Dwight D. Faught Coming Full Circle: The Old Becomes New ... · Coming Full Circle: The Old Becomes...
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Professional Issues Dwight D. Faught Coming Full Circle: The Old Becomes New Again — Cultural Competence and the Transgender Client D espite a mandate for providers and institutions to provide culturally competent health care, members of the transgender community contin- ue to experience disparities. This inequitable provision of care persists even as several states have passed anti-dis- crimination laws (Transgender Law and Policy Institute, 2012) and a number of professional organizations have offered position papers in support of equitable health care for transgender persons (Lambda Legal, 2012; Stroumsa, 2014). Along with policymakers and educa- tors, healthcare professionals play a key role in providing equal treatment. New communication skills, knowledge, and attitudes may be required to achieve this goal. The U.S. Department of Health and Human Services (n.d.) indicated, "Effective health communication is as impor- tant to health care as clinical skill" (para. 1). An understanding of culture is often described in terms of a particular body of knowledge, a body of belief and a body of behavior. Culture includes personal identification, language, thoughts, com- munications, actions, customs, beliefs, values and institutions that are often specific to ethnic, racial, religious, geographic or social groups. (National Institutes of Health, 2015, p. 1) Milton (2016) suggested healthcare professionals with knowledge and understanding of varied cultural beliefs are able to offer higher-quality health care. According to Milton, coining terms such as culture and competence potentially impedes the understanding of human differences and could harm those it was designed to help. The belief metadata can be collected on individuals from different cultures and then used to understand these groups and predict health behaviors and healthcare decisions for an entire culture puts the individual at risk. Persons are not static entities; instead they are moving constantly in ways that are unpre- dictable, unrepeatable, and unforeseeable, and continu- ally evolving (Parse, 2014). Each life experience has the potential to impact individuals in ways that cannot be predicted. This is especially true in a world where chil- dren can be adopted across oceans and raised in families of different nationalities, different races, or different religions. An individual can marry outside his or her nationality, class, culture, or religion. Dwight D. Faught, MSN, RN, PMHNP-BC, CMSRN, is Psychiatric Nurse Practitioner, Banner Behavioral Health Hospital, Scottsdale, AZ. Caring for the Individual In a paradoxical way, trying to categorize an individ- ual into a perceived culture and provide care based on knowledge of that culture essentially involves removing the individual from the equation. Providing individual- ized, patient-centered care is fundamental to the nurs- ing process. Being able to understand the patient as an individual requires the most basic nursing skill: building a therapeutic nurse-patient relationship. According to Mendes (2015), being culturally aware requires a nurse to communicate with the patient in a way that is unbi- ased so the nurse can learn from the patient about his or her personal values, healthcare needs, and goals. Nowhere is this truer, according to Xavier and co- authors (2013), than when caring for a transgender indi- vidual: a person who cannot choose or who chooses not to accept gender norms based on his or her assigned sex at birth. An individual may or may not identify as the opposite gender, may not identify with either gender, and may identify with a combination of genders. Gender identity is often fluid over time throughout the lifespan. Thus for this group, as Xavier and colleagues noted, the very nature of health care in America can present a barrier to care as the foundation of health care is based on a gender binary model. Xavier and coau- thors (2013), Cruz (2014), and Snelgrove, Jasudavisius, Rowe, Head, and Bauer (2012) have identified a number of barriers that keep transgender individuals from accessing needed health care. This author suggests these can be divided into four broad groups: social barriers, interpersonal barriers, system or institutional barriers, and provider barriers. The focus in this column will be on system or institutional and provider barriers. Institutional Barriers Leaders in institutions and health systems should begin to create forms or electronic medical records that provide more gender options than male and female. Individuals who are transgender may consider them- selves to be something other than male or female. A mechanism also is needed to allow medical records to be updated accordingly when a gender change has been made legally. The current trend of hospitals moving to all private rooms is a good start. Public restrooms should provide a gender-free option or single stall facilities (Stroumsa, 2014). M ED SU R G ntjbsiwg . July-August 2016 • Vol. 25/No. 4 285
Transcript of Dwight D. Faught Coming Full Circle: The Old Becomes New ... · Coming Full Circle: The Old Becomes...
