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Position Statement: Healthcare for Transgender and Gender Diverse Individuals

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The National Association of Nurse Practitioners in Women’s Health (NPWH) affirms each individual’s right to quality, evidence-based sexual and reproductive healthcare and celebrates diversity of sexuality, gender identity, and gender expression. NPWH is committed to providing quality sexual and reproductive healthcare to all individuals, regardless of gender identity or expression. Table 1 provides gender identity-related terminology and definitions.17

NPWH continues to support initiatives to address the healthcare needs of transgender and gender diverse (TGD) individuals and the implementation of policies and strategies to reduce barriers to inclusive, quality healthcare for these populations. As an organization, NPWH opposes all forms of discrimination against individuals based on sexual orientation, gender expression, or gender identity and urges nurse practitioners (NPs) to speak out against discrimination, violence, and maltreatment of TGD individuals.

NPWH supports the role of women’s health nurse practitioners (WHNPs) in providing gender-affirming hormone therapy and pre- and post-gender-affirming surgical care for individuals. The eighth edition of the NPWH guidelines for practice and education includes recommended content on counseling and management of gender-affirming treatments to be included in educational curricula.2 NPWH supports all WHNP educational programs to include this content.

NPWH continues to provide leadership in the care of TGD individuals through offering educational opportunities and by collaborating with other healthcare organizations that specialize in the care of these populations. NPWH also continues to collaborate with organizations and agencies to develop policies and support research that promotes inclusive, quality evidence-based care.

BACKGROUND

The number of healthcare providers (HCPs) who are adequately prepared to provide care that addresses the unique health concerns of TGD populations continues to be insufficient. Many HCPs report feeling under-trained and ill-equipped to care for these populations. Education for HCPs has not adequately addressed the health disparities and healthcare needs of TGD individuals or the provision of culturally responsive care.3

TGD individuals have a right to care that aligns with and affirms their gender identity. Transgender individuals have reported a lack of providers with knowledge and expertise in transgender care as the largest barrier to their accessing healthcare.4,5

Fear of discrimination and actual discrimination are realities for TGD individuals in every aspect of their lives, causing chronic high levels of stress that can adversely affect physical and mental health. Experience of microaggressions, misgendering, and outright discrimination in healthcare settings are additional barriers to care.3 Trauma-informed care acknowledges the need to understand a patient’s life experiences in order to deliver effective care and has the potential to improve patient engagement, treatment adherence, and health outcomes. Inadequate access to trauma-informed care before, during, and after gender-affirming treatment may lead to physical and psychological harm and avoidance of routine reproductive and sexual healthcare.6

As the rights of TGD people are being threatened by state laws, it is more important than ever to provide needed healthcare to these individuals.

IMPLICATIONS FOR WHNP PRACTICE

WHNPs provide reproductive and sexual healthcare for individuals from puberty though the adult lifespan that is inclusive of all gender identities. They play an important role in filling the need for HCPs who have the knowledge and experience to provide reproductive and sexual healthcare for TGD individuals. WHNPs should assess their current knowledge and experience related to providing care for TGD individuals and seek additional learning opportunities as needed. Table 2 provides a list of educational resources.

Reproductive and sexual health concerns for TGD individuals are in some respects similar to those of cisgender individuals and in other respects unique. As with any patient, obtaining a comprehensive reproductive and sexual health history from TGD patients is critical for tailoring and individualizing recommendations for screening, testing, and treatment. Recommendations for reproductive and sexual health screening are:

  • Cervical cancer screening for any individual with a cervix should be based on the same guidelines used for cisgender individuals.7-9
  • Prostate cancer screening for any individual with a prostate should be based on the same guidelines used for cisgender individuals.7-9
  • Sexually transmitted infection (STI) and HIV screening should be based on sexual behaviors and current anatomy.7–10

    Recommendations for reproductive and sexual health counseling are:

  • Counseling about risk reduction for STIs and HIV should be based on sexual behaviors and current anatomy.7–10
  • Reproductive life planning should include discussion of the potential for becoming pregnant or contributing to pregnancy in a sex partner, the desire for pregnancy or other types of family building, and, as appropriate, discussion about contraceptive choices.

