Project Overview

• Health Inequity:  Inadequate caregiver training and non-affirming traumatic experiences in healthcare results in inequitable health outcomes for transgender and gender diverse individuals and communities. Distrust of healthcare providers and the healthcare system is associated with numerous poor health outcomes, including poor medication adherence, poorer health outcomes, increased mortality from cancer, HIV risk, and vaccine hesitancy. In addition, distrust of healthcare providers and systems can result in poor adherence to public health measures during public health emergencies, such as the COVID-19 pandemic. 

Transgender individuals have increased risk of all-cause mortality as compared to the cisgender population. The 2022 US Trans Survey Health and Wellness report found that 34% of trans individuals report "fair" or "poor" health compared with 18% of the general population. While the vast majority (98%) of patients on gender affirming hormone therapy and 97% of individuals who received gender affirming surgeries reported increased life satisfaction as a result of those interventions, barriers to accessing that care continue to be a major stressor for trans people. In addition, 47% of trans people who responded to the survey who had seen a provider in the last year reported having at least one negative interaction, and 24% of respondents reported avoiding needed care out of fear of mistreatment. 

Despite the evident link between provider and caregiver mistrust and poor health outcomes, training for nurses on the care needs of the trans and gender diverse community is lacking, and nurses, in particular, receive on average just 2.12 hours of training on care for the LGBTQ+ community, and less for trans patients. 

• HECP Approach: Working with input from trans and gender-diverse individuals, a 4-module training course was created for practicing and pre-licensure nurses that covers trans identities and language, social determinants of health, and trauma informed nursing skills for providing best practice nursing care for trans patients. Best practice was evaluated using the WPATH Standards of Care, the American Nurses Association Nursing Code of Ethics, principles of trauma informed care, and community based research. 

The final output will be published by Toadhenge Consulting on AskMissJai.com, available for purchase by individuals and organizations. This training fills a gap as current federal policy works towards restricting access to information on gender affirming care at all levels of education. 

• Structural Change Impact: Today's nurses are tomorrow's healthcare leaders. Nurses represent the largest portion of the healthcare workforce, including registered nurses, nurses aides, practical nurses, and advanced practice nurses, and nurses often hold positions of power and leadership within healthcare organizations. While current education exists for doctors and other providers on trans health, there is a shortage of nursing-focused education that includes practical nursing skills, including assessment and care planning for trans and gender diverse individuals. 

By addressing this gap in knowledge, this project attempts to inform not only individual nurses, but create structural change within the organization that nurses work within.

• HECP Proposal:

Project Outputs

• Educational Module Slides-  The foundations for the final education modules with scripting. 

• Final Module Recordings- Final module videos.

• Foundations of Gender Affirming Care Workbook and Resources- The companion workbook and resources and bibliography for the project. 

• Community Survey- Survey is provided, results are confidential to protect participant anonymity. 

• Final Integrated Learning Experience- My Integrated Learning Experience is an APHA policy proposal recommending the inclusion of trans affirming healthcare education as a condition for nursing licensure. In addition, it calls for an increase in funding for trans research and an immediate end to federal restrictions on research into trans healthcare. 

Foundational Competency 9: Design population-based policy, program, project or intervention.

By using community member experiences in the final education curricula, in addition to formal research and statistical analysis, this project directly includes the lived experiences of the transgender and gender diverse community, and provides the learners with unique, human perspectives on the impact of the care that they provide. 

Deliverables: HECP Proposal, Final Education Modules

Foundational Competency 6: Discuss the means by which structural bias, social inequities and racism undermine health and create challenges to achieving health equity at organizational, community and societal levels.

Module Two of the final product outlines the Social/Ecological model of social determinants of health, and how these factors impact transgender and gender non-conforming individuals and communities. By approaching social, political and interpersonal factors and how they result in inequitable health outcomes, the education is designed to inform students not just how trans individuals are impacted by structural bias, but also how these factors can impact all communities. 

Deliverables: Final Education Modules

Foundational Competency 21: Integrate perspectives from other sectors and/or professions to promote and advance population health

The final education modules are designed for pre-licensure nurses, and include nursing specific information and pedological frameworks, including nursing assessment and care planning. In order to create this curricula, I collaborated with a nursing educator, ensuring that these portions of the education was audience appropriate and actionable. In addition, due to the mental health component of providing care to trans and gender diverse individuals, I worked with a trans mental health provider to review the curricula. 

Deliverables: Final Education Modules, 

Concentration Competency 4: Employ skills of community organizing, advocacy, and participatory methods to engage community members in assessing and/or addressing community health issues.

Using direct quotes from community members in the final curricula highlights the real world impacts to the trans and gender diverse community of social determinants of health and non-affirming care. My partner organization, Toadhenge Consulting, is trans-owned and operated. In addition, the work completed reflects my own experiences as a transgender individual. 

Deliverables: Final Education Modules, Community Survey

Concentration Competency 19: Communicate audience-appropriate public health content, both in writing and through oral presentation to a non-academic, non-peer audience with attention to factors such as literacy and health literacy.

The Final modules are designed for pre-licensure nursing students with a limited public health knowledge base, but basic medical/surgical nursing knowledge and literacy. Nursing knowledge is assumed to be at a foundational level, with basic assessment and care planning skills. Knowledge of transgender identities and public health knowledge is presented at a basic level, assuming no prior knowledge. 

Deliverables: Final Education Modules, Educational Workbook and Resources

Supporting Healthy Outcomes for Transgender and Gender-Diverse Individuals through Nursing Workforce Education 

Competencies demonstrated

• Foundational Competency 6: Discuss the means by which structural bias, social inequities and racism undermine health and create challenges to achieving health equity at organizational, community and societal levels

• Foundational Competency 13: Propose strategies to identify stakeholders and build coalitions and partnerships for influencing public health outcomes

• Foundational Competency 15: Evaluate policies for their impact on public health and health equity

• Concentration Competency 2: Analyze systems of oppression and structural-level determinants of health, including racism and other forms of marginalization, drawing parallels to patterns of health disparities.

Summary

My ILE, written as a policy paper for the American Public Health Association, demonstrates the relevant competencies by defining and describing how transphobia and cissexism within the healthcare system at government, organizational and interpersonal levels result in inequitable health outcomes for trans and gender diverse individuals. In addition, the paper examines how public health infrastructure is being further politicized and weaponized against trans people resulting in an overall deterioration in equitable care and potential worse outcomes for this already vulnerable population. By proposing that healthcare workers are exposed in a pre-licensure setting to trans people and trans issues, I hope to build a workforce that is sensitive to the needs of the community, and has actionable tools to both prevent further harm within the system, but also is resilient against current political trends and are more likely to become future advocates for the community within their own systems and settings. 

Integrative Learning Experience

This project would never have been completed without the help of the following individuals:

• My incredible mentor Miss Jai Smith. My presentation and education skills went from "nearly non-existent" to "not bad" with your patient support and guidance!

• My partner, Lorrie, who kept our lives together while I spent my nights and weekends buried in research. My sons Jasper and Milo for being the reason I want to work to make the world a better place. 

• Dr. Haynes and Dr. Wolongevicz and all the Simmons MPH staff and instructors for all the guidance and patience. There were so many times I worried I wouldn't make it through, but you kept me going!

• My classmates for being constantly supportive and inspiring. You all give me hope for a better world!

• My survey respondents for being open, vulnerable and honest. This is all for you, and for every trans person out there who has suffered at the hands of a provider who didn't see you and your magic. 

• My collaborators who looked over my project to tell me when I was way off base and when I had it right.

• So many others I am forgetting here!