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Leadership Initiatives in Patient-Centered Transgender Care
Patient-centered care is of fundamental importance when caring for the transgender population due to the well-established history of social stigma and systemic discrimination. Therefore, nursing education is mandated to equip graduates with culturally competent patient-centered care skills.1 In 2009, the Institute of Medicine (IOM) in partnership with the Robert Wood Johnson Foundation (RWJF) launched The Future of Nursing initiative, which outlined the major role nursing should play in transforming the health care system to meet the health care needs of diverse U.S. populations.
The initiative produced a blueprint of action-focused institutional recommendations at the local, state, and national levels that would facilitate the reforms necessary to transform the U.S. health care system. One of the recommendations of the IOM report was to increase opportunities for nurses to manage and lead collaborative efforts with physicians and other health care team members in the areas of systems redesign and research, to improve practice environments and health systems.2
The VHA is the largest integrated health care system in the U.S., serving more than 8.76 million veterans at more than 1,700 facilities. The VHA has an organizational structure that uses centralized control in Washington, DC, and branches out to 18 regional networks that are divided into local facilities in 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Philippines. This type of structure is known for promoting efficient standardization of processes and procedures across an organization.3
The VHA Blueprint for Excellence envisions the promotion of a positive culture of service and the advancement of health care innovations necessary to create an environment that all veterans deserve.4 To that end, the VHA can be a promising health care institution through which patient-centered initiatives can be standardized, promulgated nationally, and replicated as a model for the country and international health systems. However, it is important to note that the bureaucratic organizational structure of the VHA's national integrated system of care is based on a systemwide standardization effort.5 Therefore, more time may be required to implement organizational changes.
Transgender populations face significant social stigmatization, discrimination, and marginalization that contribute to negative patient outcomes. Consequently, this population experiences high rates of suicide, HIV/AIDS, substance use disorder, poverty, and homelessness.6 Due to the growing evidence of health disparities and negative health outcomes affecting transgender populations, the federal government has identified transgender patient care and outcomes as a major health concern and priority in the Healthy People Initiative 2020.2,7,8
In 2012, the VHA issued a directive mandating services for transgender veterans.9 Nevertheless, health care staff significantly lack the knowledge, skills, and cultural competencies that are vital in transgender care.
This article reviews the prevalence and demographics of the transgender population, social challenges, global health concerns, and public health policies. The article also examines how the doctor of nursing practice (DNP)-prepared nurse leader can provide transformational nursing leadership to facilitate culturally competent, patient-centered initiatives to improve access and services for transgender individuals in the VHA and provide a model for change in transgender population health.
Definitions
Gender is a behavioral, cultural, or psychological trait assigned by society that is associated with male or female sex. Sex denotes the biologic differences between males and females. Transgender is an umbrella term used to describe people whose gender identity or gender expression is different from that of their sex assigned at birth. Transsexualism is a subset of transgender persons who have taken steps to self-identify or transition to look like their preferred gender.
Demographics
Estimates of the prevalence of transgenderism are roughly drawn from less rigorous methods, such as the combination of parents who report transgenderism in children, the number of adults reportedly seeking clinical care (such as cross-sex or gender-affirming hormone therapy), and the number of surgical interventions reported in different countries.10 A meta-analysis of 21 studies concluded that the ratio of transsexuals (individuals who are altering or have already altered their birth sex) was predominantly 1:14,705 adult males and 1:38,461 adult females.11 Since all transgender persons do not identify as transsexual, these figures do not provide a precise estimation of the number of transgender persons worldwide.
About 700,000, or 0.3%, of the adult population in the U.S. identify themselves as transgender, and an estimated 134,300 identify as transgender veterans.6,12 The transgender population in the U.S. is estimated to be 55% white, 16% African American, 21% Hispanic, and 8% other races.13 The U.S. census data noted that the transgender population was geographically located across the nation. Transgender persons are more likely to be single, never married, divorced, and more educated but with significantly less household income.2 Data to provide an accurate reflection of the number of transgender people in the U.S. are lacking. Some transgender individuals also may identify as lesbian, gay, or bisexual, making population-based estimation even more challenging and difficult.
Transgender persons who have transitioned may not have changed their names or changed their identified sex on official Social Security records, which the Social Security Administration allows only if there is evidence that genital sexual reassignment surgery was performed.14 The number of transgender adults requesting treatment continues to rise.10
Social and Health Challenges
Transgender people face many challenges because of their gender identity. Surveys assessing the living conditions of transgender people have found that 43% to 60% report high levels of physical violence.15 By comparison, the National Intimate Partner and Sexual Violence Survey found that interpersonal violence and sexual violence were reported by lesbian and gay individuals at equal or higher levels than that reported by heterosexuals. Forty-four percent of lesbian women, 35% of heterosexual women, 29% of heterosexual men, and 26% of gay men reported experiencing rape or physical violence.16 A study in Spain reported 59% of transgender people experienced patterns of harassment, and in Canada, 34% of transgender people lived below the poverty level.17,18
In the U.S., the National Transgender Discrimination Survey of 6,450 transgender and nonconforming participants provided extensive data on challenges experienced by transgender people.6 Discrimination was frequently experienced in accessing health care. Due to transgender status, 19% were denied care, and 28% postponed care due to perceived harassment and violence within a health care setting.6 The same study also reported that as many as 41% live in extreme poverty with incomes of less than $10,000 per year reported. Twenty-six percent were physically assaulted, and 10% experienced sexual violence. More than 25% of the transgender population misused drugs or alcohol to cope with mistreatment.6
In the U.S., HIV infection rates for transgender individuals were more than 4 times (2.64%) the rate of the general population (0.6%).6 Internationally, there is a high prevalence of HIV in transgender women. The prevalence rate of HIV in U.S. transgender women was 21.74% of the estimated U.S. adult transgender population of about 700,000.19 One in 4 people living with HIV in the U.S. are women.20
Suicide attempt rates are extremely high among transgender people. A suicide rate of 22% to 43% has been reported across Europe, Canada, and the U.S.21 Depression and anxiety were commonly noted as a result of discrimination and social stigma. In the U.S., transgender persons reported high rates of depression, with 41% reporting attempted suicide compared with 1.6% of the general population.6 Access to health care services, such as mental health, psychosocial support, and stress management are critical for this vulnerable population.22
Health Policies
Since 1994, the UK has instituted legal employment protections for the transgender population. In the UK, transgender persons, including military and prisoners, have health care coverage that includes sexual reassignment surgery as part of the UK's National Health Service.23
In the U.S., the federal policy of "Don't Ask, Don't Tell" barring transgender persons from serving openly in the military was repealed in June 2016. This policy historically has had a silencing effect on perpetuating institutionalized biases.24 This remains problematic even after veterans have transitioned from military service to the VA for civilian care.
Between 2006 and 2013, the reported prevalence and incidence of transgender-related diagnoses in the VA have steadily increased with 40% of new diagnoses occurring since 2011.25 In fiscal year 2013, there were 32.9 per 100,000 veterans with transgender-related diagnoses.25 Health care staff, in particular health care providers (HCPs), can play a critical role in reducing health disparities and unequal treatment.26
With the passage of the U.S. Affordable Care Act (ACA), health insurance coverage for transgender persons is now guaranteed by law, and health disparities within the transgender population can begin to be properly addressed. The ACA offers the ability to purchase health insurance, possibly qualify for Medicaid, or obtain subsidies to purchase health insurance. Insurance coverage is accessible without regard to discrimination or preexisting conditions.27 As of May 2014, the Medicare program covered medically necessary hormone therapy and sex reassignment surgery.13 While VA benefits cover hormone therapy for transgender veterans, sex reassignment surgery is not currently a covered benefit.28 The ACA now increases access to primary care, preventative care, mental health services, and community health programs not previously available in the transgender community.
Healthy People 2020 Goals
One of the Healthy People 2020 stated goals is to improve the health and wellness of transgender people.29 The objective is to increase the number of population-based data collection systems used to monitor transgender people from the baseline of 2 to a total of 4 by 2020. The data systems would be assigned to collect relevant data, such as mental health; HIV status; illicit drug, alcohol, and tobacco use; cervical and breast cancer screening; health insurance coverage; and access to health care.
Health Care Staff Readiness
Transgender persons face health care challenges with major health disparities due to their gender identity. Transgender persons as a defined population are not well understood by HCPs. In a survey, 50% of transgender respondents reported that they had to teach their medical provider about transgender care.6 Negative perceptions of transgender persons are well established and have contribute to the poor health care access and services that transgender persons receive. Transgender persons are often denied access to care, denied visitation rights, and are hesitant to share information for fear of bureaucratic exclusion or isolation.
There is a lack of evidence-based studies to guide care and help HCPs gain greater understanding of this population's unique needs.30 Additionally, a significant lack of knowledge, skills, cultural competence, and awareness exist in providing transgender care. Research on nursing attitudes concerning transgender care consistently found negative attitudes, and physicians also frequently reported witnessing derogatory comments and discriminatory care from colleagues.31,32 The study by Carabez and colleagues found that practicing nurses rarely received the proper education or training in transgender health issues, and many were unaware of the needs of this population.33 In addition, many HCPs were uncomfortable working with transgender patients. Physicians also expressed knowledge deficits on gender identity disorders due to a lack of training and ethical concerns about their roles in providing gender-transitioning treatment.26
Although the VHA directive states that transgender services and treatment should be standardized, the VHA has not approved, defined, or endorsed specific standards of care or clinical guidelines within the organization for transgender care, further heightening HCP concerns.9 The clinical practice guidelines available for addressing preventive care for transgender patients are primarily based on consensus of expert opinion.34 Expert opinion has produced the Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People, published by the World Professional Association for Transgender Health (WPATH) and cited by the IOM as the major clinical practice guidelines for providing care to transgender individuals.2 Transgender care at the VHA is guided by the WPATH standards of care.35
The VHA has created national educational programs and policies with targeted goals to provide uniform, culturally competent, patient-centered care. Online transgender health presentations are available, and at least 15 VHA facilities have transgender support groups.30 While the VHA supports a patient-centered philosophy for transgender patient care, many facilities do not currently have organizational initiatives that enhance clinical preparation of HCPs or have sufficiently modified the environment to better accommodate the health care needs of transgender veterans.
DNP Preparation
The DNP terminal degree provides nurses with doctoral-level training in organizational and systems leadership, leading quality improvement, and implementing systemwide initiatives by using scientific findings to drive processes that improve quality of care for a changing patient population.36 Preparation in research analysis of evidence-based interventions also is essential to evaluating practice patterns, patient outcomes, and systems of care that can identify gaps in practice. Training in health care policy and advocacy, information systems, patient care technology, and population health also is provided so that DNPs are competent to develop system strategies to transform health care through clinical prevention and health promotion.
QSEN Framework
In keeping with the IOM's Future of Nursing initiative recommendations that graduate nurses be prepared as leaders in education, practice, administration, and research, there is an increasing focus on providing graduate-level nursing education and training to ensure quality and efficiency of health outcomes.37 The Quality and Safety Education in Nursing (QSEN) project, initiated at the RWJF by Linda Cronenwett, PhD, RN, identifies a framework for knowledge, skills, and attitudes that defines the competencies that nurses need to deliver effective care to improve quality and safety within health care systems.38 These core competencies include quality improvement, safety, teamwork and collaboration, patient-centered care, evidence-based practice, and informatics. The RWJF and the American Association of Colleges of Nursing later expanded the project initiative to prepare nursing faculty to teach the QSEN competencies in graduate nursing programs.36
The DNP nurse leader is ideally suited to manage this project by applying competencies from the QSEN framework. Using open communication and mutual respect, the nurse leader is poised to effectively develop interprofessional teams to collaborate and initiate transformational changes that improve quality and patient-centered care delivered within the health care organization.
