- Email: [email protected]
Providing Quality Care to the Transgender Patient in the Radiology Setting
Providing Quality Care to the Transgender Patient in the Radiology Setting j Valerie G. Aarne Grossman, MALS, BSN, NE-BC ABSTRACT: Care of transgender patients presents a unique challenge to nurses, technologists, physicians, and unlicensed assistive personnel in any health care setting, including radiology arenas. If staff are unaware of health concerns that are unique to this population, then the staff are at a great disadvantage in their quest to provide high-quality patient care. This article will provide the reader a better understanding of the transgender population and will allow staff to practice with confidence and competence. (J Radiol Nurs 2016;35:218-226.) KEYWORDS: Transgender; LQBTQ; Radiology and imaging nursing; Sex reassignment surgery; Radiologic technologist.
INTRODUCTION As a profession, nurses collectively approach the delivery of quality patient care in a goal-focused manner that is patient and family centered. Nurses strive to be professional at all times and to treat each patient as the individual that they are meeting their needs while in the radiologic environment. Nurses speak in a calm, inviting manner to build a trusting rapport with the patient and their visitors that will assist in obtaining the essential information needed to develop the safest and most efficient manner of providing the care patients seek. Exposed to the need for cultural competency, and when exposed to cultures and religions one is less familiar with, nurses try to be as welcoming as possible. Governing agencies have long-mandated organizations to provide employees with training and to have policies in place which promote an environment of inclusion to all patients seeking care. In complying with our professional ethics and governing mandates, nurses believe that all patients regardless of their social, religious, cul-
Valerie G. Aarne Grossman, MALS, BSN, NE-BC, Nurse Manager, Medical Imaging, University of Rochester, Highland Hospital, Macedon, NY. Corresponding author: Valerie G. Aarne Grossman, Medical Imaging, University of Rochester, Highland Hospital, PO Box 27, Macedon, NY 14502. E-mail: [email protected] 1546-0843/$36.00 Copyright Ó 2016 by the Association for Radiologic & Imaging Nursing. http://dx.doi.org/10.1016/j.jradnu.2016.06.002
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tural, or personal characteristics should be treated with dignity and respect (The Joint Commission, 2011). It falls on nurses to help the patient feel comfortable when providing the most private information. As challenging as it may be, it is essential to contain personal bias, prejudice, cultural, religious, or moral beliefs to ourselves and maintain professional communication (verbal and nonverbal) at all times. Nurses must create an environment that is calm, open, receptive, nonjudgmental, and respectful while maintaining a positive attitude and committed desire to provide the very best care. TRANSGENDER PEOPLE While most nurses would readily agree that they treat all patients equally, the transgender community will likely describe their experiences with the health care community quite differently. Transgender patients commonly describe their past experiences with health care teams and systems as being negative, including such treatment as discrimination, negative judgment, assumption, and harassment, unprofessional or unwelcoming verbal and nonverbal communication. Transgender patients often feel invisible to, and lack, trust in their health care employees. After repeated incidences of feeling unwelcome and not understood, many transgender patients delay accessing care for their health needs. By the time they do seek treatment; they may be quite ill and/or mistrusting of health care workers.
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Transgender people were born with the anatomy of one gender, but their inner soul identifies with another gender. The term “transgender” is an umbrella term for people whose gender identity, gender expressions, or behavior may be different than what society assumes it should be typically associated with the sex they were assigned at birth. There are many terms used when caring for someone in the transgender community, and health care professionals must be aware of them, their meaning, or know where to look them up (see Glossary). It is NOT the patient’s fault that nurses and other health care employees are uninformed, nor is it the responsibility of the patient seeking care to educate the health care staff with regards to transgender issues. It is an unfair burdensome expectation that a sick patient will teach a nurse what transgender means, and how it may affect their health care issues (Rubin, 2015). Most heterosexual individuals find it difficult to define or understand the transgender community (Wichinski, 2015). When the health care worker is unfamiliar with transgender people and their issues, this further causes the patient to feel unsafe and uncomfortable talking openly about their health concerns. If the health care worker refuses to acknowledge the circumstances under which a transgender or nonbinary person has lived, does live and what their health care needs may be . then the patient’s participation and trust in the care provider may be guarded and partial. Health care professionals must become trans aware to be able to fully deliver the highest quality of patient care (Cole, 2015). For most, this education or awareness will have to be self-sought, as little is included in most nursing educational programs. A recent survey revealed that current baccalaureate curricula contained an average of 2 hr devoted to the care of the Lesbian/ Gay/Bisexual/Transgender/Questioning-Queer (LGBTQ) population (Lim, Johnson, & Eliason, 2015). Younger members of the LGBTQ community were born into a society that is slightly more aware, and perhaps more accepting, than the geriatric portion of this community. The older the transgendered person is, the more they have had to live with difficulties within their community and family groups. Strong cultural and societal pressures from family and friends may have made it difficult for an individual to disclose the most private of details of their lives . yet, for the nurse, it is essential that proper, complete, and inclusive information is obtained. Older transgender patients may have spent decades dealing with discrimination and denial of their civil and human rights, which will make it even more difficult for them to open up freely to health care team (U.S. Department of Health and Human Services & Office of Disease Prevention and Health Promotion, 2020). They have gone the longest
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living in secrecy and may take longer to open up to the health care staff (Simone & Applebaum, 2011). Transgender patients may be less likely to have health insurance than others (Buchmueller & Carpenter, 2010). Many transgender people have experienced discrimination when seeking employment, education, housing, and in many public settings (Mesics, 2015). Transgender people of color, ethnic/cultural/religious minorities, low education, specific geographic locations, or a primary language other than English often experience even greater discrimination (Grant, Tanis, Harrison, Herman, & Keisling, 2011). The Trans Mental Health and Emotional Well Being Study of 2012 found a heavy toll on the mental health of transgender patients including: A
88% experience(d) depression 84% had suicidal thoughts at some point in their life A 62% had alcohol dependency or abuse issues A 38% experience(d) sexual harassment (McNeil, Bailey, Ellis, Morton, & Regan, 2012) A
ORGANIZATIONAL SENSITIVITY Organizations can establish a welcoming environment in a number of ways. These efforts must begin from the board of directors and senior leadership. Organizational leaders must be actively engaged in making their health care systems inclusive to all patients who seek care. Suggestions of ways to promote inclusion could include: A
Posters, literature, and other printed material should include transgender people A Organizations should include LGBTQ in their outreach programs A Educational programs for staff on culturally affirming care for LGBTQ people A Forms should: > Be gender neutral (not just “male or female”) Example: gender at birth and current gender > Space for both legal name and their preferred name (may be different) > Some electronic record systems are now allowing for this type of documentation A All policies should be examined to be sure they are LGBTQ inclusive: -
> Gender identity and gender expression nondiscrimination > Patients’ Bill of Rights
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> Visitation policies should include support persons who may not be legally or biologically related to them > Admitting/registration records that allow for variability between the patient’s legal name and preferred name
toms (Snelgrove, Jasudavisius, Rowe, Head, & Bauer, 2012). The motivated and dedicated health care professional can begin to gain the trust of the transgender patient by:
Registration is often where patients develop their “first impression” of their visit, so it is essential that registration staff understand speaking professionally with a transgender patient The Joint Commission recommends staff use and document a transgender patient’s preferred name, even if not the legal name.
