- Email: [email protected]
A Toolkit on Patient Centered Transgender Care for Nurse Practitioner Faculty and Clinicians
The Journal for Nurse Practitioners 15 (2019) 502e505
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
A Toolkit on Patient Centered Transgender Care for Nurse Practitioner Faculty and Clinicians National Organization of Nurse Practitioner Faculty a b s t r a c t Keywords: clinical services healthcare disparities primary care teaching resources transgender
The purpose of the Patient Centered Transgender Health: A Toolkit for Nurse Practitioner Faculty and Clinicians is to improve clinical care and reduce health disparities by closing the gap in knowledge of nurse practitioner faculty and practicing clinicians by providing evidence-based information on caring for this population. Resources, vetted by practicing clinicians in the field of transgender care who are also nurse practitioner/certified nurse midwife faculty, are provided. Faculty and clinicians can use this multimedia information to create evidence-based learning modules for students or clinicians and modify clinical services to address the needs of transgender individuals and provide solutions to those needs. © 2019 Elsevier Inc. All rights reserved.
Transgender individuals are those whose gender identity does not align with the gender assigned at birth. Gender and sexuality are 2 different phenomena that may or may not be congruent with gender identity. It is of value to understand that gender identity is not binary or heteronormative and that many individuals describe their gender as a point somewhere on the gender spectrum that may include multiple gender expressions. For the purpose of this article and the toolkit that is described, the authors use the broad term transgender to refer to the patient population and gender spectrum that these individuals represent. The Institute of Medicine published The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding1 in 2011, which brought attention to the needs of transgender populations. This report identified the mental, physical, and social health needs of this underserved population and the lack of research in this area. Clinicians and nursing faculty need resources to educate students and ways to provide clinical services for transgender populations. The goal of this article is to describe the Patient Centered Transgender Health: A Toolkit for Nurse Practitioner Faculty and Clinicians and how the content may be applied to create educational modules or presentations for practicing clinicians and for nurse practitioner (NP) and nurse midwifery students to improve their knowledge about quality and accessibility of care for transgender individuals. The overarching goal of the toolkit is to improve the care of transgender individuals by offering evidence-based resources that may be used to improve the physical, mental, and social health of this population.
regarding sexual and reproductive health. The results of that survey indicated that faculty and practicing clinicians possessed a lack of knowledge and skill in teaching about and providing care to transgender populations and a readiness for resources on this topic. Members organized a work group of NPs and certified nurse midwives with expertise as faculty and clinicians in providing transgender care. The work product from this task force is Patient Centered Transgender Health: A Toolkit for Nurse Practitioner Faculty and Clinicians.2 Toolkit Contents Content includes multimedia resources (videos, websites, blogs, peer-reviewed articles, and reports) all vetted by members of the work group who composed the toolkit. Several videos that feature transgender adults and adolescents provide insight into the lived experience of this population and their unique cultural needs. Websites, reports, and articles that provide factual information for providers on clinical aspects and best practices for care are featured. Ethical aspects of clinical care and education about transgender populations are discussed within the framework of the American Nurses’ Association “Code of Ethics: With Interpretive Statements.”3 Alignment of the NONPF core competencies with the content in the toolkit is provided so that faculty can apply resources provided when creating learning activities for NP students. The sections are described in the following sections. Cultural Humility and Access to Care
Background The National Organization of Nurse Practitioner Faculties (NONPF) conducted a survey of members to assess several factors https://doi.org/10.1016/j.nurpra.2019.03.021 1555-4155/© 2019 Elsevier Inc. All rights reserved.
The needs of transgender individuals are unique in that there is very little research available on care for these individuals. Best practices and quality benchmarking are still in development.
