Community Based Nursing Education for Affirming Transgender Care

Elizabeth Spoering BS, RN

Simmons University Public Health Graduate Program December, 2024

• Introduction - slide 3
• Abstract – slide 4
• Trans Identities and Social/Structural Determinant of Healths – slide 5
• Nursing Comfort with Trans Care - slide 6
• Problem Statement - slide 7
• Integrating Trans Experiences in Medical Education - slide 8
• Project Narrative - slides 9-10
• Project Objectives and Activities - slide 11
• Deliverables – slide 12
• Partner Organization – slide 13
• Impact – slide 16
• References – slide 15
• Appendices (attached) :
• HECP Competencies
• Goals, Objectives and Activities
• Project Timeline
• Project Logic Model

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COMMUNITY BASED NURSING EDUCATION FOR AFFIRMING TRANSGENDER CARE

Table of Contents

“Of those who saw a healthcare provider within the last 12 months, nearly one-half (48%) reported having at least one negative experience because they were transgender, such as being refused health care, being misgendered, having a provider use harsh or abusive language when treating them, or having a provider be physically rough or abusive when treating them.” 2022 U.S. Trans Survey Early Insights Report

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Abstract

The 2022 US Transgender Survey of 92,329 transgender and gender diverse individuals revealed clear disparities in how trans people experience healthcare in the United States. Twenty four percent of respondents reported avoiding healthcare in the last year due to fear of mistreatment. Of respondents who had seen a provider in the last year, 48% reported at least one negative interaction. While negative interactions with providers are a serious issue within trans health, little research is devoted to the impact of negative experiences with other healthcare staff, particularly nurses. Studies show that nursing programs provide, on average, 2.12 hours of education dedicated to LGBTQ+ issues, and that up to 80% of practicing nurses have received no formal education on LGBTQ+ health issues. Of note, these studies examined training on the entire LGBTQ+ community, time devoted to trans care needs is presumably less. The proposed project helps address this gap in knowledge by creating an online, interactive training module for current nursing students and practicing nurses, focused on the unique care needs of trans individuals. This curriculum will use a combination of statistical data, reinforced with personal narratives of care from trans individuals, as research indicates that personal narrative is effective in communicating health messages. The curriculum will teach students basic terminology, provide guidance for conversations with trans patients, and provide an overview of common health concerns that impact the trans community. The final curriculum will be made available online for students to complete as a series of self-paced modules.

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Trans Identities and Social/Structural Determinants of Health

• In 2023 a cohort study of 139,484 trans and and gender diverse individuals in the UK published in JAMA found an increased risk of death for all causes in trans/gender diverse individuals vs. cisgender individuals.
• In the 2022 U.S. Trans Survey 24% of the 92,329 respondents reported avoiding needed care within the 12 months prior to the survey.
• 34% of respondents to the U.S. Trans Survey reported currently experiencing poverty, and 30% reported homelessness in their lifetime.
• 30% of respondents reported experiencing verbal harassment in the last year, with 3% reporting physical violence.
• A 2020 meta-analysis published in the American Journal of Public Health; trans individuals are 1.7 times more likely to experience intimate partner violence than cisgender individuals in their lifetime, and 2.5 times more likely to experience sexual violence.

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COMMUNITY BASED NURSING EDUCATION FOR AFFIRMING TRANSGENDER CARE

Nursing Comfort with Trans Care

• A 2024 study published in the Journal “Nurse Educator” found that following a 2-hour online training seminar with self-reflection, student nurses reported both increased understanding and comfort with providing care for trans and gender diverse communities (Carmichael, et. al., 2024).
• A 2022 meta-analysis of studies of comfort and competence of healthcare professionals found that training is effective in increasing comfort in providing care to trans individuals (Jecke & Zepf, 2022).

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Trans Comfort with Nursing Care

• “I have experienced a lot of negativity from nursing during my transition. For example, I was in the hospital for 13 days and at each interaction I asked to be called by my preferred name and NONE of the nurses would comply. They just kept calling me ‘Sir.’ Further I could hear them laughing and exclaiming insults at the nurse’s station regarding me, it made me feel terrible.”

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• “After explaining my case again, I sort of felt like a specimen nursing would come in and look and ask questions out of curiosity.”

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• “We are not just an extreme form of being gay, we are not all on hormones, and having surgery there are just a lot of assumptions out there that we need to clarify, and nurses are in a good place to help us do that.”

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“Care without Assumption: The Perceptions of Transgender Persons Regarding Their Experiences with Nursing Care” (Rivera, 2019)

Problem Statement:��Lack of quality community informed training for Healthcare workers in providing appropriate care creates a systemic barrier to health equity for trans and gender non-conforming individuals. This results is poor health outcomes for trans people as compared to the general population.

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Integrating Trans Experiences in Medical Education

“Involving people with lived experience in education of healthcare students and professionals can assist in developing skills for collaborative, compassionate, and person-centred care.” (Parnell, et. al., 2023)

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Project Narrative

The Trans and gender non-conforming communities face stigma and discrimination in healthcare at very high rates, resulting in reluctance to seek needed care, the “weathering effect” of discrimination, and poorer health outcomes when compared to cisgender individuals.

This project seeks to improve the care provided to trans individuals by creating a curriculum for student and current nurses with the goal of reducing stigma and the internalized bias that students may feel towards these individuals. This will take the form of an online self-paced learning module, designed for nurses and other non-provider health professionals, similar to the modules created by the precepting organization, Toadhenge consulting, available here: https://www.askmissjai.com/courses. The modules will use a combination of academic data and personal narratives to personalize the material and increase the impact on potential students.