Reproductive and sexual health considerations unique to transgender individuals include:

  • Specific breast cancer screening recommendations for transgender people on estrogen hormones have not been established. The University of California San Francisco (UCSF) guidelines recommend routine breast cancer screening (mammogram) for all trans people aged 50 years and older who have been on estrogen- containing hormone therapy for 5 to 10 years.7,8
  • Transgender people who developed chest tissue via natal puberty and who have not undergone chest reconstruction/mastectomy (including those who have had only breast reduction) should have breast cancer screening per current recommendations for cisgender women.7,8
  • Transgender men and gender nonconforming individuals may experience pelvic examinations as triggering and/or traumatic. Examinations should be performed using trauma-informed care principles.
  • Information about gender-affirming hormone treatment, surgical procedures, and other interventions, as well as referral resources, should be readily available.
  • Reproductive options and fertility preservation should be discussed prior to initiation of gender-affirming medical or surgical treatment and on an ongoing basis. This discussion should include information on the potential impact gender-affirming therapy may have on fertility as well as contraception options if desired.7-10
  • It is within the scope of practice of WHNPs to provide gender-affirming hormone treatment using appropriate guidelines and resources (Table 3).2,9Mental health considerations include:
  • All patients, regardless of gender identity, should be screened for depression, anxiety, and suicidal ideation according to current guidelines.
  • Mental health referrals should be provided for transgender and gender nonconforming individuals to HCPs who are trained to address these individuals’ specific needs.

    RECOMMENDATIONS

    NPWH recommends that WHNPs:

    • Engage in learning opportunities to enhance their ability to provide culturally responsive, knowledgeable, and inclusive healthcare for TGD individuals.
    • Provide a safe and welcoming healthcare environment for TGD individuals, with implementation of inclusive nondiscrimination policies, use of gender-neutral language, written and verbal opportunities for patients to provide their name and pronouns, and consistent use of individuals’ correct name and pronouns.
    • Ensure that all staff are appropriately trained and actively participate in all aspects of providing a safe and inclusive healthcare environment for TGD individuals.
    • Provide reproductive and sexual health counseling, screening, testing, and examinations based on individual needs of all patients.
    • Provide information about options for gender- affirming medical treatment and surgical procedures.
    • Establish referral resources to ensure that patients have access to knowledgeable, culturally competent HCPs who can meet TGD individuals’ unique healthcare needs (if these needs cannot be fully met in one’s own clinical setting).NPWH will provide leadership to ensure that:
  • Continuing education programs are available for NPs to further their knowledge and cultural competency to meet the unique healthcare needs of TGD people.
  • NPs have resources available to guide the development and implementation of office policies related to nondiscrimination and inclusive healthcare environments.
  • Educational programs for WHNP students include sexual and reproductive healthcare that is inclusive of TGD people to prepare future NPs to provide evidence-based, culturally competent care for these individuals, as outlined in the eighth edition of the NPWH guidelines for practice and education.2
  • Research regarding health disparities, needs, and goals relating to TGD people is encouraged and supported.14

TABLE 1. GENDER- RELATED TERMINOLOGY AND DEFINITIONS1

Sex assigned at birth

The sex, male, female, or intersex assigned to individuals at birth based on their external genitalia or known chromosomes

Gender

A social construction assigning roles and attributes to a person, often based on sex assigned at birth

Gender identity

One’s internal sense of one’s gender

Gender expression

Outward manner in which one displays one’s gender

Cisgender

Denoting a person whose gender identity is the same as the sex they were assigned at birth

Transgender

An umbrella term for individuals whose gender identity and/or gender expression is different from cultural expectations based on the sex they were assigned at birth

Transgender man

Individual who identifies as a man/masculine and was assigned female sex at birth

Transgender woman

Individual who identifies as a woman/feminine and was assigned male sex at birth

Gender nonconforming

A broad term referring to people who do not behave in a way that conforms to the traditional expectations of their gender, or whose gender expression does not fit neatly into a category. While many also identify as transgender, not all gender nonconforming people do.