> Focus more on their reason for the health care visit then on the fact that the patient is transgender A If staff have prejudice toward the patient, they must contain their own emotion
-
-
The Joint Commission states: Note the patient’s preferred name prominently in the patient record to make sure that staff address the patient appropriately. Staff should be aware that patients who identify as transgender may have a name preference that differs from their legal name and may or may not have altered their bodies medically. (The Joint Commission, 2010).
> Education for staff to learn about proper interactions with transgender patients If staff exhibit unprofessional behavior or comments, they should be held accountable and disciplined following the organizational policies (Mesics, 2015) Semiprivate rooms should be assigned carefully Access to restrooms (single occupancy unisex restrooms are preferred) Compliance with privacy laws Coding for insurance purposes (proper ICD 10 codes; Lambda Legal, Human Rights Campaign Foundation, & New York City Bar Association, 2013; Van Wagenen, 2015) -
> > > >
HEALTH CARE STAFF Governing agencies are paying closer attention to the delivery of quality health care to the transgender patients. Increased awareness needs to occur, so health care staff can assist this population to ensure access to nonprejudicial care and for them to receive the proper health care necessary. In addition to the general health care that individuals would seek, the transgender patient may have additional concerns, signs, or symp220
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A
Building a rapport with the patient that is sensitive to their situation
> Avoid judging the patient based on your own moral terms (Snelgrove et al., 2012) A Use a “matter of fact” interview technique A Do not make a spectacle out of the patient’s transgender status A Using correct pronouns, ask open-ended questions, and be nonjudgmental when the patient answers your questions > Hide your nonverbal if the answer is out of your comfort zone A Follow the lead of the patient when interviewing > Listen for how they self-identify, what pronouns they use, and so forth. > Ask the patient “is the name on the chart, the name you prefer me to use,” and ask them how they would prefer you address them (i.e., Mr. Jones, Sally, Reverend, etc.) A Encourage patient’s questions or comments A Avoid making assumptions about the patient A If you say something wrong, do not over apologize > Just apologize and move on (be sure to get it right the next time!) A Family history may be very important to help establish a baseline of information and offer essential information to the health status of all patients, especially transgender patients. Family health history may be important to determine, as patients who are predisposed to certain health issues may have an increased risk when taking medications common in transgender health care. Living with chronic stress can worsen a patient’s well-being (so it is important for the health care team to understand family support vs. family rejection, PTSD, abuse, etc.). Because the patient is transgender, a family history may need to include (Makadon, Mayer, Potter, & Goldhammer, 2015) the following: > Coagulation disorders > Cardiovascular disease
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> Diabetes > Liver disease > Cancer (prostate, ovarian, breast, or uterine) A
Medical history should include the following: > Accurate medication reconciliation > Coronary heart disease/cerebrovascular disease > Arterial, venous or pulmonary thromboembolism > Hypertension > Diabetes > Liver disease > Hormonal therapy > Bone density > Cancer > HIV
A
Surgical history should include the following: > For male-to-female realignment surgery: -
Breast augmentation Bilateral orchiectomy Penectomy Vaginoplasty Vuvloplasty Construction of a neovagina Labioplasty Facial feminization surgery Tracheal cartilage shave Implants, liposuction, lipofillers
> For female-to-male realignment surgery: -
Mastectomy Chest reconstruction Bilateral salpingo-oophorectomy Hysterectomy Urethroplasty Clitoral free-up Vaginectomy Scrotoplasty Construction of a neophallus (phalloplasty) Metoidioplasty Implants, liposuction, lipofillers
> Complications of above surgeries can include the following: -
Wound dehisence Wound infection or necrosis Graft necrosis Seromas Hematomas
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Bladder damage Nerve injury - Rectovaginal fistula - Urethra-vaginal fistula - Urethral stricture/stenosis - Testicular implant erosion through skin - Vaginal stenosis - Granulation tissue formation - Vaginal prolapse (Mesics, 2015; Makadon et al., 2015; Fenway Health, 2015) A Psychosocial history should include the following: -
> Information regarding patient’s social circle and support system (past and present) > Economic status (including access to insurance and health care providers) > Social isolation/harassment/discrimination/ abandonment/abuse (past or present) > Employment, housing, education, and significant activities > Mental health concerns such as depression, anxiety, bipolar, substance use/abuse, or changes as a result of hormonal therapy - Testosterone can worsen some mental health conditions > Identify support group participation A Routine sexual history should include the following (if it pertains to current visit or may have an impact on current health care visit): > A gradual approach to questions > Sexual orientation, risk behaviors as related to sexually transmitted infections or pregnancy > Identify need for screening tests (Pap smear, testicular examination, prostate examination, rectal examination) > Open-ended opportunity for patient to raise questions about their own sexual health, sexual function, desires, injuries, and so forth (Simone & Applebaum, 2011; Makadon et al., 2015; Fenway Health, 2015; Makadon, 2011; American Nurses Association, 2015; National LGBT Health Education Center, 2013). COURTEOUS AND RESPECTFUL TERMINOLOGY CHOICES As health care professionals learn about those patients whose lifestyles they are less familiar with, there may be “words of wisdom” offered to assist with the sensitivity and increasing awareness of kindness for a group of patients. This occurs with the LGBTQ community. Here are some suggestions:
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Always use the patient’s preferred names and pronouns, even if it is different than their legal name > Organizations may offer two name bands to patient The standard bracelet with the legal name, date of birth, and so forth - A second band with the “preferred name” Just as with all patients, protect their privacy Take cues from the patient as they will selfdisclose and self-identify as they gain comfort and trust with you Use language that fits with the patient’s gender identity, even if the patient’s body does not seem to match When using the words transsexual, transgender, or trans . it is better to use them as an adjective instead of a noun (i.e., trans people) Refrain from asking questions regarding the patient’s genitals unless the information is essential for the care being provided to the patient at that visit Maintain patient privacy and comply with all Health Insurance Portability and Accountability regulations when a trans patient is in your care -
A A
A
A
A
A
> Respect their privacy, just as you would all other patients A If you are not sure how to address your patient, ask them in a kind, compassionate and respectful way, what their preference is A Avoid gender specific terms such as “Sir” or “Ma’am” A If you are unable to locate the patient in your system, ask if they may be listed under a “different name”
The American Nurses Association’s Code of Ethics states: an individual’s lifestyle, value system and religious beliefs should be considered in planning health care with and for each patient. Such consideration does not suggest that the nurse necessarily agrees with or condones certain individual choices, but that the nurse respects the patient as a person (American Nurses Association, 2015).