National Organization of Nurse Practitioner Faculty / The Journal for Nurse Practitioners 15 (2019) 502e505
Available resources must be properly vetted before use to prevent overt or covert harm to care recipients and misinformation for NP students learning about the needs of this population. Before one can teach about or provide services for transgender care, information about the cultural experience of this population must be understood. Transgender individuals may experience multiple stressors on a daily basis that are results of discrimination for nonconformity to societal expectations for binary gender, sexuality, or racial factors. These forms of discrimination may lead to unemployment or underemployment that results in financial distress. The intersectionality of these multiple stressors impacts physical and mental health, placing transgender individuals at high risk for multiple physical and mental health problems and creating multiple barriers to care.4 By examining these issues, clinicians and faculty can carefully evaluate communication strategies for working with this population and techniques to improve quality and access to care. Clinicians may be the source of discrimination, so using specific communication techniques builds a trusting relationship with this population and further reduces barriers to care. Self-reflection on the part of students, NP faculty, and practicing clinicians results in improved access to care and better health outcomes. There is a great need for primary care in this population. Using screening practices that are used in cisgender populations may be effective for most services. However, faculty and clinicians must remember to ask health care questions about the natal organs that remain so that health screening services may be offered. Simple modifications can be implemented to make existing clinical sites more welcoming. Many of these modifications can be used by faculty to make classroom and online courses more welcoming to students. Examples are posting welcoming symbols such as a rainbow flag, identifying the clinician or professor’s pronouns usage, and including artwork of photos that are inclusive of transgender and racial minority groups. Sexual Health History Gender transitioning is considered a spectrum that may include dressing in the desired gender, name change, use of exogenous hormones, speech therapy, or gender-affirming surgery. Individuals may choose some, all, or none of these interventions when progressing along the gender spectrum. Faculty and clinicians must rely on the best evidence available for providing these specific services and teaching students about them. For many years, the focus of transgender health has been on the transitioning spectrum or sexual health. Obtaining a through sexual health history is essential and must include the correct terminology for sexual contact and practices. Clinicians and faculty must become acquainted with effective methods for obtaining this information from transgender patients and teaching about risk reduction from condomless sexual activity. Sexuality and gender are 2 separate phenomena, so it should never be assumed that transgender individuals’ sexual preference is congruent with their gender. When obtaining a sexual health history, the clinician must ask the 5 P’s: partners, practices, pregnancy prevention, past history of sexually transmitted infections, and sexually transmitted infection prevention. Clinicians must be comfortable asking questions about each of these aspects of sexuality, and faculty must teach students these skills along with effective communication skills needed in obtaining a detailed sexual health history. Ethical Issues
for
Ethical considerations include placing the individual’s need autonomy and self-direction as paramount. Careful
503
explanations about risks, benefits, alternatives, and expected outcomes for each treatment and screening or a refusal for a given treatment or screening must be provided before care can begin. Providing equal access to care that benefits a given patient’s needs meets ethical principles of justice and beneficence. When referral or transfer of care is indicated, the clinician must make sure that the patient will be treated in a respectful and knowledgeable manner. Because so many transgender individuals have been the victims of interpersonal violence and discrimination from the general population and health care providers, addressing ethical issues of care is especially important. Clinicians must apply these ethical principles to all aspects of care, and faculty must address them in depth with students caring for transgender individuals. Alignment With NONPF Core Competencies Five of the NONPF core competencies are featured: scientific foundations, policy, health delivery systems, ethics, and independent practice. Within each of the core competencies, curriculum content to support that competency is listed, and resources for creating that curriculum content or modification of clinical care is provided. Although this section was created to assist faculty in meeting the educational needs of students, practicing clinicians may apply the resources cited to improve clinical care. Resources include websites, videos, and peerreviewed articles. See the Table for samples of resources provided in the toolkit and the application of them to clinical and educational models. Definitions of Terms Used in Caring for Transgender Individuals Learning the proper terminology to use and which terminology should be avoided is an important first step for students, faculty, and clinicians. Terminology used in caring for transgender populations is constantly evolving, which requires attention to these changes on the part of those providing services to and education about this population. The toolkit includes a list of commonly used terms when caring for transgender individuals and suggestions for making clinics more accessible. It is essential that certain derogatory terms are avoided and that acceptable terminology is used so that all faculty who teach about or clinicians who care for this population create a welcoming environment. By using commonly accepted terms and remaining current regarding frequent changes in terminology, access to and quality of care are improved. Using the Toolkit Faculty can use this information to