Know the facts to ensure safe, equitable care.
Photos courtesy of The Gender Spectrum Collection
- Transgender people deserve to be treated with dignity and respect when accessing healthcare.
- Sexual orientation and gender are distinct concepts.
- Many options exist for transgender people who want to transition socially, legally, medically, or surgically.
Transgender (trans) people encompass various genders and experiences, but generally speaking, their gender doesn’t match the sex they were assigned at birth. According to the Williams Institute, about 1.3 million adults and 300,000 youth in the United States are transgender. Unfortunately, even recent graduates of nursing programs have received little to no instructional time on transgender health, leaving them without the education needed to treat transgender people with dignity and respect. Dispelling common myths can help nurses provide more informed care.
Myth: Sex and gender are the same thing (and there are only two).
Fact: A number of factors, including chromosomes and prenatal hormone influence, determine sex. Typically, providers assign sex at birth by examining an infant’s genitalia, but genitals don’t paint a complete picture of sex or chromosomes. For example, some people have a Y chromosome and are born with a vagina, some have a penis and ovaries, and some have various other chromosomal and karyotype combinations that don’t fall within the XX = vagina/ovaries/female and XY = penis/testes/male binary. These people are intersex. Not all intersex people use the term transgender to describe themselves, but some may.
Gender consists of a person’s internal understanding of self. For many people, their gender aligns with the sex they’re assigned at birth (someone born with a penis and assigned a sex of male feels like a man). These people are cisgender. For some of us, our sense of ourselves doesn’t align with the sex assigned at birth—we’re transgender. Not all transgender people use binary gender terms such as male or female to describe themselves; many trans people are nonbinary, genderqueer, agender, Two-spirit, bigender, demiboys, demigirls, genderfluid, and many other genders not listed here. These gender terms may mean different things to the people who use them as their labels, and language evolves rapidly, so we shouldn’t make assumptions.
Nursing implications: If assessing gender is important to the care you’re providing, ask your patient what terms they would use to describe their gender. Because the definitions of terms used by individuals have nuanced meanings, ask what the labels they use to describe themselves mean to them.
Myth: Knowing someone is transgender means you know their sexual orientation.
Fact: Gender refers to an individual’s internal understanding of self. Sexual orientation refers to sexual or romantic attraction. Transgender people come in all orientations: heterosexual, bisexual, pansexual, asexual, aromantic, lesbian, gay, queer, demisexual, and many more. As with gender terms, these terms may mean different things to the people who use them.
Nursing implications: Assess gender and sexual orientation as separate concepts. Don’t assume that a transgender person is straight (a common misconception). As with gender, the terms used to describe sexual orientation are nuanced and individualized, so ask your patient what the labels they use mean to them.
Myth: Being transgender is a fad.
Fact: The media increasingly present transgender people, although not always positively or accurately. The rise of social media has allowed transgender people to connect, learn from one another, and share their experiences with cisgender people. This increased visibility has raised awareness of trans people for the first time. Some people call being trans a “new fad” or “way to get attention.”
Although the term transgender is relatively recent, people have always existed who didn’t conform to traditional or societal expectations of gender, and who might call themselves transgender if they were alive today. Examples of some of these people have remained in the historical record: Antonio de Erauso (1592–1650), Jenny Salvalette de Lange (d. 1858), We’wha (1849–1896), Murray Hall (d. 1901), Albert D.J. Cashier (1843–1915), Lucy Hicks Anderson (1886–1954), Dr. Alan Hart (1890–1962), Amelio Robles Avila (1889–1984), Billy Tipton (1914–1989), Marsha P. Johnson (1945–1992), and Sylvia Rivera (1951–2002). Certainly, many others lived and died in obscurity.
Nursing implications: Don’t tell transgender people that being trans is a phase they’ll grow out of or that they’re transitioning to get attention.
Myth: All transgender people want to “fully transition.”
Fact: Transitioning, as it relates to transgender people, refers to moving away from the sex assigned at birth. No such thing as “fully transitioning” exists. Many cisgender people use the term to describe having surgical procedures on genitalia (bottom surgery). The term implies that only one way to transition (surgically) exists, and that all transgender people want to transition in the same way. Transitioning is nuanced and personal, and individuals choose different paths.
Trans people can transition in various ways, including socially, legally, medically, or surgically. Socially transitioning may include actions such as informing people you live or work with of your new pronouns or a new name you prefer. Legally transitioning involves changing your name and/or gender marker on documents such as birth certificates, driver’s licenses, and passports. Medical transition typically includes hormone replacement therapy, such as estrogen or testosterone (sometimes called cross-sex hormones). Surgical transition options include genital surgeries and other procedures to masculinize or feminize the body.
Not all transgender people want to transition in any or all of these ways. Choosing to transition or not to transition doesn’t make someone more or less trans. Many who want to transition face financial and structural barriers. Although the Affordable Care Act placed restrictions on the categorical exclusion of some gender-affirming procedures from insurance coverage, all necessary procedures may not be covered. In addition, more trans people are under- or uninsured compared to cisgender people. Consider a phalloplasty (creation of a penis), which can cost up to $40,000-$50,000 for those without adequate insurance. A phalloplasty also requires multiple surgeries, necessitating time away from work that may not be affordable for some who want the procedure.
Nursing implications: The laws governing what procedures insurance providers must cover and the process for updating legal documents vary by state. Become familiar with the regulations in your state to help patients navigate these systems. Seek out resources to learn more about the medical and surgical options for transitioning so you can help educate patients.
Myth: Being transgender is a mental illness.