Public Health Resources
Public health resources addressing transgender patient care advocacy, public policy, community education, standards of care, cultural competency, mental health, hormone therapy, surgical interventions, reproductive health, primary care, preventative care, and research are available. For example, WPATH is an international multidisciplinary organization that has published comprehensive SOC for transgender, transsexual, and gender-nonconforming people. The seventh version of the SOC contains evidence-based guidelines for treatment.39 Additional online resources for transgender health are available from the CDC, the Center of Excellence for Transgender Health at the University of California, San Francisco; Department of Family and Community Medicine; and the National Center for Transgender Equality.13,40,41
Patient-Centered Transgender Care
The QSEN framework outlines competencies that provide applicable solutions that help prepare organizations to deliver culturally competent, patient-centered transgender care. The first step to creating patient-centered transgender care is to "analyze factors that create barriers to patient-centered care."42 The magnitude of the barriers to providing patient-centered transgender care also must be identified and understood. An assessment of individual values, beliefs, and attitudes can help to identify cultural characteristics and eliminate stereotypes that impact health practices.43
The nurse leader should solicit support from stakeholders to assess barriers to providing patient-centered transgender care at the system level. Stakeholders would include staff directly involved in patient care, such as physicians, nurse practitioners, physician assistants, registered nurses, nurse managers, nurse educators, licensed practical nurses, medical support assistants, psychologists, dieticians, and social workers. Other ancillary stakeholders with an interest in creating a patient-centered environment with positive patient outcomes include the executive leadership team of the organization, which consists of the chief of staff, director, administrative officers, and nurse executive.
The nurse leader should consult with experts in transgender care and present evidence-based research showing how deficits in staff knowledge, skills, and cultural competence negatively impact the quality of care provided to transgender persons. National data on the consequential health disparities and negative impacts on patient outcomes also should be discussed and presented to all stakeholders. The nurse leader in collaboration with the VA Office of Research and Development is ideally suited to obtain institutional review board approval of a proposal to conduct a needs assessment survey of health care staff barriers to providing patient-centered transgender care. Thereafter, the nurse leader would analyze, extract, and synthesize the data and evaluate the resources and technology available to translate this research knowledge into a clinical practice setting at the system level.44
The second solution uses the results of the survey to develop staff competency training within the organization. The nurse leader can facilitate collaboration and team building to develop practice guidelines and SOC. Competency training will prepare the staff to assist in developing strategies to improve the quality of care for transgender persons. Educationconcerning existing evidence-based clinical guidelines and SOC as well as anecdotal evidence of the needs of transgender patients should be included in competency training.45 One approach to competency training would be to trainintegrated multidisciplinary teams with expertise in transgender care to promote wellness and disease prevention.9 The nurse leader should collaborate with multiple disciplines to facilitate the development of interdisciplinary teams from nursing, medicine, social work, pharmacy, primary care, mental health, women's health, and endocrinology to participate in the Specialty Care Access Network Extension of Community Healthcare outcomes (SCAN-ECHO) training. Training can be offered by videoconferencing over several months and provides cost-effective, efficient training of providers in patient-centered transgender care.46,47 After the SCAN-ECHO program is completed, trained nursing experts could then develop a cultural sensitivity training program for nursing organizations to be offered to educate health care staff on an annual basis.
The third solution addresses the QSEN competency to "Analyze institutional features of the facilities that support or pose barriers to patient-centered care."42 Many veterans do not perceive VA environments as welcoming. In a study by Sherman and colleagues, less than one-third of veterans believed the VA environment was welcoming to sexual or gender minorities, and sexual orientation or gender identity was disclosed by only about 25% of veterans.48 Many veterans in this study felt uncomfortable disclosing their gender or sexual orientation. The majority felt that providers should not routinely ask about sexual orientation or gender identity, and 24% said they were very or somewhat uncomfortable discussing the issue. In another study, 202 VA providers were asked if they viewed the VA as welcoming, and 32% said the VA was somewhat or very unwelcoming.48
The nurse leader is trained in the essentials of health care policy advocacy, which is central to nursing practice.49 Nursing as a profession values social justice and equality, which are linked to fewer health disparities and more stable health indicators.50 Therefore, nursing can ideally provide organizational leaders by developing a culture wherein stable, patient-centered relationships can develop and thrive.
Organizational Culture
Strategies must be deployed to create an organizational culture that is welcoming, respectful, and supportive of transgender patients and family preferences. VA should develop support groups for transgender veterans in VA facilities. Support groups are helpful in diminishing stress, improving self-esteem, building confidence, and improving social relationships.51 Additionally, VA should develop community-based partnerships with other organizations that already provide institutional care and support from HCPs who support transgender persons' right to self-determination.52 These partnerships can foster environmental influences over time and lead to the development of trusting relationships between transgender veterans and the VA organization.
Another community partnership of importance for the nurse leader to develop is an alliance with local universities to train nursing students in cultural competencies in transgender care at VA facilities. The U.S. population continues to diversify in race and ethnicity and cultural influences; therefore, nurses must be prepared in cultural competencies in order to provide quality care that reduces health disparities.53
Under federal law, the VHA has a data sharing agreement with the DoD. Despite the repeal of the "Don't Ask, Don't Tell" federal law, which cleared the way for transgender persons to openly serve in the military, many transgender persons may remain fearful of reprisals, such as judgment, denial of care, or loss of benefits if gender identity is disclosed.54 Given the bureaucratic structure of the VHA, the implementation of cultural changes at the system level will require a collaborative effort between multidisciplinary teams and community partnerships to transform the VA environment over time. The authors believe that on this issue, external forces must guide and lead changes within the VA system in order to develop sustainable and trusting relationships with transgender veterans.
The fourth solution is implementation of policies that "empower patients or families in all aspects of the health care process."42 Again, the nurse leader is trained and prepared to advocate for a policy that implements a Patient Bill of Rights that explicitly guarantees health care and prohibits discrimination of gender-minority veterans. This change would foster trust and confidence from transgender individuals. A study found that 83% of providers and 83% of lesbian, gay, bisexual, and transgender veterans believe that this policy change would make the VHA environment more welcoming.48 Providing transgender-affirming materials and language on standard forms also would eliminate barriers, promote patient-centered care, and empower transgender patients by creating an environment that is more inclusive of everyone.48
Conclusion
The nurse leader is well positioned to implement the QSEN framework to integrate research, practice, and policy to create a more inclusive, patient-centered health care system for transgender veterans. By using the essential principles of doctoral education for advanced nursing practice, the nurse leader is prepared to advocate for changing the organization at the systems level. The nurse leader also is equipped to direct the implementation of patient-centered transgender care initiatives by ensuring the integration of the nursing organization as a partner in strategic planning as well as the development of solutions.
The VHA Blueprint of Excellence envisions organization and collaboration to promote new relationships that serve and benefit veterans. The DNP preparation allows the nurse leader to demonstrate the ability to collaborate with VHA stakeholders and develop alliances within and outside the organization by advocating for policy changes that will be transformational in improving health care delivery and patient outcomes to vulnerable transgender veteran populations. The IOM has tasked nurse executives with creating a health care infrastructure of doctorally prepared nurses to provide patient care that is increasingly growing more complex. With an increasing number of veterans using services, VHA has prioritized an expansion in the number of doctorally prepared nurses.55
As the largest integrated health care system in the U.S., the VHA provides an ideal setting for initiating these organizational changes as a result of having developed an integrated infrastructure to collect evidence-based data at the regional (network) and state facilities and make comparisons with national benchmarks. Therefore, changes are less difficult to disseminate throughout the hierarchy of the VHA. Consequently, the VHA has been a leader in the U.S. for equity in the health care arena and provides a model for international health care systems. Finally, these changes address an urgent need to reduce health disparities, morbidity, and mortality by improving quality care and health care delivery to a vulnerable transgender population.
1. Greiner AC, Knebel E, eds. Health Professions Education: A Bridge to Quality. Washington, DC: National Academies Press; 2003.
2. Institute of Medicine. Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academy of Sciences; 2011.
3. Mintzberg H. The structuring of organizations: a synthesis of the research. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1496182 1979. Posted November 4, 2009. Accessed November 30, 2016.
4. U.S. Department of Veterans Affairs. VHA blue print for excellence. https://www.va.gov/health/docs/VHA_Blueprint_for_Excellence.pdf. Published September 21, 2014. Accessed November 30, 2016.
5. Morgan RO, Teal CR, Reddy SG, Ford ME, Ashton CM. Measurement in Veterans Affairs Health Services Research: veterans as a special population. Health Serv Res. 2005;40(5, part 2):1573-1583.
6. Grant JM, Mottet L, Tanis JE, Harrison J, Herman J, Keisling M. Injustice at every turn: a report of the National Transgender Discrimination Survey. http://www.thetaskforce.org/static_html/downloads /reports/reports/ntds_full.pdf. Published 2011. Accessed November 30, 2016.
7. Office of Disease Prevention and Health Promotion. Lesbian, gay, bisexual, and transgender health. http://www.healthypeople.gov/2020/topics-objec tives/topic/lesbian-gay-bisexual-and-transgender -health. Updated November 16, 2016. Accessed November 16, 2016.
8. Institute of Medicine Committee on Lesbian Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academy of Sciences; 2011.
9. U.S. Department of Veterans Affairs. VHA Directive 2013-003: Providing Health Care for Transgender and Intersex Veterans. Washington, DC: U.S. Department of Veterans Affairs; 2013.
10. Zucker KJ, Lawrence AA. Epidemiology of gender identity disorder: recommendations for the Standards of Care of the World Professional Association for Transgender Health. Int J Transgenderism. 2009;11(1):8-18.
11. Arcelus J, Bouman WP, Van Den Noortgate W, Claes L, Witcomb G, Fernandez-Aranda F. Systematic review and meta-analysis of prevalence studies in transsexualism. Eur Psychiatry. 2015;30(6):807-815.
12. Gates GJ, Herman JL. Transgender military service in the United States. http://williamsinstitute.law.ucla.edu/wp-content/uploads/Transgender-Military -Service-May-2014.pdf. Published May 2014. Accessed November 30, 2016.
13. Flores AR, Brown TNT, and Herman JL. Race and ethnicity of adults who identify as transgender in the United States. http://williamsinstitute.law.ucla .edu/wp-content/uploads/Race-and-Ethnicity-of -Transgender-Identified-Adults-in-the-US.pdf. Published October 2016. Accessed December 13, 2016.
14. Harris BC. Likely Transgender individuals in US federal administrative records and the 2010 census. https://www.census.gov/srd/carra/15_03_Likely_Transgender_Individuals_in_ARs_and_2010Census.pdf. Published May 4, 2015. Accessed November 30, 2016.
15. Kenagy GP, Bostwick WB. Health and social service needs of transgender people in Chicago. Int J Transgenderism. 2005;8(2-3):57-66.
