to the full scope of their license, can improve patient outcomes and optimize everyone’s time at the clinic; building capacity for care into the system.” The medication needed to support transgender patients is very similar, as an example, to the birth control that nurses can provide for cis-gendered patients. “Nurses, or their clinics, might just need the training or the willingness. Registered nurses can provide care plans and case management for patients, also. Until recently, access to puberty suppressants remained highly controlled by endocrinologists and specialists, so in the spring of 2020, Rainbow Health started training nurse practitioners and family physicians in puberty suppression in primary care. I took it and am a primary care provider to 150 transgenderindividuals,” said Ziegler

That is the science side of it. There is also what we call the ‘art of nursing.’ Often a patient’s first medical contact in a clinic setting is with a nurse. As clinics work on updating systems to reduce binary gender-based assumptions, nurses can bridge those patient experiences with gender-affirming personal contact. Nurses can ask for a patient’s preferred name, which, for transgender individuals, often won’t match their health card. This request is one small change that health care providers can make to optimizing their availability and competency to provide care to transgenderindividuals. “We now know patients often avoid disclosing if they have to tick a gender on a box that they don’t feel is reflective of their reality. Nurses really can be the advocate to say things for patients and advocate for forms, or that make it right when they are misgendered based on preferred v.s. legal names and genders. Nurses can lead the way to make their workplaces inclusive and gender-affirming,” said Ziegler.

Ziegler’s primary focus is understanding the barriers to access faced by the transgender population, why they aren’t accessing care, and what does help them feel comfortable accessing the care they need. In addition to her research into how to optimize care for patients in care teams, she has two separate studies looking at transgender access to care in Northern and Southern Ontario. “In both cases,” she says, “there many ways nurses can do to bridge the gap.”

“I don’t feel I have the lived experience to offer advice to transgender individuals,” said Ziegler. “That said, finding a health care provider that patients feel safe and comfortable talking to is an important part of accessing care. Sometimes networking with transgender individuals can help to find referrals. I know that it can be intimidating if you don’t know what the response will be when you talk to a care provider. Rainbow Health Ontario has a database of providers who can provide trans-affirming care, and this database might be useful. Sometimes it might be more comfortable for patients to go where they know that trans-affirming care is already offered. There is still stigmatization in health care, and it can be a very vulnerable place for transgenderindividuals to go there and not know what kind of reception they will get.” 

“We have many seminars for health care providers. ‘Transgender affirmation’ is a conversation that should be happening in all health care settings - removing the gender binary from forms, using gender-affirming language, connecting with Rainbow Health Ontario. They have many course offerings, external link, opens in new window, including terminology, clinical aspects of transition like hormones, and post-operative care,” said Ziegler. “The Nurse Practitioner Association of Ontario, external link, opens in new window is doing a conference in March, and it will be a safe place for nurse practitioners to ask questions about how to provide gender affirmative care. Online learning, like Sexual Orientation and Gender Identity in Nursing, external link, opens in new window, an e-learning tool kit about providing culturally humble care to the LGBTQI2S community. The thing to know is there are many ways nurses can be part of the solution and help provide improved patient outcomes.”