How can we be more inclusive towards transgender patients?

Nurse lecturer Claire Blake gives her perspective on ensuring the best healthcare for transgender patients in primary care, drawn from her experience of working within sexual health and at a private transgender healthcare clinic

Let’s start at the beginning. Who are transgender people? A transgender – or trans – person is anyone who’s gender is different from the gender they were thought to have at birth. The last UK census in 2021 showed there were then 262,000 people identifying as trans or non-binary.¹ However, the true number may be larger than that. 

Some people think being trans or non-binary is a new ‘trend’, but the first people to undergo hormone treatment and surgeries did so many decades ago. In the 1940s, Michael Dillion became the first trans man in the world to transition from female to male. Christine Jorgensen, a trans woman in the US, started gender reassignment surgery in 1951, the same year that Roberta Elizabeth Marshall Cowell became the first British trans woman to undergo surgery.²

Some people – including some working in primary care – may have a judgmental opinion on transgender people, but of course trans people are human beings, with families, jobs and hobbies just like everyone else, and should be treated accordingly. 

In our profession specifically, for trans people to receive the best standards of health and social care, nurses and other clinicians must be properly informed. This will help remove barriers to care and communication, and to address health inequalities for this group of patients. 

Unfortunately, social and broadcast media rarely offer a positive or realistic representation of trans communities. It is important for us all to do our own research so that we can be suitably prepared for our next consultation or visit with a transgender person. 

The importance of being informed 

I first became passionate about education around transgender patients and transgender health as a general practice nurse in March 2021. I had my first trans patient sitting in front of me in a consultation and realised I had no training or awareness of the hormones the patient was receiving and how this treatment affects the body, or about the experiences of trans patients within our healthcare system. 

I spent the next couple of years researching everything that I could find on the subject, and then set up webinars to help educate other healthcare professionals. I then started working in a private transgender healthcare company as a nurse, in order to gain more experience and knowledge around the transition process and to try to make a difference. 

I have worked at the company for more than a year now, alongside teaching. 

Why is this important? Because every patient, regardless of their gender, sexuality, race or ethnicity deserves the same standard of treatment. Unfortunately, there is evidence of a lot of discrimination and inequality faced by trans patients. The authors of LGBT in Britain – Trans Report found that 41% of staff within healthcare services lacked knowledge of transgender healthcare needs.³ A Dutch ‘chart study’ in 2020  showed suicide rates were higher in transgender people than among the general population.⁴ It is so important that we get it right for our trans patients and help them in the same way as we would anyone else. It could make a huge difference to them – and it could even save a life. 

Note also that ‘gender reassignment’ is among the protected characteristics in the Equality Act (2010)⁵, and this also covers people who have not yet had hormone treatment or surgery. Regardless of our own opinions, we must all be mindful when speaking on this publicly to others, as it may hurt someone and may have a negative impact on someone’s mental health and wellbeing. Healthcare professionals can also be reported to the NMC for behaviour that contravenes discrimination policy, and also to the police, and action can be taken against them. The Equality Act defines four different types of gender reassignment discrimination⁶:

1. Direct discrimination: when someone treats another person unfairly because they are transgender. 
2. Absences from work: when a transgender person is treated differently due to taking leave of absence for reasons arising from gender reassignment. 
3. Indirect discrimination: when ways of working or workplace policies put transgender people at a disadvantage compared with others. 
4. Harassment: when someone makes a person feel degraded, ashamed or offended in relation to gender reassignment. This could include deliberately misgendering someone (identifying their gender incorrectly by using an incorrect label or pronoun).

Inclusive healthcare 

‘How can we be more inclusive for transgender patients?’ is a common question I hear from many student and qualified nurses. 

As part of my own research, I have spoken with trans people to gain a better understanding of what it means to be transgender, and how it affects them physically, mentally and socially – but most of all of how healthcare professionals can do better for them as our patients. 