16. Centers for Disease Control and Prevention. National intimate partner and sexual violence survey, 2010 summary report. https://www.cdc.gov/viole nceprevention/pdf/nisvs_report2010-a.pdf. Published November 2011. Accessed December 12, 2016.
17. Bauer GR, Travers R, Scanlon K, Coleman TA. High heterogeneity of HIV-related sexual risk among transgender people in Ontario, Canada: a province-wide respondent-driven sampling survey. BMC Public Health. 2012;12(1):292-291.
18. Devis-Devis J, Pereira-Garcia S, Valencia-Peris A, Fuentes-Miguel J, López-Cañada E, Pérez-Samaniego V. Harassment patterns and risk profile in Spanish trans persons. J Homosex. 2016. [Epub ahead of print.]
19. Gates GJ. How many people are lesbian, gay, bisexual, and transgender? http://williamsinstitute.law.ucla.edu/wp-content/uploads/Gates-How-Many -People-LGBT-Apr-2011.pdf. Published April 2011. Accessed December 1, 2016.
20. Center for Disease Control and Prevention. HIV Among Women. http://www.cdc.gov/hiv/group/gender/women/index.html. Accessed December 10, 2016.
21. Bauer GR, Scheim AI, Pyne J, Travers R, Hammond R. Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada. BMC Public Health. 2015;15(1):525.
22. McCann E. People who are transgender: mental health concerns. J Psychiatr Ment Health Nurs. 2015;22(1):76-81.
23. Green R. Transsexual legal rights in the United States and United Kingdom: employment, medical treatment, and civil status. Arch Sex Behav. 2010;39(1):153-160.
24. Sharpe VA, Uchendu US. Ensuring appropriate care for LGBT veterans in the Veterans Health Administration. Hastings Cent Rep. 2014;44(suppl 4):S53-S55.
25. Kauth MR, Shipherd JC, Lindsay J, Blosnich JR, Brown GR, Jones KT. Access to care for transgender veterans in the Veterans Health Administration: 2006-2013. Am J Public Health. 2014;104(suppl 4):S532-S534.
26. Snelgrove JW, Jasudavisius AM, Rowe BW, Head EM, Bauer GR. "Completely out-at-sea" with "two-gender medicine": a qualitative analysis of physician-side barriers to providing healthcare for transgender patients. BMC Health Serv Res. 2012;12(1):110.
27. U.S. Department of Health and Human Services. Key features of the affordable care act. http://www .hhs.gov/healthcare/facts-and-features/key-features -of-aca/index.html. Last reviewed November 18, 2014. Accessed December 1, 2016.
28. U.S. Department of Veterans Affairs. Federal benefits for veterans, dependents, and survivors. https://www.va.gov/opa/publications/benefits_book/Chapter_1_Health_Care_Benefits.asp. Accessed December 1, 2016.
29. HealthyPeople.gov. Lesbian, gay, bisexual, and transgender health. https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bi sexual-and-transgender-health. Updated December 1, 2016. Accessed December 1, 2016.
30. Lutwak N, Byne W, Erickson-Schroth L, et al. Transgender veterans are inadequately understood by health care providers. Mil Med. 2014;179(5):483-485.
31. Dorsen C. An integrative review of nurse attitudes towards lesbian, gay, bisexual, and transgender patients. Can J Nurs Res. 2012;44(3):18-43.
32. Eliason MJ, Dibble SL, Robertson PA. Lesbian, gay, bisexual, and transgender (LGBT) physicians' experiences in the workplace. J Homosex. 2011;58(10):1355-1371.
33. Carabez R, Pellegrini M, Mankovitz A, Eliason M, Ciano M, Scott M. "Never in All My Years...": Nurses' education about LGBT health. J Prof Nurs. 2015;31(4):323-329
34. Buchholz L. Transgender care moves into the mainstream. JAMA. 2015;314(17):1785-1787.
35. VA Boston Healthcare System. Patient Care Memorandum-11-046-LM. Management of transgender veteran patients. http://www.boston.va.gov/services/images/lgbt_patient_care_memo_transgender_care.pdf. Published May 2011. Accessed December 1, 2016.
36. Cronenwett L, Sherwood G, Pohl J, et al. Quality and safety education for advanced nursing practice. Nurs Outlook. 2009;57(6):338-348.
37. Institute of Medicine. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011.
38. Smith EL, Cronenwett L, Sherwood G. Current assessments of quality and safety education in nursing. Nurs Outlook. 2007;55(3):132-137.
39. World Professional Association for Transgender Health (WPATH).The standards of care. http://www.wpath.org/site_page.cfm?pk_association _webpage_menu=1351&pk_association_web page=4655. Accessed December 1, 2016.
40. University of California San Francisco Department of Family and Community Medicine. Center of Excellence for Transgender Health. http://www.tran shealth.ucsf.edu/trans?page=home-00-00 Accessed December 1, 2016.
41. Center for Disease Control and Prevention. Lesbian, gay, bisexual and transgender health. http://www.cdc.gov/lgbthealth/transgender.htm. Accessed December 1, 2016.
42. American Association of Colleges of Nursing. QSEN education consortium: graduate-level QSEN competencies, knowledge, skills and attitudes. http://www.aacn.nche.edu/faculty/qsen/competen cies.pdf. Accessed December 1, 2016.
43. Andrews MM, Boyle JS. Transcultural Concepts in Nursing Care. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.
44. Moran KJ, Burson R, Conrad D. The Doctor of Nursing Practice Scholarly Project: A Framework for Success. Burlington, MA: Jones & Bartlett; 2013.
45. Hanssmann C, Morrison D, Russian E, Shiu-Thornton S, Bowen D. A community-based program evaluation of community competency trainings. J Assoc Nurses AIDS Care.
46. Knapp H, Fletcher M, Taylor A, Chan K, Goetz MB. No clinic left behind: providing cost-effective in-services via distance learning. J Healthc Qual. 2011;33(5):17-24.
47. Kauth MR, Shipherd JC, Lindsay JA, Kirsh S, Knapp H, Matza L. Teleconsultation and training of VHA providers on transgender care: implementation of a multisite hub system. Telemed J E Health. 2015;21(12):1012-1018.
48. Sherman MD, Kauth MR, Ridener L, Shipherd JC, Bratkovich K, Beaulieu G. An empirical investigation of challenges and recommendations for welcoming sexual and gender minority veterans into VA care. Prof Psychol: Res Pract. 2014;45(6):433-442.
49. American Association of Colleges of Nursing. The essentials of doctoral education for advanced nursing practice. http://www.aacn.nche.edu/pub lications/position/DNPEssentials.pdf. Published October 2006. Accessed December 1, 2016.
50. Boutain DM. Social justice as a framework for professional nursing. J Nurs Educ. 2005;44(9):404-408.
51. Poteat T, German D, Kerrigan D. Managing uncertainty: a grounded theory of stigma in transgender health care encounters. Soc Sci Med. 2013;84:22-29.
52. Thornhill L, Klein P. Creating environments of care with transgender communities. J Assoc Nurs AIDS Care. 2010;21(3):230-239.
53. Collins J. Nursing cultural competencies: Improving patient care quality and satisfaction. Ohio Nurses Rev. 2015;90(1):10-11.
54. Sherman MD, Kauth MR, Shipherd JC, Street RL Jr. Communication between VA providers and sexual and gender minority veterans: a pilot study. Psychol Serv. 2014;11(2):235-242.
55. Cowan L, Fasoli DR, Hagle ME, et al. Creating an infrastructure to advance nursing practice and care for veterans. Nurse Leader. 2013;11(5):33-36.
Patient-centered care is of fundamental importance when caring for the transgender population due to the well-established history of social stigma and systemic discrimination. Therefore, nursing education is mandated to equip graduates with culturally competent patient-centered care skills.1 In 2009, the Institute of Medicine (IOM) in partnership with the Robert Wood Johnson Foundation (RWJF) launched The Future of Nursing initiative, which outlined the major role nursing should play in transforming the health care system to meet the health care needs of diverse U.S. populations.
The initiative produced a blueprint of action-focused institutional recommendations at the local, state, and national levels that would facilitate the reforms necessary to transform the U.S. health care system. One of the recommendations of the IOM report was to increase opportunities for nurses to manage and lead collaborative efforts with physicians and other health care team members in the areas of systems redesign and research, to improve practice environments and health systems.2
The VHA is the largest integrated health care system in the U.S., serving more than 8.76 million veterans at more than 1,700 facilities. The VHA has an organizational structure that uses centralized control in Washington, DC, and branches out to 18 regional networks that are divided into local facilities in 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Philippines. This type of structure is known for promoting efficient standardization of processes and procedures across an organization.3
The VHA Blueprint for Excellence envisions the promotion of a positive culture of service and the advancement of health care innovations necessary to create an environment that all veterans deserve.4 To that end, the VHA can be a promising health care institution through which patient-centered initiatives can be standardized, promulgated nationally, and replicated as a model for the country and international health systems. However, it is important to note that the bureaucratic organizational structure of the VHA's national integrated system of care is based on a systemwide standardization effort.5 Therefore, more time may be required to implement organizational changes.
Transgender populations face significant social stigmatization, discrimination, and marginalization that contribute to negative patient outcomes. Consequently, this population experiences high rates of suicide, HIV/AIDS, substance use disorder, poverty, and homelessness.6 Due to the growing evidence of health disparities and negative health outcomes affecting transgender populations, the federal government has identified transgender patient care and outcomes as a major health concern and priority in the Healthy People Initiative 2020.2,7,8
In 2012, the VHA issued a directive mandating services for transgender veterans.9 Nevertheless, health care staff significantly lack the knowledge, skills, and cultural competencies that are vital in transgender care.
This article reviews the prevalence and demographics of the transgender population, social challenges, global health concerns, and public health policies. The article also examines how the doctor of nursing practice (DNP)-prepared nurse leader can provide transformational nursing leadership to facilitate culturally competent, patient-centered initiatives to improve access and services for transgender individuals in the VHA and provide a model for change in transgender population health.
Definitions
Gender is a behavioral, cultural, or psychological trait assigned by society that is associated with male or female sex. Sex denotes the biologic differences between males and females. Transgender is an umbrella term used to describe people whose gender identity or gender expression is different from that of their sex assigned at birth. Transsexualism is a subset of transgender persons who have taken steps to self-identify or transition to look like their preferred gender.
Demographics
Estimates of the prevalence of transgenderism are roughly drawn from less rigorous methods, such as the combination of parents who report transgenderism in children, the number of adults reportedly seeking clinical care (such as cross-sex or gender-affirming hormone therapy), and the number of surgical interventions reported in different countries.10 A meta-analysis of 21 studies concluded that the ratio of transsexuals (individuals who are altering or have already altered their birth sex) was predominantly 1:14,705 adult males and 1:38,461 adult females.11 Since all transgender persons do not identify as transsexual, these figures do not provide a precise estimation of the number of transgender persons worldwide.
About 700,000, or 0.3%, of the adult population in the U.S. identify themselves as transgender, and an estimated 134,300 identify as transgender veterans.6,12 The transgender population in the U.S. is estimated to be 55% white, 16% African American, 21% Hispanic, and 8% other races.13 The U.S. census data noted that the transgender population was geographically located across the nation. Transgender persons are more likely to be single, never married, divorced, and more educated but with significantly less household income.2 Data to provide an accurate reflection of the number of transgender people in the U.S. are lacking. Some transgender individuals also may identify as lesbian, gay, or bisexual, making population-based estimation even more challenging and difficult.