ProfessionalIssues Dwight D. Faught
Coming Full Circle: The Old Becomes New Again — Cultural Competence and
the Transgender Client
D espite a mandate for providers and institutions to provide culturally competent health care, members of the transgender community contin
ue to experience disparities. This inequitable provision of care persists even as several states have passed anti-discrimination laws (Transgender Law and Policy Institute, 2012) and a number of professional organizations have offered position papers in support of equitable health care for transgender persons (Lambda Legal, 2012; Stroumsa, 2014). Along with policymakers and educators, healthcare professionals play a key role in providing equal treatment. New communication skills, knowledge, and attitudes may be required to achieve this goal. The U.S. Department of Health and Human Services (n.d.) indicated, "Effective health communication is as important to health care as clinical skill" (para. 1).
An understanding of culture is often described in terms of a particular body of knowledge, a body of belief and a body of behavior. Culture includes personal identification, language, thoughts, communications, actions, customs, beliefs, values and institutions that are often specific to ethnic, racial, religious, geographic or social groups. (National Institutes of Health, 2015, p. 1)Milton (2016) suggested healthcare professionals
with knowledge and understanding of varied cultural beliefs are able to offer higher-quality health care. According to Milton, coining terms such as culture and competence potentially impedes the understanding of human differences and could harm those it was designed to help. The belief metadata can be collected on individuals from different cultures and then used to understand these groups and predict health behaviors and healthcare decisions for an entire culture puts the individual at risk. Persons are not static entities; instead they are moving constantly in ways that are unpredictable, unrepeatable, and unforeseeable, and continually evolving (Parse, 2014). Each life experience has the potential to impact individuals in ways that cannot be predicted. This is especially true in a world where children can be adopted across oceans and raised in families of different nationalities, different races, or different religions. An individual can marry outside his or her nationality, class, culture, or religion.
Dwight D. Faught, MSN, RN, PMHNP-BC, CMSRN, is Psychiatric Nurse Practitioner, Banner Behavioral Health Hospital, Scottsdale, AZ.
Caring for the IndividualIn a paradoxical way, trying to categorize an individ
ual into a perceived culture and provide care based on knowledge of that culture essentially involves removing the individual from the equation. Providing individualized, patient-centered care is fundamental to the nursing process. Being able to understand the patient as an individual requires the most basic nursing skill: building a therapeutic nurse-patient relationship. According to Mendes (2015), being culturally aware requires a nurse to communicate with the patient in a way that is unbiased so the nurse can learn from the patient about his or her personal values, healthcare needs, and goals.
Nowhere is this truer, according to Xavier and coauthors (2013), than when caring for a transgender individual: a person who cannot choose or who chooses not to accept gender norms based on his or her assigned sex at birth. An individual may or may not identify as the opposite gender, may not identify with either gender, and may identify with a combination of genders. Gender identity is often fluid over time throughout the lifespan. Thus for this group, as Xavier and colleagues noted, the very nature of health care in America can present a barrier to care as the foundation of health care is based on a gender binary model. Xavier and coauthors (2013), Cruz (2014), and Snelgrove, Jasudavisius, Rowe, Head, and Bauer (2012) have identified a number of barriers that keep transgender individuals from accessing needed health care. This author suggests these can be divided into four broad groups: social barriers, interpersonal barriers, system or institutional barriers, and provider barriers. The focus in this column will be on system or institutional and provider barriers.
Institutional BarriersLeaders in institutions and health systems should
begin to create forms or electronic medical records that provide more gender options than male and female. Individuals who are transgender may consider themselves to be something other than male or female. A mechanism also is needed to allow medical records to be updated accordingly when a gender change has been made legally. The current trend of hospitals moving to all private rooms is a good start. Public restrooms should provide a gender-free option or single stall facilities (Stroumsa, 2014).
M E D S U R G ntjbsiwg. July-August 2016 • Vol. 25/No. 4 285
Professional Issues
Provider BarriersProvider fears or beliefs can present a barrier to care
access. Providers may not be willing to offer services due to inadequate knowledge of how to provide care or of internal and external resources available for consultation (Cruz, 2014). While system and provider barriers can be improved by changing policies and infrastructure where appropriate, that does not mandate a change in beliefs and attitudes of caregivers. A change in attitude or increased friendliness toward the transgender individual also does not indicate a change in the culture. Care is based, as for all other patients, on what is medically necessary and on the body parts that are present. For example, a female-to-male patient may look like a male and act like a male but may still require a gynecology appointment or examination to evaluate possible pathology. Collaboration is recommended with primary care, endocrinology, surgery, obstetrics and gynecology, psychiatry, and if indicated, infectious disease. While a psychological evaluation is no longer required before the start of hormone therapy or surgical interventions, general standards of care recommend identifying other underlying problems that may need treatment and providing emotional support throughout and following the transition as the individual adapts to life as a new gender (Coleman et al., 2011).
