In every area of nursing, knowledge and competence must reach beyond a foundational understanding of physiological concepts, applying the latest standards of care. This is especially important for the care of lesbian, gay, bisexual, and transgender (LGBT) individuals, for whom the nursing profession acknowledges disparities. Compared with cisgender (or heteronormative) patients, transgender individuals have lower insurance coverage rates and are likely to experience discrimination and a lack of cultural competence (Keepnews, 2011b; Lim, Brown, & Kim, 2014; U.S. Department of Health and Human Services, Office of Minority Health, 2013). In the past, nursing education deficits may have contributed to LGBT health care deficits (Eliason, Dibble, & DeJoseph, 2010; Lim, 2013; Rondahl, 2009) and, more broadly, to deficits in sexual health (Rowniak, 2014). In his poignant discussion of the nursing profession’s record on LGBT issues, Keepnews (2011a) proposed an agenda for change, including nursing curricula that consistently address LGBT health disparities and care. Yet, until now, LGBT-related education in nursing schools has not been studied, and, within the LGBT community, transgender individuals are the most vulnerable and underserved (Reisner, Perkovich, & Mimiaga, 2010; U.S. Department of Health and Human Services, 2011). According to Alegria (2011), as few as 10% of nursing students have a “basic level of knowledge regarding the care of the…transgender…population” (p. 175). The small-scale study described in this article assesses nursing education’s role in LGBT health care, focusing specifically on transgender people.
In a review of publications related to LGBT health in the top 10 nursing journals, Eliason, DeJoseph, Dibble, Deevey, and Chin (2011) found only one article published between 2005 and 2009 that included the keyword transgender; in fact, only 0.16% of all articles from that period addressed LGBT content. That only eight of 4,941 published articles addressed LGBT content is telling, and that only one of those eight mentioned the word transgender is even more so. Therefore, the current literature search, conducted via a Website that provides access to 21 nursing and medical databases, was likely to find similar results. Databases were excluded if they did not permit individual keyword searches and if their titles were clearly unrelated to the search. Ultimately, the following 10 databases were searched for publications: The U.S. Department of Health and Human Services’ Agency for Healthcare Research & Quality database ( http://www.ahrq.gov), Alt HealthWatch™, Academic Search Complete™, CINAHL®, Cochrane Database of Systematic Reviews, Gale Health Reference Center Academic®, Health Source®: Nursing/Academic Edition, MEDLINE®/PubMed®, MEDLINE/EBSCOhost, and Medscape. Searches were conducted using the following keywords: transgender + nursing + education + content. This yielded 40 hits; duplicates were then discarded, leaving 25. The resulting articles were then searched for the terms trans, transgender, transsexual, and transvestite, leaving a total of 19 articles. Those 19 articles were searched for mention of nurse or nursing. The searches for transgender and then for nurse or nursing left 12 of 25 relevant documents. All 12 articles mentioned education; 11 were positive for nursing education or curricula.
Repeated throughout these remaining documents was a common theme—that there is often little and sometimes no transgender-related or intersex content in contemporary nursing curricula. Some quotes selected from the documents include:
- There is a limited amount of core LGBTI content included in nursing curricula. (Brennan, Barnsteiner, Siantz, Cotter, & Everett, 2012, p. 96)
- Nursing curricula devote inadequate attention to LGBT families. (Burkholder & Burbank, 2012, p. 13)
- Nursing curricula should include “more LGBT content.” (Dorsen, 2012, p. 19)
- There is either “inadequate” (Eliason et al., 2010, p. 207) or “very little” (p. 208) nursing education on LGBT concerns.
- There is a “historic lack of attention to LGBT education…in nursing education.” (Eliason et al., 2011, p. 243)
- [A] connection can be made between the lack of curricula and teaching on LGBT health and the insensitive, uninformed care this population faces. (Lim & Bernstein, 2011, p. 173)
- Social workers (84.6%) and counselors (81.5%) were more likely than school nurses (55.8%) to report moderate or high knowledge of LGBT youth health risks. (Mahdi, Jevertson, Schrader, Nelson, & Ramos, 2014, p. 18)
- There is a paucity of evidence relating to paediatric tertiary hospital staff knowledge, attitudes and beliefs towards LBGT parents accessing care for their children. (Nicol, Chapman, Watkins, Young, & Shields, 2013, p. 3397)
- There has been limited identification of core LGBTI [LGBT and intersex] experience concepts that should be included in the nursing curricula. (Brennan et al., 2010, p. 96)
In an effort to address this deficit in nursing curricula, Strong and Folse (2015) created an intervention that resulted in a statistically significant increase in nursing students’ pre- and postknowledge and attitudes around LGBT care, specifically covering terminology, disparities, medical needs, and communication. Also documenting a significant increase in nursing students’ knowledge of related LGBT care, Carabez, Pellegrini, Mankovitz, Eliason, and Dariotis (2015) successfully devised innovative teaching methods, embedding the content within a public health course.