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heightened anxiety and fear when undergoing imaging examinations or procedures as in their general daily life; they can dress and live as they are comfortable yet when coming to radiology; the images may reveal secrets they are keeping from others. Speak calmly and professionally; be sensitive to the patient’s quietness, guarded behavior, or behavior that seems out of proportion to the situation. Again, explain to the patient that you want to take excellent care of them and need certain pieces of personal health information to provide for them. The identification of potential pregnancy is a major concern in any imaging department. If a transgender patient looks like a male with a male name, it can be quite uncomfortable when it is determined that the patient has female anatomy under their clothes. This confusion can result in a delay of imaging to the patient. If you encounter this, remain calm and professional while explaining to the patient the need for clarification of possible pregnancy testing. Ask the patient in a kind manner, what anatomical/biological body organs they have so that you can best take care of them. When interviewing the patient, ask only questions that pertain to the area of examination or the reason for the visit: if the patient is having an x-ray for a wrist injury, there is no need to question them about their sexual realignment surgery. Be aware that they may take medications that are less commonly disclosed on imaging screening forms: just ask for the spelling or what it is for.
MAMMOGRAPHY A
Annual screening may be ordered because > Testosterone therapy may cause the breast to have decreased glandular tissue and increased fibrous tissue > Prolonged exposure to estrogen can increase the risk of breast cancer > Body mass index above 35 > Family history of breast cancer > Female-to-male patients who had mastectomies and have residual breast tissue (Fenway Health, 2015; Phillips et al., 2014)
BONE DENSITOMETRY MAY BE ORDERED FOR A
CARE IN THE RADIOLOGY SETTING Specific care of the transgender patient in radiology can be especially sensitive to balance. They may experience 222
Female-to-male patients who have taken testosterone A Male-to-female patients who have stopped hormone therapy after extended periods (Makadon et al., 2015; Fenway Health, 2015)
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Terms Common to the Transgender Population The combination of masculine and feminine characteristics A person who lacks sexual orientation, attraction to others, or a low/absent interest in sexual activity. It may also be considered a variation of heterosexuality, homosexuality, or bisexuality. Biphobia An aversion/discrimination toward bisexuality and bisexual people as a social group or as individuals that may be based on negative bisexual stereotypes or irrational fear. Bigendered people A person with two gender identities Binary pronoun Male or female, him or her Bisexual A person who is sexually attracted to both men and woman “Bottom surgery” Also known as “lower surgery” which is popular terminology for genital surgery Cisgender A person who is comfortable with the biological sex they were assigned at birth Cross-dressing Wearing clothes and other accessories commonly associated with the opposite sex Demisexual A person who only experiences a sexual attraction to another person after they form a strong emotional/romantic connection with each other. Drag kings Most commonly are female performers who dress in masculine outfits (drag) and personify male gender stereotypes as part of an individual or group routine. They may be heterosexual, lesbian, transgender, genderqueer, or otherwise part of the LGBTQ community. Drag queens Most commonly, a male performer who dresses in feminine clothing (drag) and often acts with exaggerated femininity and in feminine gender roles. Female-to-male A person assigned a female sex at birth but who identifies as a male Gay Sexually attracted to someone of their same sex, usually pertaining to men Gender A grammatical term which includes nouns or pronouns that refer to a range of characteristic indicating masculinity, femininity, or neutral state as assigned by society. Gender biology An attempt by science communities to categorize people as male, female, or intersex based on an assessment of internal/external reproductive anatomy, genetic chromosomal profile, and hormonal profile Gender expressions The part of a person’s identity that expresses their gender by person appearance choices including hair, clothing, our posture, and so forth. Gender identity A person’s inner sense of being male, female, both, or neither Genderdindeterminate The gender or sex of a person is not readily obvious or apparent. Genderqueers A person who does not identify with just 1 conventional gender distinctions (male or female). They may identify with both, neither, or somewhere in between. Gender segregation The separation of the sexes, which can be enforced by rules, laws, and policies: affecting forms/documents, locker rooms, restrooms, clothing, and so forth Hermaphrodite A biological term referring to an organism that has reproductive organs normally associated with both male and female sexes. Heterosexual A person attracted to the opposite sex Homophobia Negative feelings or fears toward people perceived to be LGBT Homosexual An outdated clinical term for someone who is attracted to another person of the same sex Intersexual A general term used for a variety of conditions in which a person is born with a reproductive or sexual anatomy that does not seem to fit the typical definitions of female or male. Lesbian A woman who is sexually attracted to another woman LGBTQ Lesbian, Gay, Bisexual, Transgender, Questioning/Queer LQBTQIA Lesbian, Gay, Bisexual, Transgender,/Questioning/Queer, Intergender, Asexual Male-to-female A person assigned a male sex at birth but who identifies as a female Nonbinary An umbrella term for people who do not identify with a binary gender pronoun (he/she, male/female) but instead identify themselves with a combination or the two or neither of the two Omnigender/polygender Possess all genders. Romantic, emotional, or sexual attractions are geared toward others regardless of sex and/or gender expression. Polyamory The practice, state, or ability of having more than 1 sexual loving relationship at the same time, with the full knowledge and consent of all involved Queer An umbrella term for those who do not fall into the cisgender or heterosexual identities Sexual minorities A group of people whose sexual identity, orientation, or practices differ from most of the surrounding society Sexual orientation The manner in which a person is sexually attracted to another person. It can be broken down into affection, romantic, or erotic. Sex reassignment/realignment Surgical procedure (s) performed to assist a transgender person’s physical appearance and function of their existing sexual characteristics to change and surgery resemble that of their identified gender.
Androgynous Asexual
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The Joint Commission (2011); Cole (2015); U.S. Department of Health and Human Services and Office of Disease Prevention and Health Promotion (2020); Mesics (2015); McNeil et al. (2012); The Joint Commission (2010); Makadon et al. (2015); Fenway Health (2015); National LGBT Health Education Center (2013); Phillips et al. (2014); Gay Alliance (2016); Intersex Society of North America (ISNA) (2016); Gay Alliance (2014); Center of Excellence for Transgender Health (2011); Weber (2009); Meyer (1995); Cicero and Black (2016).
Trans woman Trans mental health Two spirit
Trans man Transphobia Transitioning Transsexual
Sex segregation Transgender
Glossary (continued )
Terms Common to the Transgender Population The physical, legal, and cultural separation of people according to their biological sex An umbrella term that includes all gender variant people: transsexual, cross-dressers, drag kings, drag queens, intersexuals, genderqueers, and bigendered people. A female transitioning to a male Intense dislike, negative feelings, or fear of those people who are transgender The term used to describe the past or present transgender journey A term that may be outdated. Transgender is a more current term. A person whose gender identity is not congruent with their biological sex. They have a strong desire to assume the physical characteristics and gender role of the opposite sex. A male transitioning to a female State of mental health associated with transgender people A culturally distinct gender term that describes indigenous North Americans individuals with dual or multiple genders or spirits
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ULTRASOUND MAY BE ORDERED FOR A
Patients on estrogen therapy as it may increase the risk of gallstones and gall bladder disease A Patients taking hormonal therapy are at an increased risk of deep vein thrombosis A If pregnancy occurs while taking testosterone, harm or death may occur to the fetus A In male-to-female patients, testosterone can lead to polycystic ovarian changes, so these patients may have annual pelvic/uterine ultrasound to assess the ovaries and endometrial lining: however, there are no data to support regular screening (Makadon et al., 2015; Fenway Health, 2015). NUCLEAR MEDICINE STUDY MAY BE ORDERED A
Patients on estrogen therapy are at an increase the risk of gallstones and gall bladder disease (Makadon et al., 2015; Fenway Health, 2015)
COMPUTERIZED AXIAL TOMOGRAPHY SCAN A
Increased risk of thromboembolism: stroke, pulmonary emboli, and myocardial infarction A Androgen blockers can affect renal function; evaluate carefully before iodinated contrast administration A Male-to-female patients are at a greater risk of thromboembolic events due to the estrogen medications A Postoperative anatomy changes or surgical complications may alter images the staff are more accustomed to preview (Makadon et al., 2015; Fenway Health, 2015). INTERVENTIONAL RADIOLOGY PROCEDURES MAY BE ORDERED A
To place drains in postoperative abscess or fluid collections A Testosterone can cause liver toxicity and increased risk of liver disease, requiring a liver biopsy (Makadon et al., 2015; Fenway Health, 2015) CONCLUSION As society allows for individuals to express themselves as to their personal beliefs, we are experiencing a greater awareness of the transgender population. There are television shows featuring this population, media reports on political dictates to bathroom topics involving transgender issues, and we are caring for an www.radiologynursing.org
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increasing number of patients who are feeling more comfortable reporting their gender identification. As health care providers who may not be familiar with this group of people, it is our professional duty to be aware and compassionate to this and all groups of patients who trust us with their health care needs.