Here are some suggestions for how best to achieve this: 

• Ask the person about themselves. Every patient is different and may go by different pronouns or be going through different hormone treatment. So, if you don’t know, just ask; they would rather you ask than make assumptions and get it wrong. 
• Use of pronouns. Telling someone your pronouns and asking theirs can be an effective way to reassure someone from LGBTQIA+ (lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual) communities that you are a safe person to talk to. 
• Do not judge anyone for who they are. This is part of the NMC Code⁷, as well as that of the General Medical Council. We should always approach patients from a non-judgmental standpoint. 
• Use the name they want you to use. The person’s birth name may be documented in the notes, but if they tell you they’ve changed their name with their gender, use that. Otherwise, you risk causing unnecessary distress. 
• Be mindful when doing intimate examinations. Take your time, respect the person and be mindful that they may have different transgender undergarments, such as a binder for their chest. 
• Listen to your patient. Listen to hear what they are telling you, rather than in order to reply.
• Have LGBTQIA+ friendly posters or articles, and perhaps the Pride Progress flag, visible in your waiting room. The flag has 11 colours to represent a rainbow and inclusivity, and is a symbol of hope. 
• Invite someone to your surgery or clinic to give a talk to and educate your team around trans patients.
• If a patient’s health issue doesn’t concern their genitals, don’t ask about them. We don’t need to know what someone’s genitals are if there is no problem in that area. Broaching the topic without good reason can trigger discomfort or distress. 
• Don’t ask to see pictures of what the person looked like before. Doing so can also be triggering.

There are currently limited specific education and training resources on transgender. However, an e-learning package on Future Learn has been created by healthcare professionals at St George’s, University of London.⁸ This is recommended to clinical colleagues who wish to gain more knowledge around transgender patients and the treatments and surgeries they may go through.

Transition processes

Not all transgender people will go through hormone and surgical procedures, and each person’s journey is different. Equally, not every trans person will struggle with gender dysphoria, which is the discomfort experienced by someone who has a mismatch between their biologic sex and their gender identity.

People will go through different processes to transition from one gender to another. 

The first thing people may initiate is a social transition, which includes but is not limited to: 

• Change of name and pronouns.
• Change of social media profile to update others.
• Talking to their family and friends.
• Telling their GP/nurse and having their details updated on the practice system.
• Change of personal appearance through clothing changes and make-up.

The next thing may be to medically transition (although not everyone will). This may involve: 

• Getting a referral from the GP to a gender identity clinic (GIC). There are guidelines for GPs and nurses to help with this process on the NHS GIC website (see resources). A GIC is a gender-specialist clinic that reviews transgender patients and can initiate hormones and refer for surgeries. This is a long process for patients who choose to go through it, so they will need thorough assessments, mental health checks and counselling before they are prescribed hormone treatments. However, the wait time is very long, and patients should be warned they could wait four to five years for their first appointment (my husband has so far waited four years).
• Starting hormone treatment. Hormones should be started at as low a dose as possible for the patient and reviewed with bloods and blood pressure every three months for the first year. If levels are stable, they can move to six-monthly and then annual reviews, according to the World Professional Association for Transgender Health standards.⁹ The aim of hormones is to make changes to their body physically to align them with their gender; bloods should be in the target range for their gender rather than biological sex. The hormones include: 
  – Trans feminine pathway – oestrogen and/or hormone blocker. 
  – Trans masculine pathway – testosterone and/or hormone blocker (a blocker is not needed for trans men unless they show unwanted symptoms of monthly periods, or puberty for youths, in which case a blocker may be used to stop these). 
  – Trans non-binary people may also choose to take hormones, depending on which route they wish to align their body with. 

Surgical procedures (surgeries are referred to in the trans community as ‘top’ and ‘bottom’ surgeries): 

• ‘Top surgery’ for trans women – breast augmentation. 
• ‘Top surgery’ for trans men – double mastectomy. 
• ‘Bottom surgery’ for trans women – this comes in several forms: 
  – Removal of the testes (orchidectomy).
  – Removal of the penis (penectomy).
  – Construction of a vagina (vaginoplasty).
  – Construction of a vulva (vulvoplasty).
  – Construction of a clitoris (clitoroplasty).

