For this week of LGBTQ Pride Month, we continue our thematic exploration in Trans Issues. In an original podcast, Wiley’s Senior Marketing Manager Kathleen Mulcahy interviews Orvis School of Nursing’s Dr. Christine Aramburu Alegría on her clinical practice article titled, “Gender nonconforming and transgender children/youth: Family, community, and implications for practice,” published in the Journal of the American Association of Nurse Practitioners. Along with podcast, we have also included a transcript below.
Don’t forget to come back each Monday as we post articles and think pieces from Wiley authors and LGBTQ advocates centered around a unique theme. Thanks for joining us as we continue the necessary conversation on LGBTQ rights, awareness, and support.
Kathleen Mulcahy: I’m talking today with Christine Aramburu Alegria, who is an Associate Professor at Orvis School of Nursing in Reno, Nevada and author of a paper titled, “Gender Nonconforming and Transgender Children/Youth: Family, community, and implications for practice,” published in the Journal of the American Association of Nurse Practitioners. Christine, welcome.
Christine Aramburu Alegría: Well thank you so much for taking the time to talk with me today and for profiling the article. Hopefully our talk and the article can be of help to NPs and other providers.
KM: Sounds great! The first question I wanted to ask you, Christine, is: if you could give us a little bit of background on this clinical practice paper and why you were interested in the topic?
CAA: Thank you, yes. Well, first of all I’ve been studying issues related to trans people and their families and other relationships for about ten years now. So, before it became a hot topic, so to speak. I’ve seen firsthand the challenges and real distress that trans people live with, particularly when I first started researching this area. There was very little research published then, and of course, now we know that it’s very prominent all with [what] we’re seeing in the news and media, especially the bathroom issue and that sort of thing.
So, all of this awareness is great; however, with this awareness comes a real responsibility to get past the hype and to know the situation and issues that may accompany it. So, my aim with this clinical paper is to provide a foundational knowledge for NPs and other providers. Hopefully they can develop at least a basic familiarity so that when they do encounter a patient with perhaps gender identity issues it isn’t quite so daunting or foreign or intimidating. And they can then know how to take just at least the initial steps towards addressing needs.
KM: Can you tell us what percentage of our youth that this is affecting worldwide?
CAA: You know, I really, really wish I could. It’s really hard, if not impossible, to know how many trans children, or trans youth, there are worldwide — or even here in the United States. What would be extremely helpful is if the Census Bureau sought that data, perhaps through a question that asked if there are people in the household who identify differently from their birth sex. If we had a more solid number, this of course could influence research, funding, policy, and other educational ventures.
But what I can tell you is that referrals to gender clinics are growing rapidly both here in the United States and abroad. Some clinics are seeing a fourfold increase or more in the number of referrals. And this is, again, because of the awareness…because, of course, the population is still marginalized, still faces many, many difficulties…however, it is more out in the open. Talk to many people now, and they will say that they somebody — or know somebody that knows somebody — that is gender nonconforming or transgender.
So people are more ready to seek help earlier. Also, a greater number of primary care providers are seeing families who present with a gender-nonconforming child. Parents and guardians may come in with concerns about behavior that is not “gender appropriate”. Pediatric endocrinology offices are seeing greater numbers of youth who are coming in with their families seeking perhaps puberty suppression or cross-gender hormones. So, I don’t have a solid number for you, but referrals are increasing rapidly.
KM: Alright, thank you. So you talked a little bit about how nurse practitioners might use this information. Can you give us a little bit more information about how that might improve the patient care of this population of patients?
CAA: Sure. Well first of all, I believe that all NPs and healthcare providers should have at least a foundational knowledge on transgenderism. You know, many schools of nursing, many medical schools and other schools of healthcare providers are being very proactive and increasing this education in their curriculum now. Not all are, but many are. And in fact, in—I think it is Washington D.C., it is now required that all providers get at least a basic knowledge of transgender-appropriate healthcare. So that’s just kind of an aside to let you know how the awareness and the need for education is growing.