create online and in-person learning modules, clinical experiences, and objective structured clinical observation to evaluate student learning of content provided. A large database of vetted video, peer-reviewed articles, and websites can provide resources for faculty and students to enhance learning. Information on alignment of the toolkit contents with NONPF core competencies is provided. Learning modules should include information on cultural humility, hormonal treatment, surgical interventions, contraceptive and sexual health needs, and ethical aspects of providing care to transgender populations. Videos, websites, and peer-reviewed articles and reports can be used as student learning resources. Summative assessment of student learning may be assessed by the use of objective structured clinical observation, written test questions, clinical case studies, or a narrative article outlining ways to meet the health needs of transgender populations. Faculty must
504
Table Sample of Application of Resources from the Toolkit Content to Support Competency
Resources for Meeting Competency
Utility of Resource
Scientific foundations: Critically analyzes data and evidence for improving advanced nursing practice
Comparison of patient data sets with evidencebased standards to improve care of the transgender population
Offers data collection for gender and sexuality minorities Provides report detailing discrimination and disparity experiences of transgender individuals, Addresses issues of health disparities in the LGBT community, lack of documentation of population numbers in data collection sources, and the need for more research on this population
Policy: Advocates for ethical policies that promote access, equity, quality, and cost
Health policy and health care reform: Federal budget National health priorities Methods for appropriation of funding Vulnerable populations The relationship between the USPSTF guidelines and Affordable Care Act implementation. Needs assessment of transgender individuals Transitional care Scope and standards of practice
HHS Office of Minority Health/Improving Data Collection for the LGBT Community; 2013 https:// minorityhealth.hhs.gov/omh/browse.aspx? lvl¼3&lvlid¼57 National Center for Transgender Equality/2015 U.S. Transgender Survey Report. http://www.ustranssurvey. org/ reports Office of Disease Prevention and Health Promotion/ Lesbian, Gay, Bisexual, and Transgender Health Healthy People 2020 https://www.healthypeople.gov/2020/ topics-objectives/topic/lesbian-gay-bisexual-andtransgender-health?topicid¼25 HealthCare.Gov/Transgender Health Care https://www. healthcare.gov/transgender-health-care/ Lambda Legal/Creating Equal Access to Quality Health Care for Transgender Patients: Transgender-Affirming Hospital Policies https://www.lambdalegal.org/issues/ transgender-rights
CARDEA/Introduction to Gender and Sexuality in a Health Care Setting http://www.cardeaservices.org/ training/providing-culturally-proficient-services-totransgender-and-gender-nonconforming-people.html National Resource Center on LGBT Aging https://www. lgbtagingcenter.org/resources/index.cfm?s¼27 The Joint Commission Division of Health Care Improvement. 2016/ “Implicit Bias in Health Care.” Quick Safety https://www.jointcommission.org/ assets/ 1/23/Quick_Safety_Issue_23_Apr_2016. pdf
Offers Internet-based training in cultural humility for clinicians caring for transgender populations Provides resources for clinicians, faculty, and administrators on issues of aging (mental health, breast health, Medicare, etc.) Highlights implicit bias that affects health care decision making and perpetuates health disparities
CDC/HIV Risk Reduction Tool https://wwwn.cdc.gov/ hivrisk/ Center of Excellence for Transgender Health. 20082009/8 Best Practices for HIV Prevention among Trans People http://transhealth.ucsf.edu/pdf/bp-prevention. pdf Center of Excellence for Transgender Health, Department of Family & Community Medicine, University of California San Francisco. 2016/Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People http:// transhealth.ucsf.edu/pdf/Transgender-PGACG-6-17-16. pdf Fenway Health. Gender Affirmation Healthcare, Terminology, Demographics, and Epidemiology 2015 http://www.lgbthealtheducation.org/wp-content/ uploads/Gender-Affirmative-Health-Care.pdf
Provides tool for calculating individual HIV risk for transgender individuals Offers best practices for clinical care for preventing HIV Benchmarking for best practices for primary care and gender affirmation care Benchmarking for excellence in transgender health and updated definitions commonly used in transgender care
Health care delivery systems: Collaborates in planning for transitions across the continuum of care
Ethics: Applies ethically sound solutions to complex issues related to individuals, populations, and systems of care
Population-specific complex ethical issues occurring in clinical practice
Independent practice: Practices independently managing previously diagnosed and undiagnosed patients 1. Provides the full spectrum of health care services to include health promotion, disease prevention, health protection, anticipatory guidance, counseling, disease management, and palliative and end-of-life care 2. Uses advanced health assessment skills to differentiate between normal, variations of normal, and abnormal findings 3. Employs screening and diagnostic strategies in the development of diagnoses 4. Prescribes medications within scope of practice 5. Manages the health/illness status of patients and families over time
Clinical decision making based on evidence and patient/ provider partnership Current and emerging professional standards Screenings specific to the LGBTQ person Health promotion, prevention, and disease management for the transgender person Provider-patient relationship Role of culture in patient-centered care Contracting a management plan with patient and/or family Culture of trust in interpersonal relationship with patient and/or families
Provides details on obtaining health insurance for transgender individuals Offers toolkit on legal rights of transgender individuals and resources for legal aid
CDC ¼ Centers for Disease Care and Prevention; HIV, human immunodeficiency virus; LGBTQ ¼ lesbian, gay, bisexual, transgender, and questioning; USPSTF ¼ United States Preventive Services Task Force.
