37.1 Overview of Transgender and Nonbinary Health

Understanding Gender Identity and Expression

Gender identity and expression shape how individuals experience themselves and move through the world. For nurses, understanding these concepts is foundational to providing competent, respectful care to transgender and nonbinary patients, and it directly informs the pharmacological interventions covered later in this unit.

Gender identity and expression

Gender identity is a person's internal sense of being male, female, neither, or another gender. It's not something you can observe from the outside.

• Cisgender: Gender identity matches sex assigned at birth (e.g., a person assigned female at birth who identifies as a woman)
• Transgender: Gender identity differs from sex assigned at birth (e.g., a person assigned male at birth who identifies as a woman)
• Nonbinary: Gender identity falls outside the male-female binary. This includes people who identify as genderfluid, agender, genderqueer, or other identities that don't fit neatly into "man" or "woman"

Gender expression is the external presentation of gender through behavior, clothing, hairstyle, voice, or other characteristics. A person's gender expression may or may not align with their gender identity or with societal expectations of masculinity or femininity. For example, a transgender man may express his gender in ways that society reads as masculine, feminine, or somewhere in between.

Sexual orientation refers to emotional, romantic, or sexual attraction to others (e.g., lesbian, gay, bisexual, pansexual). This is distinct and separate from gender identity. A transgender woman, for instance, may be attracted to men, women, both, or neither. Never assume a patient's sexual orientation based on their gender identity.

Gender Dysphoria and Healthcare for Transgender and Nonbinary Individuals

Gender dysphoria manifestations and impact

Gender dysphoria is the clinically significant distress that results from a mismatch between a person's gender identity and their sex assigned at birth. Not all transgender or nonbinary individuals experience gender dysphoria, but for those who do, it can have serious health consequences.

Gender dysphoria may present as:

• Persistent discomfort with primary or secondary sex characteristics (e.g., genitals, breasts, facial hair, voice pitch)
• Negative self-image, social withdrawal, anxiety, depression, and elevated risk of suicidal ideation
• A strong desire to change or remove sex characteristics through medical interventions

The two main categories of medical intervention are:

• Hormone therapy: Masculinizing hormones (e.g., testosterone) or feminizing hormones (e.g., estrogen, anti-androgens) that align physical characteristics with gender identity. These are the pharmacological focus of this unit.
• Gender-affirming surgeries: Procedures that modify primary or secondary sex characteristics (e.g., chest reconstruction, genital surgery). These are typically pursued alongside or after hormone therapy, though not all patients choose surgery.

Barriers to healthcare access and inclusive care strategies

Transgender and nonbinary individuals face significant barriers when seeking healthcare. As a nurse, recognizing these barriers helps you understand why patients may delay care, withhold information, or present with distrust of providers.

Stigma and discrimination in healthcare settings remain common. Many providers lack training in transgender health, which can lead to misgendering (using incorrect pronouns or names), inappropriate questions, or outright refusal of care. These experiences create an unwelcoming environment that discourages patients from seeking the care they need.

Limited access to gender-affirming care compounds the problem. Insurance coverage for hormone therapy and surgical interventions is inconsistent, creating financial barriers. There is also a shortage of providers experienced in transgender and nonbinary health, particularly in rural areas.

Strategies for providing inclusive care:

1. Educate all healthcare staff on gender identity, expression, and the specific health needs of transgender and nonbinary patients
2. Ask for and consistently use each patient's preferred name and pronouns, even when they differ from what appears in the medical record
3. Provide gender-neutral facilities (e.g., restrooms) and intake forms that include diverse gender options beyond "male" and "female"
4. Establish and enforce institutional policies that prohibit discrimination based on gender identity and expression
5. Collaborate with providers experienced in transgender health and refer patients when specialized care is needed