To varying degrees, each of these studies makes recommendations for LGBT content for health care providers, and for nursing in particular, citing “gaps in LGBT-related topics in all levels” (Lim, Brown, & Jones, 2013, p. 200). Lim and Bernstein (2011) pointed out that 150 medical schools averaged only 5 hours dedicated to LGBT-related topics in the medical curricula (Obedin-Maliver et al., 2011). Focusing on health care providers, Surreira (2014) attempted to bridge this gap by creating an LGBT educational program that is deliverable in primary care, focusing on communication. Only two studies of LGBT education in nursing programs were found, although none were specific to the most vulnerable population—the transgender population. The current study appears to be the first to poll nursing schools about education related to caring for LGBT clients and focusing on the transgender population in these curricula.
Transgender-Related Education in Texas Nursing Schools
Like the literature review conducted for this study, the current survey represents an attempt to discover whether the concepts of transgender, gender identity, and gender dysphoria—discontent with the sex assigned at birth or the gender roles associated with that sex—are taught in nursing programs, using Texas as an example. Is transgender health care education the norm or the exception?
Approval by the university institutional review board was obtained in fall 2013 to conduct an Internet-based survey of Texas nursing schools. A 12-question survey was distributed to 113 “Texas Approved Professional Nursing Education Programs,” as listed on the Texas Board of Nursing Website ( https://wwwbon.state.tx.us/pdfs/education_pdfs/education_programs/ApprovedRNschools.pdf). This study was generated by a prelicensure rotation, where the primary author (D.W.) was assisting in the care of a transwoman, at which time his preceptor referred to said client unprofessionally, highlighting for the research a lack of empathy and understanding of this underserved patient demographic. The second author (S.G.H.) has extensive research experience with underserved populations and was a member of the clinical nursing faculty at her university during this formative experience. The primary author turned to area resources, such the Transgender Education Network of Texas (TENT), in an effort to hold informal dialogues with members of the Central Texas transgender community to better understand transgender individuals’ experiences in the health care system. The survey was informed in part by these dialogues, which yielded, for example, the following insight from a transgender interviewee: “It’s like, you are the medical professional! How do you not know these things?” (D.D., personal communication, October 5, 2013) and “I’m a person no matter what box I check” (L.W., personal communication, October 12, 2013). In addition, the survey questions were developed using the literature, specifically by drawing on resources that identify terminology and treatment that clinicians need to know (e.g., the Center of Excellence for Transgender Health, 2011). The survey was distributed via SurveyMonkey™, using a Verisign™ certificate and 128-bit encryption, in compliance with the Health Insurance Portability and Accountability Act of 1996. Potential respondents were advised that their data would be kept anonymous.
Owing to multiple nursing programs at two institutions, 111 surveys were distributed to the 113 nursing schools in Texas. Ten of the 12 survey questions required a yes or no response. The response rate was 21 of 111 (18.9%), and, of those, 19 (90.5%) of the respondents answered the 10 yes or no questions fully. The survey also contained two questions requiring a nondichotomous response; 11 (52.4%) of the 21 respondents completed the survey in its entirety. The yes or no questions addressed three topics: transgender health care curriculum content, clinical care, and psychosocial care of the transgender client (see the Table for the yes or no survey questions and results).
Texas Nursing Schools’ Transgender Education Survey Results for Yes or No Questions
Addressing Transgender Content. Ten of 21 respondents (47.62%) affirmed providing nursing students with content broadly addressing transgender or transsexual individuals. Twelve (57.14%) of the 21 respondents reported teaching the concept of gender identity, and six (28.57%) of the 21 respondents reported teaching the differences among the terms transvestite, transgender, and transsexual.
Clinical Care. Schools were also asked whether they taught nursing care for the gender-reassigned patient. Three (14.29%) of the 21 respondents did report teaching care for these patients.
On questions about transitioning, three (15%) of 20 respondents thought their students would know a referral source for the transgender patient, and one (5.26%) of 19 respondents thought that their students would know medical–surgical therapy options for transgender patients. (One response stated that the respondent did not “know what my students know.”)
None of 20 respondents reported teaching the World Professional Association for Transgender Health’s (2014, pp. 8–65) standards of care, considered the “gold standard.” No evidence-based guidelines, such as those in McNair’s and Hegarty’s review (2010), were mentioned.
Psychosocial Care. When respondents were asked whether they thought their students would know where to find resources for the transgender client, eight of 20 (40%) thought that their students did. Seven of 21 respondents (33.33%) reported teaching the gender dysphoria diagnosis in the the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Association, 2013), and five of 21 (23.81%) reported teaching psychosocial support techniques.