Acknowledgment The author would like to thank Rowan Collins, Education Coordinator for the Gay Alliance of Genesee Valley in Rochester, NY, for his careful review and passionate guidance in the development of this article.
References American Nurses Association (2015). Code of ethics for nurses with interpretive statements. Retrieved from http:// nursingworld.org/DocumentVault/Ethics_1/Code-of-Ethicsfor-Nurses.html. February 27, 2016. Buchmueller, T., & Carpenter, C.S. (2010). Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-sex relationships, 2000e2007. American Journal of Public Health, 100(3), 489-495. Center of Excellence for Transgender Health (2011). Primary care protocol for transgender patient care (transgender terminology). Sacramento, CA: University of California, San Francisco, Department of Family and Community Medicine. Retrieved from http://transhealth.ucsf.edu/trans?pageZpro tocol-terminology. Cicero, E.C., & Black, B.P. (2016). I was a spectacle.a freak show at the circus”: A transgender person’s ED experience and implications for nursing practice. Journal of Emergency Medicine, 42(1), 25-30. Cole, E. (2015). Honest, open and non-judgemental. Nursing Standard, 29, 23, 19-21. Fenway health: The medical care of transgender person. Retrieved from http://www.lgbthealtheducation.org/wp-content/uploads/ The-Medical-Care-of-Transgender-Persons.pdf. February 25, 2016. Gay Alliance: A glossary of terms associated with the LGBTQ communities. Retrieved from http://www.gayalliance.org/ wp-content/uploads/2015/04/Glossary-of-Terms-updated-Feb2015.pdf. January 15, 2016. Gay Alliance: Being respectful to transgender people: Retrieved from http://www.gayalliance.org/wp-content/uploads/2015/ 04/BeingRespectfultoTransgenderPeople.pdf. January 15, 2016. Grant, J.M., Tanis, M.L., Harrison, J., Herman, J.L., & Keisling, M. (2011). Injustice at every turn: A report of the national transgender discrimination survey. Retrieved from http://endtransdiscr imination.org/PDFs/NTDS_Report.pdf. February 27, 2016. Intersex Society of North America (ISNA). FAQs. Retrieved from http://www.isna.org/faq/what_is_intersex. February 21, 2016. Lambda Legal, Human Rights Campaign Foundation, New York City Bar Association (2013). Creating equal access to quality health care for transgender patients: Transgender-affirming hospital policies. Retrieved from http://www.lgbtagingce nter.org/resources/resource.cfm?rZ625#sthash.a9swR5Xv. dpuf. December 23, 2015.
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Lim, F., Johnson, M., & Eliason, M. (2015). A national survey of faculty knowledge, experience, and readiness for teaching lesbian, gay, bisexual, and transgender health in baccalaureate nursing programs. Nursing Education Perspectives, 36(3), 144-152. Makadon, H. (2011). Ending LGBT invisibility in health care: The first step in ensuring equitable care. Cleveland Clinic Journal of Medicine, 78(4), 220-224. Makadon, H., Mayer, K., Potter, J., & Goldhammer, H. (2015). Fenway Guide to lesbian, gay, bisexual, and transgender health (2nd ed.). Philadelphia, PA: American College of Physicians. Sheridan Books. McNeil, J., Bailey, L., Ellis, S., Morton, J., & Regan, M. (2012). Trans Mental Health and Emotional Wellbeing Study. Retrieved from http://www.gires.org.uk/assets/MedproAssets/trans_mh_study.pdf. February 20, 2016. Mesics, S. (2015). Clinical care of the transgender patient. Sacramento, CA: NetCE. Retrieved from http://www.netce.com/ coursecontent.php?courseidZ1227. February 25, 2016. Meyer, I.H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36(1), 38-56. National LGBT Health Education Center (2013). A Program of the Fenway Institute. Affirmative care for transgender and gender non-conforming people: Best practices for front-line health care staff. Retrieved from http://www.lgbtheal theducation.org/wp-content/uploads/13-017_TransBestPract icesforFrontlineStaff_v6_02-19-13_FINAL.pdf. February 20, 2016. Phillips, J., Fein-Zachary, V., Mehta, T., Littlehale, N., Venkataraman, S., & Slanetz, P. (2014). Breast imaging in the transgender patient. American Journal of Roentgenology, 202(5), 1149-1156. Rubin, R. (2015). Trans health care in the USA: a long way to go. Lancet, 386(9995), 727-728. Simone, M., & Applebaum, J. (2011). Addressing the needs of older lesbian, gay, bisexual, and transgender adults. Consultant 360: Clinical Geriatrics, 19(2). Retrieved from http:// www.consultant360.com/articles/addressing-needs-older-les bian-gay-bisexual-and-transgender-adults. December 12, 2015. Snelgrove, J., Jasudavisius, A., Rowe, B., Head, E., & Bauer, G. (2012). “Completely out-at-sea” with “two-gender medicine”: A qualitative analysis of physician-side barriers to providing healthcare for transgender patients. BMC Health Services Research, 12, 110. The Joint Commission (2010). Advancing effective communication, cultural competence, and patient-and family-centered care: A roadmap for hospitals. Oakbrook Terrace, IL: The Joint Commission. Retrieved from http://www.jointcommi ssion.org/assets/1/6/aroadmapforhospitals finalversion727. pdf. February 27, 2016. The Joint Commission (2011). Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: A field guide. Oak Brook, IL: The Joint Commission. Retrieved from http://www.pwrnewmedia.com/20 11/joint_commission/lgbt/downloads/LGBTFieldGuide.pdf. February 20, 2016. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy people 2020. Lesbian, Gay, Bisexual, and Transgender Health. http://www. healthypeople.gov/2020/topics-objectives/topic/lesbian-gaybisexual-and-transgender-health?topicidZ25.
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Van Wagenen, A. (2015). TEN THINGS: Creating inclusive health care environments for LGBT people. Boston, MA: National LGBT Health Education Center. Retrieved from http:// www.lgbthealtheducation.org/wp-content/uploads/072315Welcoming-Environment-Brief-WEB.pdf. December 24, 2015.