National Organization of Nurse Practitioner Faculty / The Journal for Nurse Practitioners 15 (2019) 502e505
Competency
National Organization of Nurse Practitioner Faculty / The Journal for Nurse Practitioners 15 (2019) 502e505
emphasize the importance of student comprehension of the many facets of transgender care that include mental and physical health and general wellness through primary prevention. Toolkit content can be applied to clinical settings to expand existing services or create new ones including transgender care. Tips for reducing barriers to care that include making clinical sites more welcoming to transgender populations are provided. References to resources that offer information on direct patient care are included for the practicing clinician. Communication techniques that enhance care must be included in any clinical setting by training all clinical and support staff. Accessing the Toolkit The toolkit is available on the NONPF website located at https:// www.nonpf.org/default.aspx. There is a recorded webinar that explains how to use the content to create evidence-based learning modules for NPs, certified nurse midwives, and nursing students. Members of the Sexual and Reproductive Health Special Interest
505
Group within NONPF will revise the toolkit every 2 years to maintain accuracy. References 1. Institute of Medicine. Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: Institute of Medicine; 2011. 2. National Organization for Nurse Practitioner Faculties. Patient Centered Transgender Care: A Toolkit for Nurse Practitioner Faculty and Clinicians. Washington, DC: National Organization for Nurse Practitioner Faculties. https://cdn.ymaws.com/www. nonpf.org/resource/resmgr/files/transgender_toolkit_final.pdf. Accessed March 21, 2019. 3. American Nurses Association. Code of ethics with interpretive statements. Silver Springs, MD: American Nurses Association; 2015. 4. Selix N, Rowniak S. Provision of patient-centered transgender care. J Midwifery Womens Health. 2016;61(6):744-751. Nancy W. Selix, DNP, FNP-C, CNM is an associate professor at the School of Nursing and Health Profession in San Francisco, CA, is the corresponding author and can be contacted at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
A Toolkit on Patient Centered Transgender Care for Nurse Practitioner Faculty and Clinicians National Organization of Nurse Practitioner Faculty a b s t r a c t Keywords: clinical services healthcare disparities primary care teaching resources transgender
The purpose of the Patient Centered Transgender Health: A Toolkit for Nurse Practitioner Faculty and Clinicians is to improve clinical care and reduce health disparities by closing the gap in knowledge of nurse practitioner faculty and practicing clinicians by providing evidence-based information on caring for this population. Resources, vetted by practicing clinicians in the field of transgender care who are also nurse practitioner/certified nurse midwife faculty, are provided. Faculty and clinicians can use this multimedia information to create evidence-based learning modules for students or clinicians and modify clinical services to address the needs of transgender individuals and provide solutions to those needs. © 2019 Elsevier Inc. All rights reserved.
Transgender individuals are those whose gender identity does not align with the gender assigned at birth. Gender and sexuality are 2 different phenomena that may or may not be congruent with gender identity. It is of value to understand that gender identity is not binary or heteronormative and that many individuals describe their gender as a point somewhere on the gender spectrum that may include multiple gender expressions. For the purpose of this article and the toolkit that is described, the authors use the broad term transgender to refer to the patient population and gender spectrum that these individuals represent. The Institute of Medicine published The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding1 in 2011, which brought attention to the needs of transgender populations. This report identified the mental, physical, and social health needs of this underserved population and the lack of research in this area. Clinicians and nursing faculty need resources to educate students and ways to provide clinical services for transgender populations. The goal of this article is to describe the Patient Centered Transgender Health: A Toolkit for Nurse Practitioner Faculty and Clinicians and how the content may be applied to create educational modules or presentations for practicing clinicians and for nurse practitioner (NP) and nurse midwifery students to improve their knowledge about quality and accessibility of care for transgender individuals. The overarching goal of the toolkit is to improve the care of transgender individuals by offering evidence-based resources that may be used to improve the physical, mental, and social health of this population.
