PROFESSIONAL ISSUES
How stigma affects healthcare access for transgender sex workers Kirsten Roche and Corey Keith
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here has been recognition that stigmatisation is a major contributor to physical and emotional illness among transgender sex workers (TSWs) (Mulia, 2002; Slamah et al, 2010; Grant et al, 2011; Houston, 2011; Zunner and Grace, 2012). Likewise, it is well-known among health professionals that nurses are in a unique and powerful position as leaders and as frontline healthcare workers to improve the quality of life and health outcomes for many clients, including TSWs. Despite this, the unique needs and experiences of the TSW population are largely overlooked in nursing education curricula and in the continuing education of nursing graduates. It is not surprising, therefore, that according to some researchers, TSWs often report that nurses discriminate against them, largely because of a lack of understanding and knowledge of TSWs’ needs and experiences (Mulia, 2002; Slamah et al, 2010; Thornhill and Klein, 2010; Zunner and Grace, 2012). The purpose of this article is to draw on published literature to highlight what nurses need to know and understand about TSWs to provide respectful, sensitive care to this population. The article will begin by providing an overview of transgender sex work, including why the proportion of transgender people who have experience working in the sex industry is so high compared with that of the general population, and how the stigmatisation of TSWs among nurses can compromise their health and wellbeing. The article will then discuss the research findings: how TSWs feel healthcare workers stigmatise them; the various reasons that have been proposed why stigmatisation of TSWs is so prevalent; and how the stigmatisation of TSWs by nurses negatively affects their access to, and willingness to engage in, the healthcare system. In conclusion, the article will identify the implications of this literature for nursing practice and education.
Definitions of terms Transgender people Transgender people are:
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‘Those whose psychological self (“gender identity”) differs from the social expectations for the physical sex they were born with’ (Gender Equity Resource Center, 2014). The individual may or may not have undergone sexual reassignment surgery (formerly called ‘a sex change’) or choose to live daily as a member of the sex s/he identifies with. The term ‘transgender’ can encompass a wide variety of lifestyles and ideas of self, and whether one identifies with the term depends on personal circumstances and individual ideas about gender identity.
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Abstract
Stigmatisation of transgender sex workers (TSWs) has been recognised as contributing to illness and poorer health outcomes for this population. It could be argued that part of this stigma comes from nurses. With their frequent face-to-face interactions with their clients, nurses come from a unique place of power to influence the health outcomes and the feelings and thoughts that transgender sex workers have about the healthcare system in general, and whether or not they feel safe accessing it. Because there is very limited literature that explores stigmatisation of TSWs on the part of nurses, the needs of TSWs are scarcely being addressed. This article addresses why a higher proportion of transgender people participate in sex work compared with people in the general population; how stigmatisation by nurses affects access to healthcare resources for TSWs; why nurses experience stigmatising thoughts and beliefs; and how nurses can create a positive impact on TSW clients. The authors have found that, although there are a number of complex reasons for bias and stigma, it is extremely important for the health of these clients that nurses put empathy, sensitivity and compassion at the forefront of their practice. Key words: Transgender ■ Stigma ■ Health care ■ Stigmatisation
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Sex work
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Sex workers
Sex worker A sex worker is a person who receives money or goods in exchange for sexual services (Overs, 2012).
Stigma Stigma can be defined as: ‘The process of marginalising a group or class of people by others in a more powerful position by labelling them as different and understanding them in terms of stereotypes. This results in the loss of social status and discrimination, and affects many areas of life for those who are stigmatised’ (Hartney, 2010: 1).
Kirsten Roche, Fourth Year Nursing Student, Thompson Rivers University; Corey Keith, Postgraduate Candidate in Education, Thompson Rivers University, British Columbia, Canada Accepted for publication: October 2014
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He or she? Although TSWs may be of different genders and sexes, for the purposes of readability, TSWs will be referred to by the feminine subject pronoun ‘she’. At the time of writing, the authors were unable to find any literature that addressed female-to-male TSWs.
Sex work and transgender individuals It is estimated that 6% of the world’s sex workers are transgender (European Network for HIV/STI Prevention and Health Promotion Among Migrant Sex Workers, 2009). In contrast, while it is extremely difficult to determine what percentage of the world’s population is transgender (due to variable ‘self-labelling’ practices among individuals and to the fact that so many transgender people hide that part of their identity out of fear of discrimination or violence), it has been estimated that in the USA, only about 0.3% of the population is transgender (Gates, 2011). A 2013 study found that 16% of transgender people from Ontario, Canada, reported having engaged in sex work or exchange sex at least once (Bauer et al, 2013). There are a number of reasons why sex work attracts such a high proportion of transgender people. The most commonly reported reason is the lack of job opportunities for people who identify as, or especially live as, a member of their non-biological sex. Many transgender (also referred to as ‘trans’ for short) people leave school early as a result of bullying, limiting both job and post-secondary education prospects (Slamah et al, 2010;Tucker, 2011). A survey of 6450 transgender people released in 2011 by the National Center for Transgender Equality and the National Gay and Lesbian Task Force in the USA found that ‘90% of respondents had reported harassment or discrimination on the job’, and ‘47% said they had been fired, not hired or denied a promotion because of being transgender’ (Grant et al, 2011: 3). Self-esteem and self-concept also play a major role in the decision to enter into sex work (Tucker, 2011). In all countries, from India and Russia to Kenya and Canada, there are TSWs. However, there are few positive role models or roles in society for this population—at times, the only obvious trans people that can be seen are indeed sex workers. Not only that, but people who use their services are often ashamed to be found engaging in sexual relationships with TSWs, so may outwardly reject the advancement of rights for these populations. This objectification, sexualisation and depersonalisation of transgender people has a very negative effect on the self-worth of the group as a whole, and individuals may see sex work as their only viable option (Slamah et al, 2010). Finally, some transgender people come to North America from places such as Latin America and Southeast Asia in search of work, or to escape the violence against them in their home countries. Some arrive with a low level of
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formal education or with language barriers, and are forced to resort to sex work (Slamah et al, 2010). This group is triply stigmatised—being trans, sex workers and immigrants or from ethnic minorities—and has the added risk of being uninformed about Canadian law and unaware of available health care, language, educational and legal resources available to them (Slamah et al, 2010).