But to get back to your question on improving patient care of this population — you know we realize that NPs and other providers may not have an in-depth knowledge. Perhaps, their practice hasn’t led to an in-depth knowledge, and that is okay. So what’s important for providers to know is with whom to consult and where to refer their clients to.
Another way of improving patient care, and it’s one of the most critical and beneficial ways, is that providers can connect with their patients through nonjudgmental and compassionate care, really listen to concerns. And of course — you know I realize this may sound cliché — but without these basics of compassionate care, a therapeutic relationship really is not possible. Patients won’t disclose completely, and plans of care won’t be adhered to unless trust and rapport is established.
And again, the population knows that providers may not have all of the answers, and that’s okay. More often than not, they’re willing to help educate providers, and it’s also the providers’ responsibility to take the time to learn about transgender-appropriate healthcare. So these are some ways that patient care can be improved.
Now, the other critical piece that relates to what I just said is to make the office a safe space that conveys acceptance. I talk about this in the article. I know it’s dated, but putting up symbols such as the Human Rights Campaign logo, the parallel lines, is a great step. There are other symbols as well that can covey an open and safe space. Putting up pictures of diverse families is another way to convey receptiveness. Modifying intake forms to include diverse options is also extremely important, as is training staff to use gender-appropriate names and pronouns. So again, this improves patient care again through a receptive environment, through open communication, and establishing trust.
So beyond that, NPs and other providers, again, should familiarize themselves a bit with the trajectory of gender-nonconforming and transgender youth. Realize that gender-nonconforming behaviors can be normal. It’s not uncommon for 2, 3, 4, 5-year-olds to play with “unstereotypical gendered” toys. Girls can play with trucks; boys can play with dolls, etc. That’s normal.
So, advise parents and their caregivers to listen to their child and to follow their child’s lead. That’s critical. The situation will evolve. In some situations, a social transition is appropriate; in others, this may not be appropriate. Some youth will grow up to be transgendered — that is, perhaps experience gender dysphoria and continue with transition. Most children will not grow up to be gender dysphoric or to have a persistent cross-gender identification. So, counseling parents and caregivers that this is very much a journey — there are no solid answers — and learning how to live with uncertainty. Although this is very difficult, it’s really the rules. And of course, connecting with a network of providers who are more experienced in gender care. The article does have a list of resources in that regard.
Finally, and also very important to patient care, is that this is a very serious issue. There’s lots of mockery, of course, and jokes about bathrooms, etc. But, this is very serious. Depression, suicidal ideation and completed suicide, and now adaptive behaviors are all very real, possible consequences of transgender identification — particularly when there is not a support system for children or youth. So assess families for psychosocial issues, assess family support, and seek for help and consults as appropriate.
KM: Great. Thank you so much for sharing your findings with our community. We should all take a look at the article. For more information, readers can visit the Journal of the American Association of Nurse Practitioners online at Wiley Online Library, or feel free to email the author at firstname.lastname@example.org.
Christine, again, thank you for joining me. We really appreciate it.
CAA: Thank you so much!
Dr. Christine Aramburu Alegría is an associate professor at the University of Reno Nevada’s Orvis School of Nursing. Not only is she a certified Family Nurse Practitioner, but Aramburu Alegría also holds a PhD in Social Psychology. Identity, relationships, and health promotion in marginalized populations, in particular the transgender and obese populations; qualitative research; global health and nursing; the role and potential of the DNP in today’s dynamic healthcare environment.
Kathleen Mulcahy is a Senior Marketing Manager of the Health Sciences Community. With almost 20 years experience at Wiley-Blackwell, Mulcahy collaborates with healthcare associations and healthcare researchers and practitioners to attract readers to print and online medical publications and ensure wide dissemination in libraries, hospitals, and universities around the world.