Narrative stories will be solicited from a variety of trans voices, including non-binary, BIPOC, agender and individuals with intersecting marginal identities using social media. These stories will be shared anonymously to protect personal identifying information and prevent harm to the individuals sharing their experiences.

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Project Narrative continued

Toadhenge Consulting and AskMissJai has created online education on trans care for healthcare providers, referring to doctors, physician assistants, and nurse practitioners, but not for nursing or other ancillary healthcare staff. This focus is primarily on primary, or outpatient, care, however, should an individual require care in an inpatient (hospital or otherwise) setting, the majority of hands-on care is likely to be provided by nurses or other ancillary staff. This educational module will expand the offerings of the organization to these care providers, improving the overall care provided by the entire care team.

By improving the level of education and comfort that nurses and caregivers have with providing care to this population, the project looks to improve the health outcomes of the trans community by creating safer environments of care. Trans people are more likely to seek care if they know that this care will be provided in a safe environment free from stigma and shame.

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Project Objectives and Activities

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The project will accomplish five objectives:

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1. Using existing research, such as the 2022 US Trans Survey, create a quantitative model and narrative of disparities in care faced by Transgender and gender non-conforming individuals in the United States. This model will include disparities related to multiple marginalizations, such as race, age, geographical location and current gender identity.
2. Recruit trans and gender diverse individuals to share their personal stories and experiences of care in an anonymous, open-ended survey, and how those experiences impact their relationship with the healthcare system.
3. Research and analyze current best practices for nursing care for trans and gender diverse individuals. Create policy analysis and recommendations document.
4. Synthesize the data, narratives, and best practices into an online curriculum for nurses and healthcare professionals.
5. Demonstrate the curriculum to at least 5 practicing or student nurses or healthcare professionals, surveying knowledge and self-reported comfort with the material before and after taking the modules.

Deliverables

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Outcomes

The final product of this project will be a series of four to six scripted modules, consisting of audio, text and video components that will be available on AskMissJai.com for use by student and practicing nurses and ancillary health professionals.

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In addition to the modules, students will be asked to complete surveys before and after the modules, rating self reported comfort and knowledge of trans concepts and care. This data will be compiled into a document demonstrating the impact of the modules.

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In addition to the related modules, the project design will involve creating and analyzing existing best practices in nursing care for trans individuals, and a brief will be completed with suggested updates to these practices.

Prior to starting the educational series, students will be surveyed on their knowledge and understanding of the presented topics, as well as their attitudes towards trans and GNC individuals. Following completion of the series, the survey questions will be repeated, to gauge effectiveness of the training.

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The desired impact on the trans and GNC communities is that trained and knowledgeable caregivers and healthcare professionals will be less likely to have harmful interactions with trans patients. In addition, trained and knowledgeable caregivers and healthcare professionals will be more likely to pass this knowledge on to other professionals, becoming much-needed allies in the healthcare system.

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The long-term result of having allies and trained caregivers in the healthcare system is that the trans community will have reduced experiences of medical maltreatment and trauma, and ultimately overall better health outcomes.

Partner Organization

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“Ask Miss Jai is a capacity-building program designed to support healthcare and public health professionals goal of providing evidence-based, high-quality services for Transgender, Non-Binary, and Intersex people.” –AskMissJai.com

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Miss Jai is a non-binary, transgender, queer (she/he/they) public health consultant and educator, committed to working with healthcare providers and professionals to improve health and wellness for the trans and gender nonconforming communities. They hold a Masters in Public Health, and have been working in this capacity since 2024.

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Impact

Trans individuals face a public health emergency in the United States at this moment in history. Denial of care, discriminatory laws, lack of legal protections, and the overall erosion of LGBTQ+ acceptance and support all have had a disproportionate impact on the health and safety of trans people.

It is imperative at this time that healthcare providers are trained to provide care that reduces the harm that trans people face, and that healthcare providers are committed to preventing further harm to this vulnerable population.

Miss Jai is committed to the goal of providing this education. By expanding the scope of their services and educational offering to additional healthcare professionals, this project hopes to expand the impact of their work, and to improve the overall care received by this community.

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References

• Carmichael, T. , Copel, L. & McDermott-Levy, R. (2024). Effect of an Education Intervention on Nursing Students' Knowledge of and Attitudes Toward Caring for Transgender and Nonbinary People. Nurse Educator, 49 (5), 268-273. doi: 10.1097/NNE.0000000000001600.
• Jackson SS, Brown J, Pfeiffer RM, Shrewsbury D, O'Callaghan S, Berner AM, Gadalla SM, Shiels MS. Analysis of Mortality Among Transgender and Gender Diverse Adults in England. JAMA Netw Open. 2023 Jan 3;6(1):e2253687. doi: 10.1001/jamanetworkopen.2022.53687. PMID: 36716027; PMCID: PMC9887492.
• James, S.E., Herman, J.L., Durso, L.E., & Heng-Lehtinen, R. (2024). Early Insights: A Report of the 2022 U.S. Transgender Survey. National Center for Transgender Equality, Washington, DC
• Parnell, T., Fiske, K., Stastny, K. et al. Lived experience narratives in health professional education: educators’ perspectives of a co-designed, online mental health education resource. BMC Med Educ 23, 946 (2023). https://doi.org/10.1186/s12909-023-04956-0
• Sarah M. Peitzmeier et al. “Intimate Partner Violence in Transgender Populations: Systematic Review and Meta-analysis of Prevalence and Correlates”, American Journal of Public Health 110, no. 9 (September 1, 2020): pp. e1-e14.
• Ziegler E. The integral role of nurses in primary care for transgender people: A qualitative descriptive study. J Nurs Manag. 2021; 29: 95–103. https://doi.org/10.1111/jonm.13190

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