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Weber, S. (2009). Policy aspects and nursing care of families with parents who are sexual minorities. Journal of Family Nursing, 15(3), 384-399. Wichinski, K. (2015). Providing culturally proficient care for transgender patients. Nursing, 45(2), 58-63.
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INTRODUCTION As a profession, nurses collectively approach the delivery of quality patient care in a goal-focused manner that is patient and family centered. Nurses strive to be professional at all times and to treat each patient as the individual that they are meeting their needs while in the radiologic environment. Nurses speak in a calm, inviting manner to build a trusting rapport with the patient and their visitors that will assist in obtaining the essential information needed to develop the safest and most efficient manner of providing the care patients seek. Exposed to the need for cultural competency, and when exposed to cultures and religions one is less familiar with, nurses try to be as welcoming as possible. Governing agencies have long-mandated organizations to provide employees with training and to have policies in place which promote an environment of inclusion to all patients seeking care. In complying with our professional ethics and governing mandates, nurses believe that all patients regardless of their social, religious, cul-
Valerie G. Aarne Grossman, MALS, BSN, NE-BC, Nurse Manager, Medical Imaging, University of Rochester, Highland Hospital, Macedon, NY. Corresponding author: Valerie G. Aarne Grossman, Medical Imaging, University of Rochester, Highland Hospital, PO Box 27, Macedon, NY 14502. E-mail: [email protected] 1546-0843/$36.00 Copyright Ó 2016 by the Association for Radiologic & Imaging Nursing. http://dx.doi.org/10.1016/j.jradnu.2016.06.002
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tural, or personal characteristics should be treated with dignity and respect (The Joint Commission, 2011). It falls on nurses to help the patient feel comfortable when providing the most private information. As challenging as it may be, it is essential to contain personal bias, prejudice, cultural, religious, or moral beliefs to ourselves and maintain professional communication (verbal and nonverbal) at all times. Nurses must create an environment that is calm, open, receptive, nonjudgmental, and respectful while maintaining a positive attitude and committed desire to provide the very best care. TRANSGENDER PEOPLE While most nurses would readily agree that they treat all patients equally, the transgender community will likely describe their experiences with the health care community quite differently. Transgender patients commonly describe their past experiences with health care teams and systems as being negative, including such treatment as discrimination, negative judgment, assumption, and harassment, unprofessional or unwelcoming verbal and nonverbal communication. Transgender patients often feel invisible to, and lack, trust in their health care employees. After repeated incidences of feeling unwelcome and not understood, many transgender patients delay accessing care for their health needs. By the time they do seek treatment; they may be quite ill and/or mistrusting of health care workers.
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Transgender people were born with the anatomy of one gender, but their inner soul identifies with another gender. The term “transgender” is an umbrella term for people whose gender identity, gender expressions, or behavior may be different than what society assumes it should be typically associated with the sex they were assigned at birth. There are many terms used when caring for someone in the transgender community, and health care professionals must be aware of them, their meaning, or know where to look them up (see Glossary). It is NOT the patient’s fault that nurses and other health care employees are uninformed, nor is it the responsibility of the patient seeking care to educate the health care staff with regards to transgender issues. It is an unfair burdensome expectation that a sick patient will teach a nurse what transgender means, and how it may affect their health care issues (Rubin, 2015). Most heterosexual individuals find it difficult to define or understand the transgender community (Wichinski, 2015). When the health care worker is unfamiliar with transgender people and their issues, this further causes the patient to feel unsafe and uncomfortable talking openly about their health concerns. If the health care worker refuses to acknowledge the circumstances under which a transgender or nonbinary person has lived, does live and what their health care needs may be . then the patient’s participation and trust in the care provider may be guarded and partial. Health care professionals must become trans aware to be able to fully deliver the highest quality of patient care (Cole, 2015). For most, this education or awareness will have to be self-sought, as little is included in most nursing educational programs. A recent survey revealed that current baccalaureate curricula contained an average of 2 hr devoted to the care of the Lesbian/ Gay/Bisexual/Transgender/Questioning-Queer (LGBTQ) population (Lim, Johnson, & Eliason, 2015). Younger members of the LGBTQ community were born into a society that is slightly more aware, and perhaps more accepting, than the geriatric portion of this community. The older the transgendered person is, the more they have had to live with difficulties within their community and family groups. Strong cultural and societal pressures from family and friends may have made it difficult for an individual to disclose the most private of details of their lives . yet, for the nurse, it is essential that proper, complete, and inclusive information is obtained. Older transgender patients may have spent decades dealing with discrimination and denial of their civil and human rights, which will make it even more difficult for them to open up freely to health care team (U.S. Department of Health and Human Services & Office of Disease Prevention and Health Promotion, 2020). They have gone the longest
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living in secrecy and may take longer to open up to the health care staff (Simone & Applebaum, 2011). Transgender patients may be less likely to have health insurance than others (Buchmueller & Carpenter, 2010). Many transgender people have experienced discrimination when seeking employment, education, housing, and in many public settings (Mesics, 2015). Transgender people of color, ethnic/cultural/religious minorities, low education, specific geographic locations, or a primary language other than English often experience even greater discrimination (Grant, Tanis, Harrison, Herman, & Keisling, 2011). The Trans Mental Health and Emotional Well Being Study of 2012 found a heavy toll on the mental health of transgender patients including: A
88% experience(d) depression 84% had suicidal thoughts at some point in their life A 62% had alcohol dependency or abuse issues A 38% experience(d) sexual harassment (McNeil, Bailey, Ellis, Morton, & Regan, 2012) A
ORGANIZATIONAL SENSITIVITY Organizations can establish a welcoming environment in a number of ways. These efforts must begin from the board of directors and senior leadership. Organizational leaders must be actively engaged in making their health care systems inclusive to all patients who seek care. Suggestions of ways to promote inclusion could include: A
Posters, literature, and other printed material should include transgender people A Organizations should include LGBTQ in their outreach programs A Educational programs for staff on culturally affirming care for LGBTQ people A Forms should: > Be gender neutral (not just “male or female”) Example: gender at birth and current gender > Space for both legal name and their preferred name (may be different) > Some electronic record systems are now allowing for this type of documentation A All policies should be examined to be sure they are LGBTQ inclusive: -
> Gender identity and gender expression nondiscrimination > Patients’ Bill of Rights
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> Visitation policies should include support persons who may not be legally or biologically related to them > Admitting/registration records that allow for variability between the patient’s legal name and preferred name
toms (Snelgrove, Jasudavisius, Rowe, Head, & Bauer, 2012). The motivated and dedicated health care professional can begin to gain the trust of the transgender patient by:
Registration is often where patients develop their “first impression” of their visit, so it is essential that registration staff understand speaking professionally with a transgender patient The Joint Commission recommends staff use and document a transgender patient’s preferred name, even if not the legal name.
> Focus more on their reason for the health care visit then on the fact that the patient is transgender A If staff have prejudice toward the patient, they must contain their own emotion
-
-
The Joint Commission states: Note the patient’s preferred name prominently in the patient record to make sure that staff address the patient appropriately. Staff should be aware that patients who identify as transgender may have a name preference that differs from their legal name and may or may not have altered their bodies medically. (The Joint Commission, 2010).