regarding sexual and reproductive health. The results of that survey indicated that faculty and practicing clinicians possessed a lack of knowledge and skill in teaching about and providing care to transgender populations and a readiness for resources on this topic. Members organized a work group of NPs and certified nurse midwives with expertise as faculty and clinicians in providing transgender care. The work product from this task force is Patient Centered Transgender Health: A Toolkit for Nurse Practitioner Faculty and Clinicians.2 Toolkit Contents Content includes multimedia resources (videos, websites, blogs, peer-reviewed articles, and reports) all vetted by members of the work group who composed the toolkit. Several videos that feature transgender adults and adolescents provide insight into the lived experience of this population and their unique cultural needs. Websites, reports, and articles that provide factual information for providers on clinical aspects and best practices for care are featured. Ethical aspects of clinical care and education about transgender populations are discussed within the framework of the American Nurses’ Association “Code of Ethics: With Interpretive Statements.”3 Alignment of the NONPF core competencies with the content in the toolkit is provided so that faculty can apply resources provided when creating learning activities for NP students. The sections are described in the following sections. Cultural Humility and Access to Care
Background The National Organization of Nurse Practitioner Faculties (NONPF) conducted a survey of members to assess several factors https://doi.org/10.1016/j.nurpra.2019.03.021 1555-4155/© 2019 Elsevier Inc. All rights reserved.
The needs of transgender individuals are unique in that there is very little research available on care for these individuals. Best practices and quality benchmarking are still in development.
National Organization of Nurse Practitioner Faculty / The Journal for Nurse Practitioners 15 (2019) 502e505
Available resources must be properly vetted before use to prevent overt or covert harm to care recipients and misinformation for NP students learning about the needs of this population. Before one can teach about or provide services for transgender care, information about the cultural experience of this population must be understood. Transgender individuals may experience multiple stressors on a daily basis that are results of discrimination for nonconformity to societal expectations for binary gender, sexuality, or racial factors. These forms of discrimination may lead to unemployment or underemployment that results in financial distress. The intersectionality of these multiple stressors impacts physical and mental health, placing transgender individuals at high risk for multiple physical and mental health problems and creating multiple barriers to care.4 By examining these issues, clinicians and faculty can carefully evaluate communication strategies for working with this population and techniques to improve quality and access to care. Clinicians may be the source of discrimination, so using specific communication techniques builds a trusting relationship with this population and further reduces barriers to care. Self-reflection on the part of students, NP faculty, and practicing clinicians results in improved access to care and better health outcomes. There is a great need for primary care in this population. Using screening practices that are used in cisgender populations may be effective for most services. However, faculty and clinicians must remember to ask health care questions about the natal organs that remain so that health screening services may be offered. Simple modifications can be implemented to make existing clinical sites more welcoming. Many of these modifications can be used by faculty to make classroom and online courses more welcoming to students. Examples are posting welcoming symbols such as a rainbow flag, identifying the clinician or professor’s pronouns usage, and including artwork of photos that are inclusive of transgender and racial minority groups. Sexual Health History Gender transitioning is considered a spectrum that may include dressing in the desired gender, name change, use of exogenous hormones, speech therapy, or gender-affirming surgery. Individuals may choose some, all, or none of these interventions when progressing along the gender spectrum. Faculty and clinicians must rely on the best evidence available for providing these specific services and teaching students about them. For many years, the focus of transgender health has been on the transitioning spectrum or sexual health. Obtaining a through sexual health history is essential and must include the correct terminology for sexual contact and practices. Clinicians and faculty must become acquainted with effective methods for obtaining this information from transgender patients and teaching about risk reduction from condomless sexual activity. Sexuality and gender are 2 separate phenomena, so it should never be assumed that transgender individuals’ sexual preference is congruent with their gender. When obtaining a sexual health history, the clinician must ask the 5 P’s: partners, practices, pregnancy prevention, past history of sexually transmitted infections, and sexually transmitted infection prevention. Clinicians must be comfortable asking questions about each of these aspects of sexuality, and faculty must teach students these skills along with effective communication skills needed in obtaining a detailed sexual health history. Ethical Issues
for