Nonbinary

An adjective describing a person who does not identify exclusively as a man or a woman. Nonbinary people may identify as being both a man and a woman, somewhere in between, or as falling completely outside these categories. While many also identify as transgender, not all nonbinary people do. Nonbinary can also be used as an umbrella term encompassing identities such as agender, bigender, genderqueer, two spirit, or gender-fluid.

Gender-affirming treatment

Medical, surgical, legal, spiritual, social, or other intervention used to align gender expression, social perception, and/or physical appearance with gender identity

Sexual orientation

A person’s pattern of emotional, romantic, and sexual attraction (not directly related to gender identity)

TABLE 2 . RESOURCES FOR CONTINUING EDUCATION

National LGBTQIA+ Health Education Center – The Fenway Institute 
GLMA – Health Professionals Advancing LGBTQ Equality
Center of Excellence for Transgender Health – UCSF
World Professional Association for Transgender Health (WPATH)
Human Rights Campaign
National Center for Transgender Equality
Williams Institute

TABLE 3 . RESOURCES AND GUIDE LINES FOR GENDER-AFFIRMING HORMONE THERAPY 7, 8 ,11 –13

Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People – UCSF Center of Excellence for Transgender Care

Medical Care of Trans and Gender Diverse Adults – Fenway Health

Protocols for the Provision of Hormone Therapy – Callen-Lorde Community Health Center Transgender Health Services

Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People – World Professional Association for Transgender Health (WPATH)

Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline

REFERENCES

  1. Human Rights Campaign. Glossary of terms.

  2. National Association of Nurse Practitioners in Women’s Health. Women’s Health Nurse Practitioner Guidelines for Practice and Education, 8th ed. Washington, DC: NPWH; 2020.

  3. James SE, Herman JL, Rankin S, et al. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016.

  4. Waryold JM, Kornahrens A. Decreasing barriers to sexual health in the lesbian, gay, bisexual, transgender, and queer community. Nurs Clin North Am. 2020;55(3):393-402.

  5. Safer JD, Coleman E, Feldman J, et al. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes. 2016;23(2):168-171.

  6. Tillman S. Consent in pelvic care. J Midwifery Womens Health. 2020;65(6):749-758.

  7. Deutsch MB, ed. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. 2nd ed. San Francisco, CA: UCSF Transgender Care; 2016.

  8. Thompson J, Hopwood RA, de Normand S, Cavanaugh T. Medical Care of Trans and Gender Diverse Adults. March 2021. Fenway Health, Boston, MA.
  9. American College of Obstetricians and Gynecologists. Committee opinion no. 823. Health care for transgender and gender diverse individuals. Obstet Gynecol. 2021;137(3):e75-e88.

  10. Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2012;70(4):1-187.

  11. Callen-Lorde Community Health Center. Transgender health. Protocols for the Provision of Hormone Therapy. 2014.

  12. World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 7th version. 2011.

  13. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):3869-3903.

  14. Agénor M, Murchison GR, Najarro J, et al. Mapping the scientific literature on reproductive health among transgender and gender diverse people: a scoping review. Sex Reprod Health Matters. 2021;29(1):1886395.

Approved by the NPWH Board of Directors: October 2017, as Healthcare for Transgender and Gender Non-Conforming Individuals

NPWH gratefully acknowledges Becky Altman, MPH, MSN, WHNP-BC, FNP-BC; Catherine Dezynski, CNM, WHNP-BC; Liz Higgins, WHNP-BC, ANP-C; Beth Kelsey, EdD, WHNP-BC, FAANP; Coralie Pederson, MSN, WHNP-BC; Susan Rawlins, MS, WHNP-BC, and Michelle Schramm, MS, WHNP-BC for their contributions as writing group members for the original position statement.

Update approved by the NPWH Board of Directors, May 2022

NPWH gratefully acknowledges Hanne Harbison, MHSPH, MSN, WHNP-BC (Lead Writer); Casey Benchimol, MSN, WHNP-BC, AGNP-BC; Kristin Gianelis, DNP, ANP-BC, WHNP-BC; Beth Kelsey, EdD, WHNP-BC, FAANP; Heather Quaile, DNP, WHNP-BC; and Michelle Schramm, DNP, CRNP, WHNP-BC, for their contributions as writing group members for this position statement update.

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