Transgender persons who have transitioned may not have changed their names or changed their identified sex on official Social Security records, which the Social Security Administration allows only if there is evidence that genital sexual reassignment surgery was performed.14 The number of transgender adults requesting treatment continues to rise.10
Social and Health Challenges
Transgender people face many challenges because of their gender identity. Surveys assessing the living conditions of transgender people have found that 43% to 60% report high levels of physical violence.15 By comparison, the National Intimate Partner and Sexual Violence Survey found that interpersonal violence and sexual violence were reported by lesbian and gay individuals at equal or higher levels than that reported by heterosexuals. Forty-four percent of lesbian women, 35% of heterosexual women, 29% of heterosexual men, and 26% of gay men reported experiencing rape or physical violence.16 A study in Spain reported 59% of transgender people experienced patterns of harassment, and in Canada, 34% of transgender people lived below the poverty level.17,18
In the U.S., the National Transgender Discrimination Survey of 6,450 transgender and nonconforming participants provided extensive data on challenges experienced by transgender people.6 Discrimination was frequently experienced in accessing health care. Due to transgender status, 19% were denied care, and 28% postponed care due to perceived harassment and violence within a health care setting.6 The same study also reported that as many as 41% live in extreme poverty with incomes of less than $10,000 per year reported. Twenty-six percent were physically assaulted, and 10% experienced sexual violence. More than 25% of the transgender population misused drugs or alcohol to cope with mistreatment.6
In the U.S., HIV infection rates for transgender individuals were more than 4 times (2.64%) the rate of the general population (0.6%).6 Internationally, there is a high prevalence of HIV in transgender women. The prevalence rate of HIV in U.S. transgender women was 21.74% of the estimated U.S. adult transgender population of about 700,000.19 One in 4 people living with HIV in the U.S. are women.20
Suicide attempt rates are extremely high among transgender people. A suicide rate of 22% to 43% has been reported across Europe, Canada, and the U.S.21 Depression and anxiety were commonly noted as a result of discrimination and social stigma. In the U.S., transgender persons reported high rates of depression, with 41% reporting attempted suicide compared with 1.6% of the general population.6 Access to health care services, such as mental health, psychosocial support, and stress management are critical for this vulnerable population.22
Health Policies
Since 1994, the UK has instituted legal employment protections for the transgender population. In the UK, transgender persons, including military and prisoners, have health care coverage that includes sexual reassignment surgery as part of the UK's National Health Service.23
In the U.S., the federal policy of "Don't Ask, Don't Tell" barring transgender persons from serving openly in the military was repealed in June 2016. This policy historically has had a silencing effect on perpetuating institutionalized biases.24 This remains problematic even after veterans have transitioned from military service to the VA for civilian care.
Between 2006 and 2013, the reported prevalence and incidence of transgender-related diagnoses in the VA have steadily increased with 40% of new diagnoses occurring since 2011.25 In fiscal year 2013, there were 32.9 per 100,000 veterans with transgender-related diagnoses.25 Health care staff, in particular health care providers (HCPs), can play a critical role in reducing health disparities and unequal treatment.26
With the passage of the U.S. Affordable Care Act (ACA), health insurance coverage for transgender persons is now guaranteed by law, and health disparities within the transgender population can begin to be properly addressed. The ACA offers the ability to purchase health insurance, possibly qualify for Medicaid, or obtain subsidies to purchase health insurance. Insurance coverage is accessible without regard to discrimination or preexisting conditions.27 As of May 2014, the Medicare program covered medically necessary hormone therapy and sex reassignment surgery.13 While VA benefits cover hormone therapy for transgender veterans, sex reassignment surgery is not currently a covered benefit.28 The ACA now increases access to primary care, preventative care, mental health services, and community health programs not previously available in the transgender community.
Healthy People 2020 Goals
One of the Healthy People 2020 stated goals is to improve the health and wellness of transgender people.29 The objective is to increase the number of population-based data collection systems used to monitor transgender people from the baseline of 2 to a total of 4 by 2020. The data systems would be assigned to collect relevant data, such as mental health; HIV status; illicit drug, alcohol, and tobacco use; cervical and breast cancer screening; health insurance coverage; and access to health care.
Health Care Staff Readiness
Transgender persons face health care challenges with major health disparities due to their gender identity. Transgender persons as a defined population are not well understood by HCPs. In a survey, 50% of transgender respondents reported that they had to teach their medical provider about transgender care.6 Negative perceptions of transgender persons are well established and have contribute to the poor health care access and services that transgender persons receive. Transgender persons are often denied access to care, denied visitation rights, and are hesitant to share information for fear of bureaucratic exclusion or isolation.
There is a lack of evidence-based studies to guide care and help HCPs gain greater understanding of this population's unique needs.30 Additionally, a significant lack of knowledge, skills, cultural competence, and awareness exist in providing transgender care. Research on nursing attitudes concerning transgender care consistently found negative attitudes, and physicians also frequently reported witnessing derogatory comments and discriminatory care from colleagues.31,32 The study by Carabez and colleagues found that practicing nurses rarely received the proper education or training in transgender health issues, and many were unaware of the needs of this population.33 In addition, many HCPs were uncomfortable working with transgender patients. Physicians also expressed knowledge deficits on gender identity disorders due to a lack of training and ethical concerns about their roles in providing gender-transitioning treatment.26
Although the VHA directive states that transgender services and treatment should be standardized, the VHA has not approved, defined, or endorsed specific standards of care or clinical guidelines within the organization for transgender care, further heightening HCP concerns.9 The clinical practice guidelines available for addressing preventive care for transgender patients are primarily based on consensus of expert opinion.34 Expert opinion has produced the Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People, published by the World Professional Association for Transgender Health (WPATH) and cited by the IOM as the major clinical practice guidelines for providing care to transgender individuals.2 Transgender care at the VHA is guided by the WPATH standards of care.35
The VHA has created national educational programs and policies with targeted goals to provide uniform, culturally competent, patient-centered care. Online transgender health presentations are available, and at least 15 VHA facilities have transgender support groups.30 While the VHA supports a patient-centered philosophy for transgender patient care, many facilities do not currently have organizational initiatives that enhance clinical preparation of HCPs or have sufficiently modified the environment to better accommodate the health care needs of transgender veterans.
DNP Preparation
The DNP terminal degree provides nurses with doctoral-level training in organizational and systems leadership, leading quality improvement, and implementing systemwide initiatives by using scientific findings to drive processes that improve quality of care for a changing patient population.36 Preparation in research analysis of evidence-based interventions also is essential to evaluating practice patterns, patient outcomes, and systems of care that can identify gaps in practice. Training in health care policy and advocacy, information systems, patient care technology, and population health also is provided so that DNPs are competent to develop system strategies to transform health care through clinical prevention and health promotion.
QSEN Framework
In keeping with the IOM's Future of Nursing initiative recommendations that graduate nurses be prepared as leaders in education, practice, administration, and research, there is an increasing focus on providing graduate-level nursing education and training to ensure quality and efficiency of health outcomes.37 The Quality and Safety Education in Nursing (QSEN) project, initiated at the RWJF by Linda Cronenwett, PhD, RN, identifies a framework for knowledge, skills, and attitudes that defines the competencies that nurses need to deliver effective care to improve quality and safety within health care systems.38 These core competencies include quality improvement, safety, teamwork and collaboration, patient-centered care, evidence-based practice, and informatics. The RWJF and the American Association of Colleges of Nursing later expanded the project initiative to prepare nursing faculty to teach the QSEN competencies in graduate nursing programs.36
The DNP nurse leader is ideally suited to manage this project by applying competencies from the QSEN framework. Using open communication and mutual respect, the nurse leader is poised to effectively develop interprofessional teams to collaborate and initiate transformational changes that improve quality and patient-centered care delivered within the health care organization.
Public Health Resources
Public health resources addressing transgender patient care advocacy, public policy, community education, standards of care, cultural competency, mental health, hormone therapy, surgical interventions, reproductive health, primary care, preventative care, and research are available. For example, WPATH is an international multidisciplinary organization that has published comprehensive SOC for transgender, transsexual, and gender-nonconforming people. The seventh version of the SOC contains evidence-based guidelines for treatment.39 Additional online resources for transgender health are available from the CDC, the Center of Excellence for Transgender Health at the University of California, San Francisco; Department of Family and Community Medicine; and the National Center for Transgender Equality.13,40,41
Patient-Centered Transgender Care
The QSEN framework outlines competencies that provide applicable solutions that help prepare organizations to deliver culturally competent, patient-centered transgender care. The first step to creating patient-centered transgender care is to "analyze factors that create barriers to patient-centered care."42 The magnitude of the barriers to providing patient-centered transgender care also must be identified and understood. An assessment of individual values, beliefs, and attitudes can help to identify cultural characteristics and eliminate stereotypes that impact health practices.43
The nurse leader should solicit support from stakeholders to assess barriers to providing patient-centered transgender care at the system level. Stakeholders would include staff directly involved in patient care, such as physicians, nurse practitioners, physician assistants, registered nurses, nurse managers, nurse educators, licensed practical nurses, medical support assistants, psychologists, dieticians, and social workers. Other ancillary stakeholders with an interest in creating a patient-centered environment with positive patient outcomes include the executive leadership team of the organization, which consists of the chief of staff, director, administrative officers, and nurse executive.
The nurse leader should consult with experts in transgender care and present evidence-based research showing how deficits in staff knowledge, skills, and cultural competence negatively impact the quality of care provided to transgender persons. National data on the consequential health disparities and negative impacts on patient outcomes also should be discussed and presented to all stakeholders. The nurse leader in collaboration with the VA Office of Research and Development is ideally suited to obtain institutional review board approval of a proposal to conduct a needs assessment survey of health care staff barriers to providing patient-centered transgender care. Thereafter, the nurse leader would analyze, extract, and synthesize the data and evaluate the resources and technology available to translate this research knowledge into a clinical practice setting at the system level.44
The second solution uses the results of the survey to develop staff competency training within the organization. The nurse leader can facilitate collaboration and team building to develop practice guidelines and SOC. Competency training will prepare the staff to assist in developing strategies to improve the quality of care for transgender persons. Educationconcerning existing evidence-based clinical guidelines and SOC as well as anecdotal evidence of the needs of transgender patients should be included in competency training.45 One approach to competency training would be to trainintegrated multidisciplinary teams with expertise in transgender care to promote wellness and disease prevention.9 The nurse leader should collaborate with multiple disciplines to facilitate the development of interdisciplinary teams from nursing, medicine, social work, pharmacy, primary care, mental health, women's health, and endocrinology to participate in the Specialty Care Access Network Extension of Community Healthcare outcomes (SCAN-ECHO) training. Training can be offered by videoconferencing over several months and provides cost-effective, efficient training of providers in patient-centered transgender care.46,47 After the SCAN-ECHO program is completed, trained nursing experts could then develop a cultural sensitivity training program for nursing organizations to be offered to educate health care staff on an annual basis.