Classroom Hours and Incorporating LGBT Education Into Nursing Programs. The last two questions called for responses regarding total transgender content hours and the incorporation of transgender content into the respective programs. Fifteen of 21 respondents answered the first question; those representatives’ programs averaged 1.63 hours of LGBT content, with a median of 1.5 hours. None of the 15 respondents reported more than 4 total hours of content, and four of the 15 respondents reported no hours at all. One respondent added that content was “Unfortunately, very limited,” and another wrote there was “NOT ENOUGH!!!”
Survey recipients were also asked to describe ways in which transgender education was, or potentially could be, incorporated. Ten responses were submitted, and, of those respondents, three replied that they did not think that transgender education could be incorporated. Another wrote that to add or increase transgender health care concepts within the curriculum, those concepts “would need to be a part of the NCLEX-RN® blueprint and included in textbooks.”
The findings of the current review and survey suggest three implications for nursing. First, nursing schools are responsible not only for teaching students how to integrate LGBT standards of care into their practice but also for requiring faculty competency in teaching this content. The low response rate may indicate a more conservative faculty than might perhaps be found in states where social norms are thought to be more progressive. The small sample size prevents a conclusive answer as to whether LGBT education is the norm or the exception in Texas.
Second, because nursing schools focus entire courses on underserved populations, in those classes they should recognize the health care needs of the most vulnerable LGBT community—transgender people—just as they do for those of other segments of priority populations experiencing health care disparities. This can be done beyond the classroom, as well; in addition to the five survey respondents who reported covering LGBT content in their mental health courses, Jones and Smith (2014) reported incorporating this content in a vulnerable population advocacy activity in their school’s public health curriculum.
If nursing curricula do not reflect a faculty’s conscious effort to include current transgender content, nursing schools risk contributing to societal stigma. Still, nursing schools are not uniquely negligent. “Transgender patients are particularly vulnerable in healthcare,” said Meghan Stabler (personal communication, August 13, 2013), a member of the President’s LGBT leadership circle. She stated, “They can face long waits for care, pointing, laughter, negative comments…denial of (or challenges to) bathroom use and room assignments that reflect the sex assigned to them at birth, rather than their actual gender identity.”
A final implication of the current literature review and survey is that LGBT-related nursing care should be integrated into existing nursing school courses. Evidence-based practice guidelines exist (Lim et al., 2014). As Brennan et al. (2012) stated, faculty must themselves identify the best fit for such content, but clear examples can be found. Unfortunately, the current research suggests that at least in some Texas nursing schools, students may not be receiving adequate education, given the reported average of 1.6 hours of LGBT content in 15 Texas nursing programs. Nursing education can do better for this priority population.
With respect to the limitation of outcomes, it should be mentioned that one survey question asked how many hours the respondent’s programs spent on LGBT content. Although this wording did allow schools to reference the broadest topic of LGBT health, it did not allow a specific result for transgender health. Also, three questions asked “Do students know…?” about aspects of transgender care, rather than whether those aspects were taught in the curriculum; the latter might have been a better measure. The expectation is that at least the 10 schools that responded “yes” impact nursing students’ awareness of transgender culture and health needs but, as noted by Sumpter and Carthon (2011), although faculty may teach cultural content, their students may not perceive it as adequate, or, in some cases, as even existent.
This research study had a small sample size and a limited response rate. The authors approached a broad topic that has far-reaching implications, with the narrower research objective of determining what, if any, transgender education is being provided to Texas nursing students, in the hope that these results might inform further inquiry. Generalizing the results of the survey to all nursing schools in Texas is not possible and whether respondents differed from nonrespondents in any way, and, if so, how they might have differed, cannot be determined. Challenges abound, yet nursing education moves forward—one study at a time.
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- Center of Excellence for Transgender Health, University of California, San Francisco, Department of Family and Community Medicine. (2011). Primary care protocol for transgender patient care. Retrieved from http://transhealth.ucsf.edu/trans?page=protocol-00-00
- Dorsen, C. (2012). An integrative review of nurse attitudes towards lesbian, gay, bisexual, and transgender patients. Canadian Journal of Nursing Research, 44(3), 18–43.
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Texas Nursing Schools’ Transgender Education Survey Results for Yes or No Questions
|Dichotomous Survey Item||Yes Responses (%)||No. of Yes Replies/Total No.|
|Does your class or curriculum address transgender or transsexual individuals?||47.62||10/21|
|Do you teach the difference between transvestite, transgender, and transsexual?||28.57||6/21|
|Do you teach nursing care for gender-reassigned patients?a||14.29||3/21|
|Do you teach psychosocial support techniques for counseling transgender youth or adults?||23.81||5/21|
|Do you teach the concept of gender identity?||57.14||12/21|
|Do students know to whom they can refer a transgender patient considering transitioning?||15||3/20|
|Do you teach the gender dysphoria diagnosis in the The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition?||33.33||7/21|
|Do students know hormone therapy and psychosocial support options for transgender patients?||5.26||1/19|
|Do you teach World Professional Association for Transgender Health standards of care?||0||0/20|
|Do students know where to look for transgender resources?||40||8/20|