Ethical considerations include placing the individual’s need autonomy and self-direction as paramount. Careful
503
explanations about risks, benefits, alternatives, and expected outcomes for each treatment and screening or a refusal for a given treatment or screening must be provided before care can begin. Providing equal access to care that benefits a given patient’s needs meets ethical principles of justice and beneficence. When referral or transfer of care is indicated, the clinician must make sure that the patient will be treated in a respectful and knowledgeable manner. Because so many transgender individuals have been the victims of interpersonal violence and discrimination from the general population and health care providers, addressing ethical issues of care is especially important. Clinicians must apply these ethical principles to all aspects of care, and faculty must address them in depth with students caring for transgender individuals. Alignment With NONPF Core Competencies Five of the NONPF core competencies are featured: scientific foundations, policy, health delivery systems, ethics, and independent practice. Within each of the core competencies, curriculum content to support that competency is listed, and resources for creating that curriculum content or modification of clinical care is provided. Although this section was created to assist faculty in meeting the educational needs of students, practicing clinicians may apply the resources cited to improve clinical care. Resources include websites, videos, and peerreviewed articles. See the Table for samples of resources provided in the toolkit and the application of them to clinical and educational models. Definitions of Terms Used in Caring for Transgender Individuals Learning the proper terminology to use and which terminology should be avoided is an important first step for students, faculty, and clinicians. Terminology used in caring for transgender populations is constantly evolving, which requires attention to these changes on the part of those providing services to and education about this population. The toolkit includes a list of commonly used terms when caring for transgender individuals and suggestions for making clinics more accessible. It is essential that certain derogatory terms are avoided and that acceptable terminology is used so that all faculty who teach about or clinicians who care for this population create a welcoming environment. By using commonly accepted terms and remaining current regarding frequent changes in terminology, access to and quality of care are improved. Using the Toolkit Faculty can use this information to create online and in-person learning modules, clinical experiences, and objective structured clinical observation to evaluate student learning of content provided. A large database of vetted video, peer-reviewed articles, and websites can provide resources for faculty and students to enhance learning. Information on alignment of the toolkit contents with NONPF core competencies is provided. Learning modules should include information on cultural humility, hormonal treatment, surgical interventions, contraceptive and sexual health needs, and ethical aspects of providing care to transgender populations. Videos, websites, and peer-reviewed articles and reports can be used as student learning resources. Summative assessment of student learning may be assessed by the use of objective structured clinical observation, written test questions, clinical case studies, or a narrative article outlining ways to meet the health needs of transgender populations. Faculty must
504
Table Sample of Application of Resources from the Toolkit Content to Support Competency
Resources for Meeting Competency
Utility of Resource
Scientific foundations: Critically analyzes data and evidence for improving advanced nursing practice
Comparison of patient data sets with evidencebased standards to improve care of the transgender population
Offers data collection for gender and sexuality minorities Provides report detailing discrimination and disparity experiences of transgender individuals, Addresses issues of health disparities in the LGBT community, lack of documentation of population numbers in data collection sources, and the need for more research on this population
Policy: Advocates for ethical policies that promote access, equity, quality, and cost
Health policy and health care reform: Federal budget National health priorities Methods for appropriation of funding Vulnerable populations The relationship between the USPSTF guidelines and Affordable Care Act implementation. Needs assessment of transgender individuals Transitional care Scope and standards of practice
HHS Office of Minority Health/Improving Data Collection for the LGBT Community; 2013 https:// minorityhealth.hhs.gov/omh/browse.aspx? lvl¼3&lvlid¼57 National Center for Transgender Equality/2015 U.S. Transgender Survey Report. http://www.ustranssurvey. org/ reports Office of Disease Prevention and Health Promotion/ Lesbian, Gay, Bisexual, and Transgender Health Healthy People 2020 https://www.healthypeople.gov/2020/ topics-objectives/topic/lesbian-gay-bisexual-andtransgender-health?topicid¼25 HealthCare.Gov/Transgender Health Care https://www. healthcare.gov/transgender-health-care/ Lambda Legal/Creating Equal Access to Quality Health Care for Transgender Patients: Transgender-Affirming Hospital Policies https://www.lambdalegal.org/issues/ transgender-rights