The third solution addresses the QSEN competency to "Analyze institutional features of the facilities that support or pose barriers to patient-centered care."42 Many veterans do not perceive VA environments as welcoming. In a study by Sherman and colleagues, less than one-third of veterans believed the VA environment was welcoming to sexual or gender minorities, and sexual orientation or gender identity was disclosed by only about 25% of veterans.48 Many veterans in this study felt uncomfortable disclosing their gender or sexual orientation. The majority felt that providers should not routinely ask about sexual orientation or gender identity, and 24% said they were very or somewhat uncomfortable discussing the issue. In another study, 202 VA providers were asked if they viewed the VA as welcoming, and 32% said the VA was somewhat or very unwelcoming.48
The nurse leader is trained in the essentials of health care policy advocacy, which is central to nursing practice.49 Nursing as a profession values social justice and equality, which are linked to fewer health disparities and more stable health indicators.50 Therefore, nursing can ideally provide organizational leaders by developing a culture wherein stable, patient-centered relationships can develop and thrive.
Organizational Culture
Strategies must be deployed to create an organizational culture that is welcoming, respectful, and supportive of transgender patients and family preferences. VA should develop support groups for transgender veterans in VA facilities. Support groups are helpful in diminishing stress, improving self-esteem, building confidence, and improving social relationships.51 Additionally, VA should develop community-based partnerships with other organizations that already provide institutional care and support from HCPs who support transgender persons' right to self-determination.52 These partnerships can foster environmental influences over time and lead to the development of trusting relationships between transgender veterans and the VA organization.
Another community partnership of importance for the nurse leader to develop is an alliance with local universities to train nursing students in cultural competencies in transgender care at VA facilities. The U.S. population continues to diversify in race and ethnicity and cultural influences; therefore, nurses must be prepared in cultural competencies in order to provide quality care that reduces health disparities.53
Under federal law, the VHA has a data sharing agreement with the DoD. Despite the repeal of the "Don't Ask, Don't Tell" federal law, which cleared the way for transgender persons to openly serve in the military, many transgender persons may remain fearful of reprisals, such as judgment, denial of care, or loss of benefits if gender identity is disclosed.54 Given the bureaucratic structure of the VHA, the implementation of cultural changes at the system level will require a collaborative effort between multidisciplinary teams and community partnerships to transform the VA environment over time. The authors believe that on this issue, external forces must guide and lead changes within the VA system in order to develop sustainable and trusting relationships with transgender veterans.
The fourth solution is implementation of policies that "empower patients or families in all aspects of the health care process."42 Again, the nurse leader is trained and prepared to advocate for a policy that implements a Patient Bill of Rights that explicitly guarantees health care and prohibits discrimination of gender-minority veterans. This change would foster trust and confidence from transgender individuals. A study found that 83% of providers and 83% of lesbian, gay, bisexual, and transgender veterans believe that this policy change would make the VHA environment more welcoming.48 Providing transgender-affirming materials and language on standard forms also would eliminate barriers, promote patient-centered care, and empower transgender patients by creating an environment that is more inclusive of everyone.48
Conclusion
The nurse leader is well positioned to implement the QSEN framework to integrate research, practice, and policy to create a more inclusive, patient-centered health care system for transgender veterans. By using the essential principles of doctoral education for advanced nursing practice, the nurse leader is prepared to advocate for changing the organization at the systems level. The nurse leader also is equipped to direct the implementation of patient-centered transgender care initiatives by ensuring the integration of the nursing organization as a partner in strategic planning as well as the development of solutions.
The VHA Blueprint of Excellence envisions organization and collaboration to promote new relationships that serve and benefit veterans. The DNP preparation allows the nurse leader to demonstrate the ability to collaborate with VHA stakeholders and develop alliances within and outside the organization by advocating for policy changes that will be transformational in improving health care delivery and patient outcomes to vulnerable transgender veteran populations. The IOM has tasked nurse executives with creating a health care infrastructure of doctorally prepared nurses to provide patient care that is increasingly growing more complex. With an increasing number of veterans using services, VHA has prioritized an expansion in the number of doctorally prepared nurses.55
As the largest integrated health care system in the U.S., the VHA provides an ideal setting for initiating these organizational changes as a result of having developed an integrated infrastructure to collect evidence-based data at the regional (network) and state facilities and make comparisons with national benchmarks. Therefore, changes are less difficult to disseminate throughout the hierarchy of the VHA. Consequently, the VHA has been a leader in the U.S. for equity in the health care arena and provides a model for international health care systems. Finally, these changes address an urgent need to reduce health disparities, morbidity, and mortality by improving quality care and health care delivery to a vulnerable transgender population.
Patient-centered care is of fundamental importance when caring for the transgender population due to the well-established history of social stigma and systemic discrimination. Therefore, nursing education is mandated to equip graduates with culturally competent patient-centered care skills.1 In 2009, the Institute of Medicine (IOM) in partnership with the Robert Wood Johnson Foundation (RWJF) launched The Future of Nursing initiative, which outlined the major role nursing should play in transforming the health care system to meet the health care needs of diverse U.S. populations.
The initiative produced a blueprint of action-focused institutional recommendations at the local, state, and national levels that would facilitate the reforms necessary to transform the U.S. health care system. One of the recommendations of the IOM report was to increase opportunities for nurses to manage and lead collaborative efforts with physicians and other health care team members in the areas of systems redesign and research, to improve practice environments and health systems.2
The VHA is the largest integrated health care system in the U.S., serving more than 8.76 million veterans at more than 1,700 facilities. The VHA has an organizational structure that uses centralized control in Washington, DC, and branches out to 18 regional networks that are divided into local facilities in 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Philippines. This type of structure is known for promoting efficient standardization of processes and procedures across an organization.3
The VHA Blueprint for Excellence envisions the promotion of a positive culture of service and the advancement of health care innovations necessary to create an environment that all veterans deserve.4 To that end, the VHA can be a promising health care institution through which patient-centered initiatives can be standardized, promulgated nationally, and replicated as a model for the country and international health systems. However, it is important to note that the bureaucratic organizational structure of the VHA's national integrated system of care is based on a systemwide standardization effort.5 Therefore, more time may be required to implement organizational changes.
Transgender populations face significant social stigmatization, discrimination, and marginalization that contribute to negative patient outcomes. Consequently, this population experiences high rates of suicide, HIV/AIDS, substance use disorder, poverty, and homelessness.6 Due to the growing evidence of health disparities and negative health outcomes affecting transgender populations, the federal government has identified transgender patient care and outcomes as a major health concern and priority in the Healthy People Initiative 2020.2,7,8
In 2012, the VHA issued a directive mandating services for transgender veterans.9 Nevertheless, health care staff significantly lack the knowledge, skills, and cultural competencies that are vital in transgender care.
This article reviews the prevalence and demographics of the transgender population, social challenges, global health concerns, and public health policies. The article also examines how the doctor of nursing practice (DNP)-prepared nurse leader can provide transformational nursing leadership to facilitate culturally competent, patient-centered initiatives to improve access and services for transgender individuals in the VHA and provide a model for change in transgender population health.
Definitions
Gender is a behavioral, cultural, or psychological trait assigned by society that is associated with male or female sex. Sex denotes the biologic differences between males and females. Transgender is an umbrella term used to describe people whose gender identity or gender expression is different from that of their sex assigned at birth. Transsexualism is a subset of transgender persons who have taken steps to self-identify or transition to look like their preferred gender.
Demographics
Estimates of the prevalence of transgenderism are roughly drawn from less rigorous methods, such as the combination of parents who report transgenderism in children, the number of adults reportedly seeking clinical care (such as cross-sex or gender-affirming hormone therapy), and the number of surgical interventions reported in different countries.10 A meta-analysis of 21 studies concluded that the ratio of transsexuals (individuals who are altering or have already altered their birth sex) was predominantly 1:14,705 adult males and 1:38,461 adult females.11 Since all transgender persons do not identify as transsexual, these figures do not provide a precise estimation of the number of transgender persons worldwide.
About 700,000, or 0.3%, of the adult population in the U.S. identify themselves as transgender, and an estimated 134,300 identify as transgender veterans.6,12 The transgender population in the U.S. is estimated to be 55% white, 16% African American, 21% Hispanic, and 8% other races.13 The U.S. census data noted that the transgender population was geographically located across the nation. Transgender persons are more likely to be single, never married, divorced, and more educated but with significantly less household income.2 Data to provide an accurate reflection of the number of transgender people in the U.S. are lacking. Some transgender individuals also may identify as lesbian, gay, or bisexual, making population-based estimation even more challenging and difficult.
Transgender persons who have transitioned may not have changed their names or changed their identified sex on official Social Security records, which the Social Security Administration allows only if there is evidence that genital sexual reassignment surgery was performed.14 The number of transgender adults requesting treatment continues to rise.10
Social and Health Challenges
Transgender people face many challenges because of their gender identity. Surveys assessing the living conditions of transgender people have found that 43% to 60% report high levels of physical violence.15 By comparison, the National Intimate Partner and Sexual Violence Survey found that interpersonal violence and sexual violence were reported by lesbian and gay individuals at equal or higher levels than that reported by heterosexuals. Forty-four percent of lesbian women, 35% of heterosexual women, 29% of heterosexual men, and 26% of gay men reported experiencing rape or physical violence.16 A study in Spain reported 59% of transgender people experienced patterns of harassment, and in Canada, 34% of transgender people lived below the poverty level.17,18
In the U.S., the National Transgender Discrimination Survey of 6,450 transgender and nonconforming participants provided extensive data on challenges experienced by transgender people.6 Discrimination was frequently experienced in accessing health care. Due to transgender status, 19% were denied care, and 28% postponed care due to perceived harassment and violence within a health care setting.6 The same study also reported that as many as 41% live in extreme poverty with incomes of less than $10,000 per year reported. Twenty-six percent were physically assaulted, and 10% experienced sexual violence. More than 25% of the transgender population misused drugs or alcohol to cope with mistreatment.6
In the U.S., HIV infection rates for transgender individuals were more than 4 times (2.64%) the rate of the general population (0.6%).6 Internationally, there is a high prevalence of HIV in transgender women. The prevalence rate of HIV in U.S. transgender women was 21.74% of the estimated U.S. adult transgender population of about 700,000.19 One in 4 people living with HIV in the U.S. are women.20
Suicide attempt rates are extremely high among transgender people. A suicide rate of 22% to 43% has been reported across Europe, Canada, and the U.S.21 Depression and anxiety were commonly noted as a result of discrimination and social stigma. In the U.S., transgender persons reported high rates of depression, with 41% reporting attempted suicide compared with 1.6% of the general population.6 Access to health care services, such as mental health, psychosocial support, and stress management are critical for this vulnerable population.22
Health Policies
Since 1994, the UK has instituted legal employment protections for the transgender population. In the UK, transgender persons, including military and prisoners, have health care coverage that includes sexual reassignment surgery as part of the UK's National Health Service.23
In the U.S., the federal policy of "Don't Ask, Don't Tell" barring transgender persons from serving openly in the military was repealed in June 2016. This policy historically has had a silencing effect on perpetuating institutionalized biases.24 This remains problematic even after veterans have transitioned from military service to the VA for civilian care.