> Education for staff to learn about proper interactions with transgender patients If staff exhibit unprofessional behavior or comments, they should be held accountable and disciplined following the organizational policies (Mesics, 2015) Semiprivate rooms should be assigned carefully Access to restrooms (single occupancy unisex restrooms are preferred) Compliance with privacy laws Coding for insurance purposes (proper ICD 10 codes; Lambda Legal, Human Rights Campaign Foundation, & New York City Bar Association, 2013; Van Wagenen, 2015) -
> > > >
HEALTH CARE STAFF Governing agencies are paying closer attention to the delivery of quality health care to the transgender patients. Increased awareness needs to occur, so health care staff can assist this population to ensure access to nonprejudicial care and for them to receive the proper health care necessary. In addition to the general health care that individuals would seek, the transgender patient may have additional concerns, signs, or symp220
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A
Building a rapport with the patient that is sensitive to their situation
> Avoid judging the patient based on your own moral terms (Snelgrove et al., 2012) A Use a “matter of fact” interview technique A Do not make a spectacle out of the patient’s transgender status A Using correct pronouns, ask open-ended questions, and be nonjudgmental when the patient answers your questions > Hide your nonverbal if the answer is out of your comfort zone A Follow the lead of the patient when interviewing > Listen for how they self-identify, what pronouns they use, and so forth. > Ask the patient “is the name on the chart, the name you prefer me to use,” and ask them how they would prefer you address them (i.e., Mr. Jones, Sally, Reverend, etc.) A Encourage patient’s questions or comments A Avoid making assumptions about the patient A If you say something wrong, do not over apologize > Just apologize and move on (be sure to get it right the next time!) A Family history may be very important to help establish a baseline of information and offer essential information to the health status of all patients, especially transgender patients. Family health history may be important to determine, as patients who are predisposed to certain health issues may have an increased risk when taking medications common in transgender health care. Living with chronic stress can worsen a patient’s well-being (so it is important for the health care team to understand family support vs. family rejection, PTSD, abuse, etc.). Because the patient is transgender, a family history may need to include (Makadon, Mayer, Potter, & Goldhammer, 2015) the following: > Coagulation disorders > Cardiovascular disease
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> Diabetes > Liver disease > Cancer (prostate, ovarian, breast, or uterine) A
Medical history should include the following: > Accurate medication reconciliation > Coronary heart disease/cerebrovascular disease > Arterial, venous or pulmonary thromboembolism > Hypertension > Diabetes > Liver disease > Hormonal therapy > Bone density > Cancer > HIV
A
Surgical history should include the following: > For male-to-female realignment surgery: -
Breast augmentation Bilateral orchiectomy Penectomy Vaginoplasty Vuvloplasty Construction of a neovagina Labioplasty Facial feminization surgery Tracheal cartilage shave Implants, liposuction, lipofillers
> For female-to-male realignment surgery: -
Mastectomy Chest reconstruction Bilateral salpingo-oophorectomy Hysterectomy Urethroplasty Clitoral free-up Vaginectomy Scrotoplasty Construction of a neophallus (phalloplasty) Metoidioplasty Implants, liposuction, lipofillers
> Complications of above surgeries can include the following: -
Wound dehisence Wound infection or necrosis Graft necrosis Seromas Hematomas
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Bladder damage Nerve injury - Rectovaginal fistula - Urethra-vaginal fistula - Urethral stricture/stenosis - Testicular implant erosion through skin - Vaginal stenosis - Granulation tissue formation - Vaginal prolapse (Mesics, 2015; Makadon et al., 2015; Fenway Health, 2015) A Psychosocial history should include the following: -
> Information regarding patient’s social circle and support system (past and present) > Economic status (including access to insurance and health care providers) > Social isolation/harassment/discrimination/ abandonment/abuse (past or present) > Employment, housing, education, and significant activities > Mental health concerns such as depression, anxiety, bipolar, substance use/abuse, or changes as a result of hormonal therapy - Testosterone can worsen some mental health conditions > Identify support group participation A Routine sexual history should include the following (if it pertains to current visit or may have an impact on current health care visit): > A gradual approach to questions > Sexual orientation, risk behaviors as related to sexually transmitted infections or pregnancy > Identify need for screening tests (Pap smear, testicular examination, prostate examination, rectal examination) > Open-ended opportunity for patient to raise questions about their own sexual health, sexual function, desires, injuries, and so forth (Simone & Applebaum, 2011; Makadon et al., 2015; Fenway Health, 2015; Makadon, 2011; American Nurses Association, 2015; National LGBT Health Education Center, 2013). COURTEOUS AND RESPECTFUL TERMINOLOGY CHOICES As health care professionals learn about those patients whose lifestyles they are less familiar with, there may be “words of wisdom” offered to assist with the sensitivity and increasing awareness of kindness for a group of patients. This occurs with the LGBTQ community. Here are some suggestions:
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Always use the patient’s preferred names and pronouns, even if it is different than their legal name > Organizations may offer two name bands to patient The standard bracelet with the legal name, date of birth, and so forth - A second band with the “preferred name” Just as with all patients, protect their privacy Take cues from the patient as they will selfdisclose and self-identify as they gain comfort and trust with you Use language that fits with the patient’s gender identity, even if the patient’s body does not seem to match When using the words transsexual, transgender, or trans . it is better to use them as an adjective instead of a noun (i.e., trans people) Refrain from asking questions regarding the patient’s genitals unless the information is essential for the care being provided to the patient at that visit Maintain patient privacy and comply with all Health Insurance Portability and Accountability regulations when a trans patient is in your care -
A A
A
A
A
A
> Respect their privacy, just as you would all other patients A If you are not sure how to address your patient, ask them in a kind, compassionate and respectful way, what their preference is A Avoid gender specific terms such as “Sir” or “Ma’am” A If you are unable to locate the patient in your system, ask if they may be listed under a “different name”
The American Nurses Association’s Code of Ethics states: an individual’s lifestyle, value system and religious beliefs should be considered in planning health care with and for each patient. Such consideration does not suggest that the nurse necessarily agrees with or condones certain individual choices, but that the nurse respects the patient as a person (American Nurses Association, 2015).
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heightened anxiety and fear when undergoing imaging examinations or procedures as in their general daily life; they can dress and live as they are comfortable yet when coming to radiology; the images may reveal secrets they are keeping from others. Speak calmly and professionally; be sensitive to the patient’s quietness, guarded behavior, or behavior that seems out of proportion to the situation. Again, explain to the patient that you want to take excellent care of them and need certain pieces of personal health information to provide for them. The identification of potential pregnancy is a major concern in any imaging department. If a transgender patient looks like a male with a male name, it can be quite uncomfortable when it is determined that the patient has female anatomy under their clothes. This confusion can result in a delay of imaging to the patient. If you encounter this, remain calm and professional while explaining to the patient the need for clarification of possible pregnancy testing. Ask the patient in a kind manner, what anatomical/biological body organs they have so that you can best take care of them. When interviewing the patient, ask only questions that pertain to the area of examination or the reason for the visit: if the patient is having an x-ray for a wrist injury, there is no need to question them about their sexual realignment surgery. Be aware that they may take medications that are less commonly disclosed on imaging screening forms: just ask for the spelling or what it is for.