• Bottom surgery for trans men: 
  – Construction of a penis (phalloplasty or metoidioplasty).
  – Construction of a scrotum (scrotoplasty) and testicular implants.
  – Penile implant.

Other surgery for trans men, removal of the womb (hysterectomy) and the ovaries and fallopian tubes (salpingo-oophorectomy), may also be considered.¹⁰

Legal considerations of transition

How does someone start to transition legally? A Gender Recognition Certificate (GRC) allows a person’s gender to be registered legally in the UK. However, people do not need a GRC to change their gender and name on legal documents such as their passport, driving licence, HMRC record or GP record. All that is needed is a deed poll and a letter from a UK-based doctor or psychologist. A GRC is only required to get married, and to die with dignity in the gender they are – people who are transgender need a GRC to legally marry in their current gender, and also for their gender to be applied to their death certificate. If they do not have a GRC in place, then legally their biological sex will be recorded on the certificate by default. If a trans person wishes to marry without a GRC, their birth sex will be on the marriage certificate; if they have changed their name by deed poll, their new name can be used but must be followed by ‘formerly known as’ and their birth name.

A GRC application can be made on the gov.uk website.¹¹ The person will need evidence to show they have been living in their gender for two or more years prior to the application; this can be in the form of a deed poll, a statutory declaration, payslips, utility bills or medical letters. They also need two separate statements from UK-registered doctors, or one from a doctor and one from a psychologist. One of these must be a gender specialist. This is all submitted online with an application fee. The government panel will assess the evidence and make a decision (an application can sometimes be declined). As of May 2023, the current wait in the UK was around six months for evidence to be taken to the panel, due to a backlog in applications.

Claire Blake and her husband George Blake, a transgender man, offer education on transgender health online, at gc-health.uk

Resources

For patients:

• Gender GP: Resources with different guidelines, policies and documents to help you care for your patients. Link
• Human Fertilisation and Embryology Authority: Information for trans and non-binary people seeking fertility treatment. 2022. Link
• Patient information on how to safely chest bind 2021. Link
• CQC: Adult transgender care pathway guidelines. 2022. Link
• What is genital tucking? Link

For professionals:

• Department of Health (2009) Guidance on NHS patients who wish to pay for additional private care. Link
• Endocrine Society. Endocrine treatment of gender-dysphoric/gender incongruent Persons. 2010. Link
• NHS England. Delivering same sex spaces for transgender people. 2019. Link
• NHS Gender Identity Clinic. Clinical information and guidance for hormone therapy. Link
• NHS GIC resources. Link
• NHS Sunderland. Guidelines for the use of feminising hormone therapy in gender dysphoria. 2015. Link
• Pride in Practice. Chest binding: A physicians guide. 2019. Link
• Royal College of Physicians. Good practice guidelines for the assessment and treatment of adults with gender dysphoria. 2013. Link
• Time from first onset chest binding related symptoms in transgender youths. Link
• Understanding the effects of lung function when using a binder: Link 
• Understanding the impact of chest binding or genital tucking. Link
• World Professional Association of Transgender Health. Link

References

1. 2021 census: What do we know about the LGBT+ population? Link
2. Hudson A. Trans pioneers: Michael Dillon & Roberta Cowell. 2021. Link
3. Bachmann C and Gooch B. LGBT in Britain – Trans Report. 2017.  Link
4. Wiepjes C et al. Trends in suicide death risk in transgender people. Acta Psychiatrica Scandinavica 2020;141:6:486-491. Link
5. Equality Act 2010: Protected characteristics. Link
6. Equality Act 2010: Gender reassignment discrimination. Link
7. NMC Code: Being inclusive and challenging discrimination. Link
8. Future Learn. Transgender healthcare: Caring for trans patients. Link
9. World Professional Association for Transgender Health standards. 2022. Link 
10. NHS. Treatment: gender dysphoria. 2020. Link
11. Gov.uk. Apply for a Gender Recognition Certificate. Link
12. Stonewall. A beginner’s guide to pronouns and using pronouns in the workplace. 2022. tinyurl.com/Stonewall-pronouns