Between 2006 and 2013, the reported prevalence and incidence of transgender-related diagnoses in the VA have steadily increased with 40% of new diagnoses occurring since 2011.25 In fiscal year 2013, there were 32.9 per 100,000 veterans with transgender-related diagnoses.25 Health care staff, in particular health care providers (HCPs), can play a critical role in reducing health disparities and unequal treatment.26
With the passage of the U.S. Affordable Care Act (ACA), health insurance coverage for transgender persons is now guaranteed by law, and health disparities within the transgender population can begin to be properly addressed. The ACA offers the ability to purchase health insurance, possibly qualify for Medicaid, or obtain subsidies to purchase health insurance. Insurance coverage is accessible without regard to discrimination or preexisting conditions.27 As of May 2014, the Medicare program covered medically necessary hormone therapy and sex reassignment surgery.13 While VA benefits cover hormone therapy for transgender veterans, sex reassignment surgery is not currently a covered benefit.28 The ACA now increases access to primary care, preventative care, mental health services, and community health programs not previously available in the transgender community.
Healthy People 2020 Goals
One of the Healthy People 2020 stated goals is to improve the health and wellness of transgender people.29 The objective is to increase the number of population-based data collection systems used to monitor transgender people from the baseline of 2 to a total of 4 by 2020. The data systems would be assigned to collect relevant data, such as mental health; HIV status; illicit drug, alcohol, and tobacco use; cervical and breast cancer screening; health insurance coverage; and access to health care.
Health Care Staff Readiness
Transgender persons face health care challenges with major health disparities due to their gender identity. Transgender persons as a defined population are not well understood by HCPs. In a survey, 50% of transgender respondents reported that they had to teach their medical provider about transgender care.6 Negative perceptions of transgender persons are well established and have contribute to the poor health care access and services that transgender persons receive. Transgender persons are often denied access to care, denied visitation rights, and are hesitant to share information for fear of bureaucratic exclusion or isolation.
There is a lack of evidence-based studies to guide care and help HCPs gain greater understanding of this population's unique needs.30 Additionally, a significant lack of knowledge, skills, cultural competence, and awareness exist in providing transgender care. Research on nursing attitudes concerning transgender care consistently found negative attitudes, and physicians also frequently reported witnessing derogatory comments and discriminatory care from colleagues.31,32 The study by Carabez and colleagues found that practicing nurses rarely received the proper education or training in transgender health issues, and many were unaware of the needs of this population.33 In addition, many HCPs were uncomfortable working with transgender patients. Physicians also expressed knowledge deficits on gender identity disorders due to a lack of training and ethical concerns about their roles in providing gender-transitioning treatment.26
Although the VHA directive states that transgender services and treatment should be standardized, the VHA has not approved, defined, or endorsed specific standards of care or clinical guidelines within the organization for transgender care, further heightening HCP concerns.9 The clinical practice guidelines available for addressing preventive care for transgender patients are primarily based on consensus of expert opinion.34 Expert opinion has produced the Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People, published by the World Professional Association for Transgender Health (WPATH) and cited by the IOM as the major clinical practice guidelines for providing care to transgender individuals.2 Transgender care at the VHA is guided by the WPATH standards of care.35
The VHA has created national educational programs and policies with targeted goals to provide uniform, culturally competent, patient-centered care. Online transgender health presentations are available, and at least 15 VHA facilities have transgender support groups.30 While the VHA supports a patient-centered philosophy for transgender patient care, many facilities do not currently have organizational initiatives that enhance clinical preparation of HCPs or have sufficiently modified the environment to better accommodate the health care needs of transgender veterans.
DNP Preparation
The DNP terminal degree provides nurses with doctoral-level training in organizational and systems leadership, leading quality improvement, and implementing systemwide initiatives by using scientific findings to drive processes that improve quality of care for a changing patient population.36 Preparation in research analysis of evidence-based interventions also is essential to evaluating practice patterns, patient outcomes, and systems of care that can identify gaps in practice. Training in health care policy and advocacy, information systems, patient care technology, and population health also is provided so that DNPs are competent to develop system strategies to transform health care through clinical prevention and health promotion.
QSEN Framework
In keeping with the IOM's Future of Nursing initiative recommendations that graduate nurses be prepared as leaders in education, practice, administration, and research, there is an increasing focus on providing graduate-level nursing education and training to ensure quality and efficiency of health outcomes.37 The Quality and Safety Education in Nursing (QSEN) project, initiated at the RWJF by Linda Cronenwett, PhD, RN, identifies a framework for knowledge, skills, and attitudes that defines the competencies that nurses need to deliver effective care to improve quality and safety within health care systems.38 These core competencies include quality improvement, safety, teamwork and collaboration, patient-centered care, evidence-based practice, and informatics. The RWJF and the American Association of Colleges of Nursing later expanded the project initiative to prepare nursing faculty to teach the QSEN competencies in graduate nursing programs.36
The DNP nurse leader is ideally suited to manage this project by applying competencies from the QSEN framework. Using open communication and mutual respect, the nurse leader is poised to effectively develop interprofessional teams to collaborate and initiate transformational changes that improve quality and patient-centered care delivered within the health care organization.
Public Health Resources
Public health resources addressing transgender patient care advocacy, public policy, community education, standards of care, cultural competency, mental health, hormone therapy, surgical interventions, reproductive health, primary care, preventative care, and research are available. For example, WPATH is an international multidisciplinary organization that has published comprehensive SOC for transgender, transsexual, and gender-nonconforming people. The seventh version of the SOC contains evidence-based guidelines for treatment.39 Additional online resources for transgender health are available from the CDC, the Center of Excellence for Transgender Health at the University of California, San Francisco; Department of Family and Community Medicine; and the National Center for Transgender Equality.13,40,41
Patient-Centered Transgender Care
The QSEN framework outlines competencies that provide applicable solutions that help prepare organizations to deliver culturally competent, patient-centered transgender care. The first step to creating patient-centered transgender care is to "analyze factors that create barriers to patient-centered care."42 The magnitude of the barriers to providing patient-centered transgender care also must be identified and understood. An assessment of individual values, beliefs, and attitudes can help to identify cultural characteristics and eliminate stereotypes that impact health practices.43
The nurse leader should solicit support from stakeholders to assess barriers to providing patient-centered transgender care at the system level. Stakeholders would include staff directly involved in patient care, such as physicians, nurse practitioners, physician assistants, registered nurses, nurse managers, nurse educators, licensed practical nurses, medical support assistants, psychologists, dieticians, and social workers. Other ancillary stakeholders with an interest in creating a patient-centered environment with positive patient outcomes include the executive leadership team of the organization, which consists of the chief of staff, director, administrative officers, and nurse executive.
The nurse leader should consult with experts in transgender care and present evidence-based research showing how deficits in staff knowledge, skills, and cultural competence negatively impact the quality of care provided to transgender persons. National data on the consequential health disparities and negative impacts on patient outcomes also should be discussed and presented to all stakeholders. The nurse leader in collaboration with the VA Office of Research and Development is ideally suited to obtain institutional review board approval of a proposal to conduct a needs assessment survey of health care staff barriers to providing patient-centered transgender care. Thereafter, the nurse leader would analyze, extract, and synthesize the data and evaluate the resources and technology available to translate this research knowledge into a clinical practice setting at the system level.44
The second solution uses the results of the survey to develop staff competency training within the organization. The nurse leader can facilitate collaboration and team building to develop practice guidelines and SOC. Competency training will prepare the staff to assist in developing strategies to improve the quality of care for transgender persons. Educationconcerning existing evidence-based clinical guidelines and SOC as well as anecdotal evidence of the needs of transgender patients should be included in competency training.45 One approach to competency training would be to trainintegrated multidisciplinary teams with expertise in transgender care to promote wellness and disease prevention.9 The nurse leader should collaborate with multiple disciplines to facilitate the development of interdisciplinary teams from nursing, medicine, social work, pharmacy, primary care, mental health, women's health, and endocrinology to participate in the Specialty Care Access Network Extension of Community Healthcare outcomes (SCAN-ECHO) training. Training can be offered by videoconferencing over several months and provides cost-effective, efficient training of providers in patient-centered transgender care.46,47 After the SCAN-ECHO program is completed, trained nursing experts could then develop a cultural sensitivity training program for nursing organizations to be offered to educate health care staff on an annual basis.
The third solution addresses the QSEN competency to "Analyze institutional features of the facilities that support or pose barriers to patient-centered care."42 Many veterans do not perceive VA environments as welcoming. In a study by Sherman and colleagues, less than one-third of veterans believed the VA environment was welcoming to sexual or gender minorities, and sexual orientation or gender identity was disclosed by only about 25% of veterans.48 Many veterans in this study felt uncomfortable disclosing their gender or sexual orientation. The majority felt that providers should not routinely ask about sexual orientation or gender identity, and 24% said they were very or somewhat uncomfortable discussing the issue. In another study, 202 VA providers were asked if they viewed the VA as welcoming, and 32% said the VA was somewhat or very unwelcoming.48
The nurse leader is trained in the essentials of health care policy advocacy, which is central to nursing practice.49 Nursing as a profession values social justice and equality, which are linked to fewer health disparities and more stable health indicators.50 Therefore, nursing can ideally provide organizational leaders by developing a culture wherein stable, patient-centered relationships can develop and thrive.
Organizational Culture
Strategies must be deployed to create an organizational culture that is welcoming, respectful, and supportive of transgender patients and family preferences. VA should develop support groups for transgender veterans in VA facilities. Support groups are helpful in diminishing stress, improving self-esteem, building confidence, and improving social relationships.51 Additionally, VA should develop community-based partnerships with other organizations that already provide institutional care and support from HCPs who support transgender persons' right to self-determination.52 These partnerships can foster environmental influences over time and lead to the development of trusting relationships between transgender veterans and the VA organization.
Another community partnership of importance for the nurse leader to develop is an alliance with local universities to train nursing students in cultural competencies in transgender care at VA facilities. The U.S. population continues to diversify in race and ethnicity and cultural influences; therefore, nurses must be prepared in cultural competencies in order to provide quality care that reduces health disparities.53
Under federal law, the VHA has a data sharing agreement with the DoD. Despite the repeal of the "Don't Ask, Don't Tell" federal law, which cleared the way for transgender persons to openly serve in the military, many transgender persons may remain fearful of reprisals, such as judgment, denial of care, or loss of benefits if gender identity is disclosed.54 Given the bureaucratic structure of the VHA, the implementation of cultural changes at the system level will require a collaborative effort between multidisciplinary teams and community partnerships to transform the VA environment over time. The authors believe that on this issue, external forces must guide and lead changes within the VA system in order to develop sustainable and trusting relationships with transgender veterans.
The fourth solution is implementation of policies that "empower patients or families in all aspects of the health care process."42 Again, the nurse leader is trained and prepared to advocate for a policy that implements a Patient Bill of Rights that explicitly guarantees health care and prohibits discrimination of gender-minority veterans. This change would foster trust and confidence from transgender individuals. A study found that 83% of providers and 83% of lesbian, gay, bisexual, and transgender veterans believe that this policy change would make the VHA environment more welcoming.48 Providing transgender-affirming materials and language on standard forms also would eliminate barriers, promote patient-centered care, and empower transgender patients by creating an environment that is more inclusive of everyone.48
Conclusion
The nurse leader is well positioned to implement the QSEN framework to integrate research, practice, and policy to create a more inclusive, patient-centered health care system for transgender veterans. By using the essential principles of doctoral education for advanced nursing practice, the nurse leader is prepared to advocate for changing the organization at the systems level. The nurse leader also is equipped to direct the implementation of patient-centered transgender care initiatives by ensuring the integration of the nursing organization as a partner in strategic planning as well as the development of solutions.