MAMMOGRAPHY A
Annual screening may be ordered because > Testosterone therapy may cause the breast to have decreased glandular tissue and increased fibrous tissue > Prolonged exposure to estrogen can increase the risk of breast cancer > Body mass index above 35 > Family history of breast cancer > Female-to-male patients who had mastectomies and have residual breast tissue (Fenway Health, 2015; Phillips et al., 2014)
BONE DENSITOMETRY MAY BE ORDERED FOR A
CARE IN THE RADIOLOGY SETTING Specific care of the transgender patient in radiology can be especially sensitive to balance. They may experience 222
Female-to-male patients who have taken testosterone A Male-to-female patients who have stopped hormone therapy after extended periods (Makadon et al., 2015; Fenway Health, 2015)
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Terms Common to the Transgender Population The combination of masculine and feminine characteristics A person who lacks sexual orientation, attraction to others, or a low/absent interest in sexual activity. It may also be considered a variation of heterosexuality, homosexuality, or bisexuality. Biphobia An aversion/discrimination toward bisexuality and bisexual people as a social group or as individuals that may be based on negative bisexual stereotypes or irrational fear. Bigendered people A person with two gender identities Binary pronoun Male or female, him or her Bisexual A person who is sexually attracted to both men and woman “Bottom surgery” Also known as “lower surgery” which is popular terminology for genital surgery Cisgender A person who is comfortable with the biological sex they were assigned at birth Cross-dressing Wearing clothes and other accessories commonly associated with the opposite sex Demisexual A person who only experiences a sexual attraction to another person after they form a strong emotional/romantic connection with each other. Drag kings Most commonly are female performers who dress in masculine outfits (drag) and personify male gender stereotypes as part of an individual or group routine. They may be heterosexual, lesbian, transgender, genderqueer, or otherwise part of the LGBTQ community. Drag queens Most commonly, a male performer who dresses in feminine clothing (drag) and often acts with exaggerated femininity and in feminine gender roles. Female-to-male A person assigned a female sex at birth but who identifies as a male Gay Sexually attracted to someone of their same sex, usually pertaining to men Gender A grammatical term which includes nouns or pronouns that refer to a range of characteristic indicating masculinity, femininity, or neutral state as assigned by society. Gender biology An attempt by science communities to categorize people as male, female, or intersex based on an assessment of internal/external reproductive anatomy, genetic chromosomal profile, and hormonal profile Gender expressions The part of a person’s identity that expresses their gender by person appearance choices including hair, clothing, our posture, and so forth. Gender identity A person’s inner sense of being male, female, both, or neither Genderdindeterminate The gender or sex of a person is not readily obvious or apparent. Genderqueers A person who does not identify with just 1 conventional gender distinctions (male or female). They may identify with both, neither, or somewhere in between. Gender segregation The separation of the sexes, which can be enforced by rules, laws, and policies: affecting forms/documents, locker rooms, restrooms, clothing, and so forth Hermaphrodite A biological term referring to an organism that has reproductive organs normally associated with both male and female sexes. Heterosexual A person attracted to the opposite sex Homophobia Negative feelings or fears toward people perceived to be LGBT Homosexual An outdated clinical term for someone who is attracted to another person of the same sex Intersexual A general term used for a variety of conditions in which a person is born with a reproductive or sexual anatomy that does not seem to fit the typical definitions of female or male. Lesbian A woman who is sexually attracted to another woman LGBTQ Lesbian, Gay, Bisexual, Transgender, Questioning/Queer LQBTQIA Lesbian, Gay, Bisexual, Transgender,/Questioning/Queer, Intergender, Asexual Male-to-female A person assigned a male sex at birth but who identifies as a female Nonbinary An umbrella term for people who do not identify with a binary gender pronoun (he/she, male/female) but instead identify themselves with a combination or the two or neither of the two Omnigender/polygender Possess all genders. Romantic, emotional, or sexual attractions are geared toward others regardless of sex and/or gender expression. Polyamory The practice, state, or ability of having more than 1 sexual loving relationship at the same time, with the full knowledge and consent of all involved Queer An umbrella term for those who do not fall into the cisgender or heterosexual identities Sexual minorities A group of people whose sexual identity, orientation, or practices differ from most of the surrounding society Sexual orientation The manner in which a person is sexually attracted to another person. It can be broken down into affection, romantic, or erotic. Sex reassignment/realignment Surgical procedure (s) performed to assist a transgender person’s physical appearance and function of their existing sexual characteristics to change and surgery resemble that of their identified gender.
Androgynous Asexual
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The Joint Commission (2011); Cole (2015); U.S. Department of Health and Human Services and Office of Disease Prevention and Health Promotion (2020); Mesics (2015); McNeil et al. (2012); The Joint Commission (2010); Makadon et al. (2015); Fenway Health (2015); National LGBT Health Education Center (2013); Phillips et al. (2014); Gay Alliance (2016); Intersex Society of North America (ISNA) (2016); Gay Alliance (2014); Center of Excellence for Transgender Health (2011); Weber (2009); Meyer (1995); Cicero and Black (2016).
Trans woman Trans mental health Two spirit
Trans man Transphobia Transitioning Transsexual
Sex segregation Transgender
Glossary (continued )
Terms Common to the Transgender Population The physical, legal, and cultural separation of people according to their biological sex An umbrella term that includes all gender variant people: transsexual, cross-dressers, drag kings, drag queens, intersexuals, genderqueers, and bigendered people. A female transitioning to a male Intense dislike, negative feelings, or fear of those people who are transgender The term used to describe the past or present transgender journey A term that may be outdated. Transgender is a more current term. A person whose gender identity is not congruent with their biological sex. They have a strong desire to assume the physical characteristics and gender role of the opposite sex. A male transitioning to a female State of mental health associated with transgender people A culturally distinct gender term that describes indigenous North Americans individuals with dual or multiple genders or spirits
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ULTRASOUND MAY BE ORDERED FOR A
Patients on estrogen therapy as it may increase the risk of gallstones and gall bladder disease A Patients taking hormonal therapy are at an increased risk of deep vein thrombosis A If pregnancy occurs while taking testosterone, harm or death may occur to the fetus A In male-to-female patients, testosterone can lead to polycystic ovarian changes, so these patients may have annual pelvic/uterine ultrasound to assess the ovaries and endometrial lining: however, there are no data to support regular screening (Makadon et al., 2015; Fenway Health, 2015). NUCLEAR MEDICINE STUDY MAY BE ORDERED A
Patients on estrogen therapy are at an increase the risk of gallstones and gall bladder disease (Makadon et al., 2015; Fenway Health, 2015)
COMPUTERIZED AXIAL TOMOGRAPHY SCAN A
Increased risk of thromboembolism: stroke, pulmonary emboli, and myocardial infarction A Androgen blockers can affect renal function; evaluate carefully before iodinated contrast administration A Male-to-female patients are at a greater risk of thromboembolic events due to the estrogen medications A Postoperative anatomy changes or surgical complications may alter images the staff are more accustomed to preview (Makadon et al., 2015; Fenway Health, 2015). INTERVENTIONAL RADIOLOGY PROCEDURES MAY BE ORDERED A
To place drains in postoperative abscess or fluid collections A Testosterone can cause liver toxicity and increased risk of liver disease, requiring a liver biopsy (Makadon et al., 2015; Fenway Health, 2015) CONCLUSION As society allows for individuals to express themselves as to their personal beliefs, we are experiencing a greater awareness of the transgender population. There are television shows featuring this population, media reports on political dictates to bathroom topics involving transgender issues, and we are caring for an www.radiologynursing.org
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increasing number of patients who are feeling more comfortable reporting their gender identification. As health care providers who may not be familiar with this group of people, it is our professional duty to be aware and compassionate to this and all groups of patients who trust us with their health care needs.