Fact: Some trans people may experience feelings of gender dysphoria (mental or emotional distress caused by the incongruence between their bodies and their gender), but this isn’t a universal experience for all transgender people. Some can name feelings of distress as gender dysphoria, others may not recognize past feelings of dysphoria until they experience gender euphoria (the opposite of dysphoria; a feeling of mental and emotional well-being related to the alignment of one’s body with one’s gender). Still others may never experience or recognize having dysphoria, but feel good when their body aligns with a gender that isn’t the sex assigned at birth. Regardless of whether someone does experience gender dysphoria, being transgender doesn’t make someone mentally ill.
What isn’t a myth, however, are the increased rates of depression, anxiety, substance use, and suicide related to family rejection and social stigma. The Williams Institute found that suicide attempts among transgender people is nearly 20 times higher than the general population, with direct links to family rejection, religious community rejection, and poor treatment by service providers in areas such as education and healthcare. The Williams Institute also found that family support and access to gender-affirming medical care significantly lowers suicidal thoughts and attempts. Accepting and supporting transgender people equals suicide prevention.
Nursing implications: Recognize that experiences of gender dysphoria aren’t universal in transgender people and aren’t required for someone to be transgender. Like all patients, evaluate transgender people for depression, anxiety, suicide risk, and substance use. If mental health concerns exist, a number of local and national organizations focus on transgender mental health, including the Trevor Project and Trans Lifeline. Many local LGBTQ+ organizations maintain lists of mental health providers that specialize in working with transgender patients or host support groups.
Myth: Transgender children medically or surgically transition.
Fact: For young transgender children, care focuses on social transitioning. Before puberty, families and schools can support trans kids by allowing them to wear clothes they feel good in, use the name and pronouns they like, get a haircut that makes them happy, and engage in activities they enjoy. When a child starts showing early signs of puberty, they may begin puberty blockers to delay puberty onset. For example, in a child born with a uterus and ovaries, puberty blockers pause breast growth and prevent the onset of menses. If puberty blockers are discontinued without administering cross-sex hormones, development of secondary sex characteristics resumes. Many providers specializing in transgender adolescent health begin administrating cross-sex hormones at age 16, with parent or guardian consent.
Nursing implications: If you work with a pediatric or adolescent population, become familiar with how the transitioning process varies by age. Keep a list of specialists who provide transition-related care available for referral, especially for patients at or approaching puberty. For all ages, be aware of local support groups for transgender children and adolescents, as well as for parents of transgender children.
Myth: Trans people want special rights or special treatment.
Fact: Transgender people want to live their lives in ways that make them happy and fulfilled. They don’t want to worry about being abused or denied care when they interact with healthcare providers. Unfortunately, research shows that many transgender people experience mistreatment when accessing care.
As nurses, we pride ourselves on person-centered care. Transgender people want to be seen holistically, and they want to be treated with dignity and respect. Remember, treating everyone equitably is different from treating everyone the same. Assess what’s important to your patient, and tailor your care accordingly.
Nursing implications: Ask patients what name and pronouns they use, and make sure your communication with the patient and other providers reflects their response. Ask who from their support system they want to include in their care, and be intentional about following through with this inclusion. If you work in a setting that provides transition-related care, ask your patient about their transition goals.
Actions to support transgender people
Learning to affirm and support transgender people is an ongoing process. Consider these suggestions to get started:
- Don’t ask personal questions about body parts or genitals unless absolutely necessary for the care you’re providing. If it’s necessary, explain to your patient why you need to know.
- Remember the importance of chosen names. Even if your patient hasn’t legally changed their name yet, address them by their chosen name. If the chart includes space for designating a chosen name, ask your patient if they’d like you to enter into the record.
- Seek out continuing education or information from reputable sources on transgender health, such as the National LGBTQIA+ Health Education Center or the National Resource Center on LGBT Aging.
- Don’t assume that a patient wants you to document that they’re transgender in the medical record; you may unwittingly place them at risk for harm. Ask your patient for permission and respect their decision. Just because they trust you with information doesn’t mean they trust all providers who may access their records.
- Contract with transgender people to train staff and help create environments that maintain dignity and respect. Advocate for hiring transgender staff in all areas of your organization, not just those that specialize in transgender health.
- Speak up when you hear a colleague say negative things about transgender people or use the wrong name or pronouns for a transgender patient.
- If you accidentally use the wrong name or pronouns for a transgender patient, correct yourself and move on (for example, “I told him—I mean, them—to make sure they ambulate.”). Don’t react in a way that centers your discomfort about misgendering someone or puts your patient in the position of having to comfort or reassure you.
S. Alexander Kemery is an associate professor at the University of Indianapolis School of Nursing in Indianapolis, Indiana.
American College of Obstetricians and Gynecologists. Health care for transgender teens. June 2019.
Beemyn G. Transgender history in the United States: A special unabridged version of a book chapter from Trans Bodies, Trans Selves. In: Erickson-Schroth L, ed. Trans Bodies, Trans Selves New York, NY: Oxford University Press; 2014.
GLAAD. Glossary of terms: Transgender.
Gutierrez J. Bar Chee Ampe and beyond: Uncovering two-spirit identity, Part 2. New-York Historical Society Museum & Library.
Herman JL, Brown TNT, Haas AP. Suicide thoughts and attempts among transgender adults: Findings from the 2015 U.S. transgender survey. Williams Institute. September 2019.
Herman JL, Flores AR, O’Neill KK. How many adults and youth identify as transgender in the United States. Williams Institute. June 2022.
What an informative and useful article! Thank you so much for the information and for including implications for nursing.
Helpful and informative in order to provide patient-centered and respectful care.