The VHA Blueprint of Excellence envisions organization and collaboration to promote new relationships that serve and benefit veterans. The DNP preparation allows the nurse leader to demonstrate the ability to collaborate with VHA stakeholders and develop alliances within and outside the organization by advocating for policy changes that will be transformational in improving health care delivery and patient outcomes to vulnerable transgender veteran populations. The IOM has tasked nurse executives with creating a health care infrastructure of doctorally prepared nurses to provide patient care that is increasingly growing more complex. With an increasing number of veterans using services, VHA has prioritized an expansion in the number of doctorally prepared nurses.55
As the largest integrated health care system in the U.S., the VHA provides an ideal setting for initiating these organizational changes as a result of having developed an integrated infrastructure to collect evidence-based data at the regional (network) and state facilities and make comparisons with national benchmarks. Therefore, changes are less difficult to disseminate throughout the hierarchy of the VHA. Consequently, the VHA has been a leader in the U.S. for equity in the health care arena and provides a model for international health care systems. Finally, these changes address an urgent need to reduce health disparities, morbidity, and mortality by improving quality care and health care delivery to a vulnerable transgender population.
1. Greiner AC, Knebel E, eds. Health Professions Education: A Bridge to Quality. Washington, DC: National Academies Press; 2003.
2. Institute of Medicine. Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academy of Sciences; 2011.
3. Mintzberg H. The structuring of organizations: a synthesis of the research. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1496182 1979. Posted November 4, 2009. Accessed November 30, 2016.
4. U.S. Department of Veterans Affairs. VHA blue print for excellence. https://www.va.gov/health/docs/VHA_Blueprint_for_Excellence.pdf. Published September 21, 2014. Accessed November 30, 2016.
5. Morgan RO, Teal CR, Reddy SG, Ford ME, Ashton CM. Measurement in Veterans Affairs Health Services Research: veterans as a special population. Health Serv Res. 2005;40(5, part 2):1573-1583.
6. Grant JM, Mottet L, Tanis JE, Harrison J, Herman J, Keisling M. Injustice at every turn: a report of the National Transgender Discrimination Survey. http://www.thetaskforce.org/static_html/downloads /reports/reports/ntds_full.pdf. Published 2011. Accessed November 30, 2016.
7. Office of Disease Prevention and Health Promotion. Lesbian, gay, bisexual, and transgender health. http://www.healthypeople.gov/2020/topics-objec tives/topic/lesbian-gay-bisexual-and-transgender -health. Updated November 16, 2016. Accessed November 16, 2016.
8. Institute of Medicine Committee on Lesbian Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academy of Sciences; 2011.
9. U.S. Department of Veterans Affairs. VHA Directive 2013-003: Providing Health Care for Transgender and Intersex Veterans. Washington, DC: U.S. Department of Veterans Affairs; 2013.
10. Zucker KJ, Lawrence AA. Epidemiology of gender identity disorder: recommendations for the Standards of Care of the World Professional Association for Transgender Health. Int J Transgenderism. 2009;11(1):8-18.
11. Arcelus J, Bouman WP, Van Den Noortgate W, Claes L, Witcomb G, Fernandez-Aranda F. Systematic review and meta-analysis of prevalence studies in transsexualism. Eur Psychiatry. 2015;30(6):807-815.
12. Gates GJ, Herman JL. Transgender military service in the United States. http://williamsinstitute.law.ucla.edu/wp-content/uploads/Transgender-Military -Service-May-2014.pdf. Published May 2014. Accessed November 30, 2016.
13. Flores AR, Brown TNT, and Herman JL. Race and ethnicity of adults who identify as transgender in the United States. http://williamsinstitute.law.ucla .edu/wp-content/uploads/Race-and-Ethnicity-of -Transgender-Identified-Adults-in-the-US.pdf. Published October 2016. Accessed December 13, 2016.
14. Harris BC. Likely Transgender individuals in US federal administrative records and the 2010 census. https://www.census.gov/srd/carra/15_03_Likely_Transgender_Individuals_in_ARs_and_2010Census.pdf. Published May 4, 2015. Accessed November 30, 2016.
15. Kenagy GP, Bostwick WB. Health and social service needs of transgender people in Chicago. Int J Transgenderism. 2005;8(2-3):57-66.
16. Centers for Disease Control and Prevention. National intimate partner and sexual violence survey, 2010 summary report. https://www.cdc.gov/viole nceprevention/pdf/nisvs_report2010-a.pdf. Published November 2011. Accessed December 12, 2016.
17. Bauer GR, Travers R, Scanlon K, Coleman TA. High heterogeneity of HIV-related sexual risk among transgender people in Ontario, Canada: a province-wide respondent-driven sampling survey. BMC Public Health. 2012;12(1):292-291.
18. Devis-Devis J, Pereira-Garcia S, Valencia-Peris A, Fuentes-Miguel J, López-Cañada E, Pérez-Samaniego V. Harassment patterns and risk profile in Spanish trans persons. J Homosex. 2016. [Epub ahead of print.]
19. Gates GJ. How many people are lesbian, gay, bisexual, and transgender? http://williamsinstitute.law.ucla.edu/wp-content/uploads/Gates-How-Many -People-LGBT-Apr-2011.pdf. Published April 2011. Accessed December 1, 2016.
20. Center for Disease Control and Prevention. HIV Among Women. http://www.cdc.gov/hiv/group/gender/women/index.html. Accessed December 10, 2016.
21. Bauer GR, Scheim AI, Pyne J, Travers R, Hammond R. Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada. BMC Public Health. 2015;15(1):525.
22. McCann E. People who are transgender: mental health concerns. J Psychiatr Ment Health Nurs. 2015;22(1):76-81.
23. Green R. Transsexual legal rights in the United States and United Kingdom: employment, medical treatment, and civil status. Arch Sex Behav. 2010;39(1):153-160.
24. Sharpe VA, Uchendu US. Ensuring appropriate care for LGBT veterans in the Veterans Health Administration. Hastings Cent Rep. 2014;44(suppl 4):S53-S55.
25. Kauth MR, Shipherd JC, Lindsay J, Blosnich JR, Brown GR, Jones KT. Access to care for transgender veterans in the Veterans Health Administration: 2006-2013. Am J Public Health. 2014;104(suppl 4):S532-S534.
26. Snelgrove JW, Jasudavisius AM, Rowe BW, Head EM, Bauer GR. "Completely out-at-sea" with "two-gender medicine": a qualitative analysis of physician-side barriers to providing healthcare for transgender patients. BMC Health Serv Res. 2012;12(1):110.
27. U.S. Department of Health and Human Services. Key features of the affordable care act. http://www .hhs.gov/healthcare/facts-and-features/key-features -of-aca/index.html. Last reviewed November 18, 2014. Accessed December 1, 2016.
28. U.S. Department of Veterans Affairs. Federal benefits for veterans, dependents, and survivors. https://www.va.gov/opa/publications/benefits_book/Chapter_1_Health_Care_Benefits.asp. Accessed December 1, 2016.
29. HealthyPeople.gov. Lesbian, gay, bisexual, and transgender health. https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bi sexual-and-transgender-health. Updated December 1, 2016. Accessed December 1, 2016.
30. Lutwak N, Byne W, Erickson-Schroth L, et al. Transgender veterans are inadequately understood by health care providers. Mil Med. 2014;179(5):483-485.
31. Dorsen C. An integrative review of nurse attitudes towards lesbian, gay, bisexual, and transgender patients. Can J Nurs Res. 2012;44(3):18-43.
32. Eliason MJ, Dibble SL, Robertson PA. Lesbian, gay, bisexual, and transgender (LGBT) physicians' experiences in the workplace. J Homosex. 2011;58(10):1355-1371.
33. Carabez R, Pellegrini M, Mankovitz A, Eliason M, Ciano M, Scott M. "Never in All My Years...": Nurses' education about LGBT health. J Prof Nurs. 2015;31(4):323-329
34. Buchholz L. Transgender care moves into the mainstream. JAMA. 2015;314(17):1785-1787.
35. VA Boston Healthcare System. Patient Care Memorandum-11-046-LM. Management of transgender veteran patients. http://www.boston.va.gov/services/images/lgbt_patient_care_memo_transgender_care.pdf. Published May 2011. Accessed December 1, 2016.
36. Cronenwett L, Sherwood G, Pohl J, et al. Quality and safety education for advanced nursing practice. Nurs Outlook. 2009;57(6):338-348.
37. Institute of Medicine. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011.
38. Smith EL, Cronenwett L, Sherwood G. Current assessments of quality and safety education in nursing. Nurs Outlook. 2007;55(3):132-137.
39. World Professional Association for Transgender Health (WPATH).The standards of care. http://www.wpath.org/site_page.cfm?pk_association _webpage_menu=1351&pk_association_web page=4655. Accessed December 1, 2016.
40. University of California San Francisco Department of Family and Community Medicine. Center of Excellence for Transgender Health. http://www.tran shealth.ucsf.edu/trans?page=home-00-00 Accessed December 1, 2016.
41. Center for Disease Control and Prevention. Lesbian, gay, bisexual and transgender health. http://www.cdc.gov/lgbthealth/transgender.htm. Accessed December 1, 2016.
42. American Association of Colleges of Nursing. QSEN education consortium: graduate-level QSEN competencies, knowledge, skills and attitudes. http://www.aacn.nche.edu/faculty/qsen/competen cies.pdf. Accessed December 1, 2016.
43. Andrews MM, Boyle JS. Transcultural Concepts in Nursing Care. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.
44. Moran KJ, Burson R, Conrad D. The Doctor of Nursing Practice Scholarly Project: A Framework for Success. Burlington, MA: Jones & Bartlett; 2013.
45. Hanssmann C, Morrison D, Russian E, Shiu-Thornton S, Bowen D. A community-based program evaluation of community competency trainings. J Assoc Nurses AIDS Care.
46. Knapp H, Fletcher M, Taylor A, Chan K, Goetz MB. No clinic left behind: providing cost-effective in-services via distance learning. J Healthc Qual. 2011;33(5):17-24.
47. Kauth MR, Shipherd JC, Lindsay JA, Kirsh S, Knapp H, Matza L. Teleconsultation and training of VHA providers on transgender care: implementation of a multisite hub system. Telemed J E Health. 2015;21(12):1012-1018.
48. Sherman MD, Kauth MR, Ridener L, Shipherd JC, Bratkovich K, Beaulieu G. An empirical investigation of challenges and recommendations for welcoming sexual and gender minority veterans into VA care. Prof Psychol: Res Pract. 2014;45(6):433-442.
49. American Association of Colleges of Nursing. The essentials of doctoral education for advanced nursing practice. http://www.aacn.nche.edu/pub lications/position/DNPEssentials.pdf. Published October 2006. Accessed December 1, 2016.
50. Boutain DM. Social justice as a framework for professional nursing. J Nurs Educ. 2005;44(9):404-408.
51. Poteat T, German D, Kerrigan D. Managing uncertainty: a grounded theory of stigma in transgender health care encounters. Soc Sci Med. 2013;84:22-29.