Acknowledgment The author would like to thank Rowan Collins, Education Coordinator for the Gay Alliance of Genesee Valley in Rochester, NY, for his careful review and passionate guidance in the development of this article.
References American Nurses Association (2015). Code of ethics for nurses with interpretive statements. Retrieved from http:// nursingworld.org/DocumentVault/Ethics_1/Code-of-Ethicsfor-Nurses.html. February 27, 2016. Buchmueller, T., & Carpenter, C.S. (2010). Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-sex relationships, 2000e2007. American Journal of Public Health, 100(3), 489-495. Center of Excellence for Transgender Health (2011). Primary care protocol for transgender patient care (transgender terminology). Sacramento, CA: University of California, San Francisco, Department of Family and Community Medicine. Retrieved from http://transhealth.ucsf.edu/trans?pageZpro tocol-terminology. Cicero, E.C., & Black, B.P. (2016). I was a spectacle.a freak show at the circus”: A transgender person’s ED experience and implications for nursing practice. Journal of Emergency Medicine, 42(1), 25-30. Cole, E. (2015). Honest, open and non-judgemental. Nursing Standard, 29, 23, 19-21. Fenway health: The medical care of transgender person. Retrieved from http://www.lgbthealtheducation.org/wp-content/uploads/ The-Medical-Care-of-Transgender-Persons.pdf. February 25, 2016. Gay Alliance: A glossary of terms associated with the LGBTQ communities. Retrieved from http://www.gayalliance.org/ wp-content/uploads/2015/04/Glossary-of-Terms-updated-Feb2015.pdf. January 15, 2016. Gay Alliance: Being respectful to transgender people: Retrieved from http://www.gayalliance.org/wp-content/uploads/2015/ 04/BeingRespectfultoTransgenderPeople.pdf. January 15, 2016. Grant, J.M., Tanis, M.L., Harrison, J., Herman, J.L., & Keisling, M. (2011). Injustice at every turn: A report of the national transgender discrimination survey. Retrieved from http://endtransdiscr imination.org/PDFs/NTDS_Report.pdf. February 27, 2016. Intersex Society of North America (ISNA). FAQs. Retrieved from http://www.isna.org/faq/what_is_intersex. February 21, 2016. Lambda Legal, Human Rights Campaign Foundation, New York City Bar Association (2013). Creating equal access to quality health care for transgender patients: Transgender-affirming hospital policies. Retrieved from http://www.lgbtagingce nter.org/resources/resource.cfm?rZ625#sthash.a9swR5Xv. dpuf. December 23, 2015.
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Lim, F., Johnson, M., & Eliason, M. (2015). A national survey of faculty knowledge, experience, and readiness for teaching lesbian, gay, bisexual, and transgender health in baccalaureate nursing programs. Nursing Education Perspectives, 36(3), 144-152. Makadon, H. (2011). Ending LGBT invisibility in health care: The first step in ensuring equitable care. Cleveland Clinic Journal of Medicine, 78(4), 220-224. Makadon, H., Mayer, K., Potter, J., & Goldhammer, H. (2015). Fenway Guide to lesbian, gay, bisexual, and transgender health (2nd ed.). Philadelphia, PA: American College of Physicians. Sheridan Books. McNeil, J., Bailey, L., Ellis, S., Morton, J., & Regan, M. (2012). Trans Mental Health and Emotional Wellbeing Study. Retrieved from http://www.gires.org.uk/assets/MedproAssets/trans_mh_study.pdf. February 20, 2016. Mesics, S. (2015). Clinical care of the transgender patient. Sacramento, CA: NetCE. Retrieved from http://www.netce.com/ coursecontent.php?courseidZ1227. February 25, 2016. Meyer, I.H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36(1), 38-56. National LGBT Health Education Center (2013). A Program of the Fenway Institute. Affirmative care for transgender and gender non-conforming people: Best practices for front-line health care staff. Retrieved from http://www.lgbtheal theducation.org/wp-content/uploads/13-017_TransBestPract icesforFrontlineStaff_v6_02-19-13_FINAL.pdf. February 20, 2016. Phillips, J., Fein-Zachary, V., Mehta, T., Littlehale, N., Venkataraman, S., & Slanetz, P. (2014). Breast imaging in the transgender patient. American Journal of Roentgenology, 202(5), 1149-1156. Rubin, R. (2015). Trans health care in the USA: a long way to go. Lancet, 386(9995), 727-728. Simone, M., & Applebaum, J. (2011). Addressing the needs of older lesbian, gay, bisexual, and transgender adults. Consultant 360: Clinical Geriatrics, 19(2). Retrieved from http:// www.consultant360.com/articles/addressing-needs-older-les bian-gay-bisexual-and-transgender-adults. December 12, 2015. Snelgrove, J., Jasudavisius, A., Rowe, B., Head, E., & Bauer, G. (2012). “Completely out-at-sea” with “two-gender medicine”: A qualitative analysis of physician-side barriers to providing healthcare for transgender patients. BMC Health Services Research, 12, 110. The Joint Commission (2010). Advancing effective communication, cultural competence, and patient-and family-centered care: A roadmap for hospitals. Oakbrook Terrace, IL: The Joint Commission. Retrieved from http://www.jointcommi ssion.org/assets/1/6/aroadmapforhospitals finalversion727. pdf. February 27, 2016. The Joint Commission (2011). Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: A field guide. Oak Brook, IL: The Joint Commission. Retrieved from http://www.pwrnewmedia.com/20 11/joint_commission/lgbt/downloads/LGBTFieldGuide.pdf. February 20, 2016. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy people 2020. Lesbian, Gay, Bisexual, and Transgender Health. http://www. healthypeople.gov/2020/topics-objectives/topic/lesbian-gaybisexual-and-transgender-health?topicidZ25.
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Van Wagenen, A. (2015). TEN THINGS: Creating inclusive health care environments for LGBT people. Boston, MA: National LGBT Health Education Center. Retrieved from http:// www.lgbthealtheducation.org/wp-content/uploads/072315Welcoming-Environment-Brief-WEB.pdf. December 24, 2015.
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Weber, S. (2009). Policy aspects and nursing care of families with parents who are sexual minorities. Journal of Family Nursing, 15(3), 384-399. Wichinski, K. (2015). Providing culturally proficient care for transgender patients. Nursing, 45(2), 58-63.
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