Care for Gender-Expansive Patients Must Be Built on Trust, Advocacy and Collaboration

Providing compassionate care to gender-diverse patients in the emergency department should be the first step nurses take to understand their individual needs.

Madison Bird, RN, BSN, CEN, TCRN
Madison Bird, RN, BSN, CEN, TCRN

“Especially with your vulnerable populations, taking the time to provide trauma-informed care is important,” said Madison Bird, RN, BSN, CEN, TCRN. “The three pillars of trauma-informed care are trust, advocacy and collaboration. So, trust is building that safe space for that transgender or gender-expressive patient to come and be safe in that environment.”

Bird, an educator with 17 years of emergency nursing experience from Anchorage, Alaska, presented the session “Care of the Transgender and Gender-Expansive Patient in the Emergency Department” on Sept. 23 at Emergency Nursing 2023.

Concrete steps emergency nurses can take to help create a safe environment for gender-expansive patients include the nurse sharing their own pronouns via name tag, asking the patient for their name and pronouns, acknowledging when they get patient pronouns wrong while striving to get them right in the future, asking questions pertinent to care, avoiding statements that are invalidating, seeking permission to do an examination, and letting the patient know why the nurse is doing what they are doing.

Examples of invalidating statements are: “You are so pretty; I never would have guessed you are trans” and “I never would have guessed you used to be female.”

Bird encourages emergency nurses to examine their personal biases because they can interfere with providing appropriate care for patients.

“There’s always room to grow,” she said. “There’s always room to become more self-aware.”

The care of gender-expansive patients also can be hampered by trans broken arm syndrome, a colloquial term for gender-related medical misattribution and invasive questioning.

“You assume the patient’s problem is based on the fact that they’re transgender and ignore the fact that this person may actually have legitimate pathophysiology,” Bird said.

Fear of being outed as transgender, fear of violence and fear of discrimination are other barriers to care for this population.

“Remember, the patient brings everything in their past with them,” Bird said while sharing a case study. “So, this is a transfeminine patient, a person who was assigned male at birth, and they bring in any baggage that they’ve had with health care providers before — if they’ve been made fun of, if they’ve been belittled, whatever kind of religious trauma they may have, sexual assault, physical assault. They bring that with them when they come to the ED.”

Health care providers must be willing to acknowledge that other people have experiences that differ from their own and that they are just as legitimate. This theory of cultural humility recognizes that cultural competency is an ongoing process rather than a final destination.

“I don’t get to prescribe to you the way that you should be,” Bird said. “And that’s one of the things I want you to really embrace is that the person who’s experiencing gender dysphoria knows more about their dysphoria than we do, and to let them express themselves or take whatever action to make that congruence happen where their external body or their gender identity matches their gender expression.”

According to the 2021 U.S. Census, 1.6 million people, or 0.6%, identified as transgender, while almost three times as many (1.7%) identified as neither male nor female.

Gender dysphoria exists when at least two of the following are true for an individual.

  • A marked incongruence between one’s experienced/expressed gender and one’s primary and/or secondary sex characteristics.
  • A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).
  • A strong desire for the primary and/or secondary sex characteristics of the other gender.
  • A strong desire to be treated as the other gender (or some alternative gender different from one’s designated gender).
  • A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s designated gender).

Treatments for gender dysphoria fall into three categories, but each patient with gender dysphoria may require a unique combination of treatment options to eliminate the incongruences related to their gender identity, Bird said.

Social treatment for a transfeminine individual might include starting to use the women’s restroom, using a new name, using she/her pronouns or wearing dresses. Legal measures might be changing her name and gender on her driver’s license and other identification. Medical intervention might include taking hormones or undergoing a gender-affirming surgery.

Sexual minorities face increased risks to their health quality and equity, including homelessness, human trafficking and sexually transmitted infections. Bird said 23.1% of gender-expansive adolescents reported using drugs compared to 14% of their cisgender heterosexual peers. More than half (58.5%) of sexual minorities in 9th through 12th grades had suicidal ideation compared to 18.8% of cisgender heterosexual youth, according to U.S. Department of Health and Human Services data.

Whether adolescent or adult, care for transgender patients in the ED should include a mental health screening, Bird said.

She shared the following resources for bedside caregivers.