52. Thornhill L, Klein P. Creating environments of care with transgender communities. J Assoc Nurs AIDS Care. 2010;21(3):230-239.
53. Collins J. Nursing cultural competencies: Improving patient care quality and satisfaction. Ohio Nurses Rev. 2015;90(1):10-11.
54. Sherman MD, Kauth MR, Shipherd JC, Street RL Jr. Communication between VA providers and sexual and gender minority veterans: a pilot study. Psychol Serv. 2014;11(2):235-242.
55. Cowan L, Fasoli DR, Hagle ME, et al. Creating an infrastructure to advance nursing practice and care for veterans. Nurse Leader. 2013;11(5):33-36.
1. Greiner AC, Knebel E, eds. Health Professions Education: A Bridge to Quality. Washington, DC: National Academies Press; 2003.
2. Institute of Medicine. Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academy of Sciences; 2011.
3. Mintzberg H. The structuring of organizations: a synthesis of the research. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1496182 1979. Posted November 4, 2009. Accessed November 30, 2016.
4. U.S. Department of Veterans Affairs. VHA blue print for excellence. https://www.va.gov/health/docs/VHA_Blueprint_for_Excellence.pdf. Published September 21, 2014. Accessed November 30, 2016.
5. Morgan RO, Teal CR, Reddy SG, Ford ME, Ashton CM. Measurement in Veterans Affairs Health Services Research: veterans as a special population. Health Serv Res. 2005;40(5, part 2):1573-1583.
6. Grant JM, Mottet L, Tanis JE, Harrison J, Herman J, Keisling M. Injustice at every turn: a report of the National Transgender Discrimination Survey. http://www.thetaskforce.org/static_html/downloads /reports/reports/ntds_full.pdf. Published 2011. Accessed November 30, 2016.
7. Office of Disease Prevention and Health Promotion. Lesbian, gay, bisexual, and transgender health. http://www.healthypeople.gov/2020/topics-objec tives/topic/lesbian-gay-bisexual-and-transgender -health. Updated November 16, 2016. Accessed November 16, 2016.
8. Institute of Medicine Committee on Lesbian Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academy of Sciences; 2011.
9. U.S. Department of Veterans Affairs. VHA Directive 2013-003: Providing Health Care for Transgender and Intersex Veterans. Washington, DC: U.S. Department of Veterans Affairs; 2013.
10. Zucker KJ, Lawrence AA. Epidemiology of gender identity disorder: recommendations for the Standards of Care of the World Professional Association for Transgender Health. Int J Transgenderism. 2009;11(1):8-18.
11. Arcelus J, Bouman WP, Van Den Noortgate W, Claes L, Witcomb G, Fernandez-Aranda F. Systematic review and meta-analysis of prevalence studies in transsexualism. Eur Psychiatry. 2015;30(6):807-815.
12. Gates GJ, Herman JL. Transgender military service in the United States. http://williamsinstitute.law.ucla.edu/wp-content/uploads/Transgender-Military -Service-May-2014.pdf. Published May 2014. Accessed November 30, 2016.
13. Flores AR, Brown TNT, and Herman JL. Race and ethnicity of adults who identify as transgender in the United States. http://williamsinstitute.law.ucla .edu/wp-content/uploads/Race-and-Ethnicity-of -Transgender-Identified-Adults-in-the-US.pdf. Published October 2016. Accessed December 13, 2016.
14. Harris BC. Likely Transgender individuals in US federal administrative records and the 2010 census. https://www.census.gov/srd/carra/15_03_Likely_Transgender_Individuals_in_ARs_and_2010Census.pdf. Published May 4, 2015. Accessed November 30, 2016.
15. Kenagy GP, Bostwick WB. Health and social service needs of transgender people in Chicago. Int J Transgenderism. 2005;8(2-3):57-66.
16. Centers for Disease Control and Prevention. National intimate partner and sexual violence survey, 2010 summary report. https://www.cdc.gov/viole nceprevention/pdf/nisvs_report2010-a.pdf. Published November 2011. Accessed December 12, 2016.
17. Bauer GR, Travers R, Scanlon K, Coleman TA. High heterogeneity of HIV-related sexual risk among transgender people in Ontario, Canada: a province-wide respondent-driven sampling survey. BMC Public Health. 2012;12(1):292-291.
18. Devis-Devis J, Pereira-Garcia S, Valencia-Peris A, Fuentes-Miguel J, López-Cañada E, Pérez-Samaniego V. Harassment patterns and risk profile in Spanish trans persons. J Homosex. 2016. [Epub ahead of print.]
19. Gates GJ. How many people are lesbian, gay, bisexual, and transgender? http://williamsinstitute.law.ucla.edu/wp-content/uploads/Gates-How-Many -People-LGBT-Apr-2011.pdf. Published April 2011. Accessed December 1, 2016.
20. Center for Disease Control and Prevention. HIV Among Women. http://www.cdc.gov/hiv/group/gender/women/index.html. Accessed December 10, 2016.
21. Bauer GR, Scheim AI, Pyne J, Travers R, Hammond R. Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada. BMC Public Health. 2015;15(1):525.
22. McCann E. People who are transgender: mental health concerns. J Psychiatr Ment Health Nurs. 2015;22(1):76-81.
23. Green R. Transsexual legal rights in the United States and United Kingdom: employment, medical treatment, and civil status. Arch Sex Behav. 2010;39(1):153-160.
24. Sharpe VA, Uchendu US. Ensuring appropriate care for LGBT veterans in the Veterans Health Administration. Hastings Cent Rep. 2014;44(suppl 4):S53-S55.
25. Kauth MR, Shipherd JC, Lindsay J, Blosnich JR, Brown GR, Jones KT. Access to care for transgender veterans in the Veterans Health Administration: 2006-2013. Am J Public Health. 2014;104(suppl 4):S532-S534.
26. Snelgrove JW, Jasudavisius AM, Rowe BW, Head EM, Bauer GR. "Completely out-at-sea" with "two-gender medicine": a qualitative analysis of physician-side barriers to providing healthcare for transgender patients. BMC Health Serv Res. 2012;12(1):110.
27. U.S. Department of Health and Human Services. Key features of the affordable care act. http://www .hhs.gov/healthcare/facts-and-features/key-features -of-aca/index.html. Last reviewed November 18, 2014. Accessed December 1, 2016.
28. U.S. Department of Veterans Affairs. Federal benefits for veterans, dependents, and survivors. https://www.va.gov/opa/publications/benefits_book/Chapter_1_Health_Care_Benefits.asp. Accessed December 1, 2016.
29. HealthyPeople.gov. Lesbian, gay, bisexual, and transgender health. https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bi sexual-and-transgender-health. Updated December 1, 2016. Accessed December 1, 2016.
30. Lutwak N, Byne W, Erickson-Schroth L, et al. Transgender veterans are inadequately understood by health care providers. Mil Med. 2014;179(5):483-485.
31. Dorsen C. An integrative review of nurse attitudes towards lesbian, gay, bisexual, and transgender patients. Can J Nurs Res. 2012;44(3):18-43.
32. Eliason MJ, Dibble SL, Robertson PA. Lesbian, gay, bisexual, and transgender (LGBT) physicians' experiences in the workplace. J Homosex. 2011;58(10):1355-1371.
33. Carabez R, Pellegrini M, Mankovitz A, Eliason M, Ciano M, Scott M. "Never in All My Years...": Nurses' education about LGBT health. J Prof Nurs. 2015;31(4):323-329
34. Buchholz L. Transgender care moves into the mainstream. JAMA. 2015;314(17):1785-1787.
35. VA Boston Healthcare System. Patient Care Memorandum-11-046-LM. Management of transgender veteran patients. http://www.boston.va.gov/services/images/lgbt_patient_care_memo_transgender_care.pdf. Published May 2011. Accessed December 1, 2016.
36. Cronenwett L, Sherwood G, Pohl J, et al. Quality and safety education for advanced nursing practice. Nurs Outlook. 2009;57(6):338-348.
37. Institute of Medicine. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011.
38. Smith EL, Cronenwett L, Sherwood G. Current assessments of quality and safety education in nursing. Nurs Outlook. 2007;55(3):132-137.
39. World Professional Association for Transgender Health (WPATH).The standards of care. http://www.wpath.org/site_page.cfm?pk_association _webpage_menu=1351&pk_association_web page=4655. Accessed December 1, 2016.
40. University of California San Francisco Department of Family and Community Medicine. Center of Excellence for Transgender Health. http://www.tran shealth.ucsf.edu/trans?page=home-00-00 Accessed December 1, 2016.
41. Center for Disease Control and Prevention. Lesbian, gay, bisexual and transgender health. http://www.cdc.gov/lgbthealth/transgender.htm. Accessed December 1, 2016.
42. American Association of Colleges of Nursing. QSEN education consortium: graduate-level QSEN competencies, knowledge, skills and attitudes. http://www.aacn.nche.edu/faculty/qsen/competen cies.pdf. Accessed December 1, 2016.
43. Andrews MM, Boyle JS. Transcultural Concepts in Nursing Care. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.
44. Moran KJ, Burson R, Conrad D. The Doctor of Nursing Practice Scholarly Project: A Framework for Success. Burlington, MA: Jones & Bartlett; 2013.
45. Hanssmann C, Morrison D, Russian E, Shiu-Thornton S, Bowen D. A community-based program evaluation of community competency trainings. J Assoc Nurses AIDS Care.
46. Knapp H, Fletcher M, Taylor A, Chan K, Goetz MB. No clinic left behind: providing cost-effective in-services via distance learning. J Healthc Qual. 2011;33(5):17-24.
47. Kauth MR, Shipherd JC, Lindsay JA, Kirsh S, Knapp H, Matza L. Teleconsultation and training of VHA providers on transgender care: implementation of a multisite hub system. Telemed J E Health. 2015;21(12):1012-1018.
48. Sherman MD, Kauth MR, Ridener L, Shipherd JC, Bratkovich K, Beaulieu G. An empirical investigation of challenges and recommendations for welcoming sexual and gender minority veterans into VA care. Prof Psychol: Res Pract. 2014;45(6):433-442.
49. American Association of Colleges of Nursing. The essentials of doctoral education for advanced nursing practice. http://www.aacn.nche.edu/pub lications/position/DNPEssentials.pdf. Published October 2006. Accessed December 1, 2016.
50. Boutain DM. Social justice as a framework for professional nursing. J Nurs Educ. 2005;44(9):404-408.
51. Poteat T, German D, Kerrigan D. Managing uncertainty: a grounded theory of stigma in transgender health care encounters. Soc Sci Med. 2013;84:22-29.
52. Thornhill L, Klein P. Creating environments of care with transgender communities. J Assoc Nurs AIDS Care. 2010;21(3):230-239.
53. Collins J. Nursing cultural competencies: Improving patient care quality and satisfaction. Ohio Nurses Rev. 2015;90(1):10-11.
54. Sherman MD, Kauth MR, Shipherd JC, Street RL Jr. Communication between VA providers and sexual and gender minority veterans: a pilot study. Psychol Serv. 2014;11(2):235-242.
55. Cowan L, Fasoli DR, Hagle ME, et al. Creating an infrastructure to advance nursing practice and care for veterans. Nurse Leader. 2013;11(5):33-36.