CARDEA/Introduction to Gender and Sexuality in a Health Care Setting http://www.cardeaservices.org/ training/providing-culturally-proficient-services-totransgender-and-gender-nonconforming-people.html National Resource Center on LGBT Aging https://www. lgbtagingcenter.org/resources/index.cfm?s¼27 The Joint Commission Division of Health Care Improvement. 2016/ “Implicit Bias in Health Care.” Quick Safety https://www.jointcommission.org/ assets/ 1/23/Quick_Safety_Issue_23_Apr_2016. pdf
Offers Internet-based training in cultural humility for clinicians caring for transgender populations Provides resources for clinicians, faculty, and administrators on issues of aging (mental health, breast health, Medicare, etc.) Highlights implicit bias that affects health care decision making and perpetuates health disparities
CDC/HIV Risk Reduction Tool https://wwwn.cdc.gov/ hivrisk/ Center of Excellence for Transgender Health. 20082009/8 Best Practices for HIV Prevention among Trans People http://transhealth.ucsf.edu/pdf/bp-prevention. pdf Center of Excellence for Transgender Health, Department of Family & Community Medicine, University of California San Francisco. 2016/Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People http:// transhealth.ucsf.edu/pdf/Transgender-PGACG-6-17-16. pdf Fenway Health. Gender Affirmation Healthcare, Terminology, Demographics, and Epidemiology 2015 http://www.lgbthealtheducation.org/wp-content/ uploads/Gender-Affirmative-Health-Care.pdf
Provides tool for calculating individual HIV risk for transgender individuals Offers best practices for clinical care for preventing HIV Benchmarking for best practices for primary care and gender affirmation care Benchmarking for excellence in transgender health and updated definitions commonly used in transgender care
Health care delivery systems: Collaborates in planning for transitions across the continuum of care
Ethics: Applies ethically sound solutions to complex issues related to individuals, populations, and systems of care
Population-specific complex ethical issues occurring in clinical practice
Independent practice: Practices independently managing previously diagnosed and undiagnosed patients 1. Provides the full spectrum of health care services to include health promotion, disease prevention, health protection, anticipatory guidance, counseling, disease management, and palliative and end-of-life care 2. Uses advanced health assessment skills to differentiate between normal, variations of normal, and abnormal findings 3. Employs screening and diagnostic strategies in the development of diagnoses 4. Prescribes medications within scope of practice 5. Manages the health/illness status of patients and families over time
Clinical decision making based on evidence and patient/ provider partnership Current and emerging professional standards Screenings specific to the LGBTQ person Health promotion, prevention, and disease management for the transgender person Provider-patient relationship Role of culture in patient-centered care Contracting a management plan with patient and/or family Culture of trust in interpersonal relationship with patient and/or families
Provides details on obtaining health insurance for transgender individuals Offers toolkit on legal rights of transgender individuals and resources for legal aid
CDC ¼ Centers for Disease Care and Prevention; HIV, human immunodeficiency virus; LGBTQ ¼ lesbian, gay, bisexual, transgender, and questioning; USPSTF ¼ United States Preventive Services Task Force.
National Organization of Nurse Practitioner Faculty / The Journal for Nurse Practitioners 15 (2019) 502e505
Competency
National Organization of Nurse Practitioner Faculty / The Journal for Nurse Practitioners 15 (2019) 502e505
emphasize the importance of student comprehension of the many facets of transgender care that include mental and physical health and general wellness through primary prevention. Toolkit content can be applied to clinical settings to expand existing services or create new ones including transgender care. Tips for reducing barriers to care that include making clinical sites more welcoming to transgender populations are provided. References to resources that offer information on direct patient care are included for the practicing clinician. Communication techniques that enhance care must be included in any clinical setting by training all clinical and support staff. Accessing the Toolkit The toolkit is available on the NONPF website located at https:// www.nonpf.org/default.aspx. There is a recorded webinar that explains how to use the content to create evidence-based learning modules for NPs, certified nurse midwives, and nursing students. Members of the Sexual and Reproductive Health Special Interest
505
Group within NONPF will revise the toolkit every 2 years to maintain accuracy. References 1. Institute of Medicine. Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: Institute of Medicine; 2011. 2. National Organization for Nurse Practitioner Faculties. Patient Centered Transgender Care: A Toolkit for Nurse Practitioner Faculty and Clinicians. Washington, DC: National Organization for Nurse Practitioner Faculties. https://cdn.ymaws.com/www. nonpf.org/resource/resmgr/files/transgender_toolkit_final.pdf. Accessed March 21, 2019. 3. American Nurses Association. Code of ethics with interpretive statements. Silver Springs, MD: American Nurses Association; 2015. 4. Selix N, Rowniak S. Provision of patient-centered transgender care. J Midwifery Womens Health. 2016;61(6):744-751. Nancy W. Selix, DNP, FNP-C, CNM is an associate professor at the School of Nursing and Health Profession in San Francisco, CA, is the corresponding author and can be contacted at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.