Internal BarriersA third barrier to health care faced by transgender
persons is an internal barrier found in individuals who have lived a history of harassment, intimidation, victimization, and injustice. Transgender individuals often believe they will face hostile or insensitive reactions from providers (Cruz, 2014). Cruz (2014) and Xavier and associates (2013) have documented experiences by transgender individuals of verbal abuse and a perception of being treated roughly and disrespectfully during an exam, as well as a belief they received substandard care. In some documented cases, providers refused to see a patient once they learned of the transgender status or focused care solely on the patient's transgender status rather than the current health problem. These experiences have led to a long history of uneasiness between transgender persons and the healthcare system (Cruz, 2014).
Open CommunicationAccording to Redfern and Sinclair (2014), lines of
communication between the provider and the transgender patient are enhanced when care is culturally competent, provides opportunity for patient feedback, and ensures quality. This is essential to build a beneficial partnership that enhances communication. Staff need to feel comfortable asking transgender individuals about the name or pronoun they prefer to use when referring to self and, in a respectful way, abide by these during
their hospital stay. Not all transgender individuals will begin the process of transition with hormone therapy or surgery. Care providers should avoid making assumptions and asking embarrassing questions by gaining knowledge of patients' past experiences (Cruz, 2014).
The transgender individual deserves to be treated with dignity and respect. Open communication is key to building a therapeutic nurse-patient relationship that is culturally aware and allows provision of individualized care. Working with other providers within and outside the institution can help create a welcoming, affirming environment for the transgender patient. While environmental and policy changes can help overcome system barriers, they will not change employees' attitudes and beliefs. Advocating for the transgender patient with policymakers and third-party payers also can improve access to care. Encouraging nursing and medical educators to include transgender health in their curricula can decrease fear of not knowing how to treat individuals who are transgender (Xavier et al., 2013). PHTH
REFERENCESColeman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere,
G., Feldman, J., ... Zucker, K. (2011). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism, 13, 165-232. doi:10.1080/15532739.2011.700873
Cruz, T.M. (2014). Assessing access to care for transgender and gender nonconforming people: A consider of diversity in combating discrimination. Social Science and Medicine, 110, 65-73. doi:10.1016/j.socscimed,2014.03.032
Lambda Legal. (2012). Professional organization statements supporting transgender people in health care. Retrieved from https:// www.lambdalegal.org/sites/default/files/publications/downloads/ fs_professional-org-statements-supporting-trans-health_1.pdf
Milton, C. (2016). Ethics and defining cultural competence: An alternative view. Nursing Science Quarterly, 29(1), 21-23.
Mendes, A. (2015). Culture and religion in nursing: Providing culturally sensitive care. British Journal of Nursing, 24(8), 459.
National Institutes of Health. (2015). Cultural respect. Retrieved from http://www.nih.gov/institutes-nih/nih-office-director/office-communi cations-public-liaison/clear-communication/cultural-respect
Parse, R.R. (2014). The humanbecoming paradigm: A transformational worldview. Pittsburgh, PA: Discovery International Publications.
Redfern, J.S., & Sinclair, B. (2014). Improving health care encounters and communication with transgender patients. Journal of Communication in Healthcare, 7(1), 25-40.
Snelgrove, J.W., Jasudavisius, A.M., Rowe, B.W., Head, E.M., & Bauer, G.R. (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. doi: 10.1186/1472-6963-12-110
Stroumsa, D. (2014). The state of transgender health care: Policy, law and medical frameworks. American Journal of Public Health, 104(3), e31-e38 doi:10.2105/AJPH.2013.301789
Transgender Law and Policy Institute. (2012). Non-discrimination laws that include gender identity and expression. Retrieved from http://www.transgenderlaw.org/ndlaws/
U.S. Department of Health and Human Services, (n.d.). Culture, language, and health competency. Retrieved from http://www.hrsa. gov/culturalcompetence/index.html
Xavier, J., Bradford, J., Hendricks, M., Safford, L., McKee, R., Martin, E., & Hannold, J.A. (2013). Transgender health care access in Virginia: A qualitative study. International Journal of Transgenderism, 14, 3-17. doi: 10.1080/15532739.2013.689153
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