Consequences for the health of TSWs of nurse stigmatisation Stigma, discrimination and prejudice from nurses affects access to health care in a multitude of ways, and can have significant effects on health outcomes for TSW patients. One of the primary concerns relating to the health of TSWs who have experienced discrimination in a healthcare setting is that they tend to delay seeking medical care in the future. Blanchard and Lurie (2004) found that 31% of patients who felt ‘disrespected’ by care providers delayed seeking medical care. The National Transgender Discrimination Survey in the USA found similar results, with 28% of transgender survey respondents reporting that they had postponed medical care due to fear of discrimination (Grant et al, 2011: 4). A Canadian study found that 21% of trans Ontarians reported avoiding the emergency department when emergency care was required due to fear of discrimination on grounds of their transgender status (Bauer et al, 2013). Delaying medical care until the need is urgent can mean waiting until a seemingly insignificant medical issue becomes serious and often more difficult to treat, or even lifethreatening. Localised infections may enter the bloodstream, important treatment measures for chronic conditions may be ignored, and sexually transmitted infections (STIs) or HIV testing may be postponed due to fear. This may increase the risk that the patient passes the virus or infection on to her sex-trade clients. One TSW explained: ‘I used to get tested every 3 months prior to working in the sex industry, as I believed it was always a good idea to stay safe and inform partner(s) if anything did happen. However, as a trans individual, I was hesitant to go to the clinics as you never know the criticisms you might get from staff or doctors. For one, you never know who you are going to get—one week you could get a real positive person and another you could be getting someone that is real sex negative or transphobic. Once I started sex work I put it off or avoided getting checked because I just don’t want to deal with the judgement from the staff. If I got this much grief and negative attitude just for being trans and getting an STI check, I could only imagine what would be the judgements if I told them I am a sex worker. Today, I still have not told my family doctor for the same reason’ (‘Amy’, Central Interior Region of British Columbia, Canada: personal communication, 2013) Stigmatisation by nurses can influence how much
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The Canadian Mental Health Commission (2014) describes it as ‘a complex social process that marginalises and disenfranchises people,’ while ‘prejudicial attitudes and discriminatory behaviours fuel inaccurate notions’ about them (Langille, 2014).
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PROFESSIONAL ISSUES information a patient is willing to share about their health and their life. Chapmen et al (2011) noted that when a person feels disrespected by healthcare workers, she can easily lose the sense of trust she has towards those workers, or not develop one at all. Once that has happened, she will be less likely to share information that is important in order to provide the best possible care. Employment, lifestyle and relationships affect one’s health greatly, and the less that the patient discloses about those areas of her life, the less likely the nurse is to know what kind of resources, information or support the patient needs. This could also potentially contribute to misdiagnosis. One TSW said in an interview about her healthcare experiences: ‘If you’re already transgender, often you’re going to hide the sex work part of things. Why would you want to add more stigma? Many don’t want to be in the line of work and are ashamed already—they’re self-stigmatising … they don’t want to add stigma from others as well. You’re on your guard when sharing information’ (‘Amy’, Central Interior Region of British Columbia, Canada: personal communication, 2013) Because care delays, mismanaged pain and inadequate information about patients can worsen health outcomes, nurses have a responsibility to prevent these things from happening (Zunner and Grace, 2012). Nurses are in an excellent position, with their relational skills and frequency of direct patient care, to provide support and help for this group of patients.
The reasons for stigma of TSWs among nurses There are numerous factors that contribute to nurses’ stigmatisation of TSWs. The stigma may be due to the individual’s transgender status, the type of work she is involved in, the lifestyle she lives, or other factors. According to Zunner and Grace (2012: 62), reasons for discrimination may include ‘discomfort, prior experience, unexplored prejudice, immaturity, poor self-esteem and so on’. Other reasons may include parental or family attitudes, religious and cultural beliefs, and fear. Chapman et al (2011) found that nursing students were less or more supportive of lesbian, gay, bisexual and transgender people depending on the student’s race, sex, religious beliefs, attendance at religious services, and having a friend who is openly gay, lesbian, bisexual or transgender, with Caucasian women who do not consider themselves religious being the most supportive.
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Prior experience A common reason for discrimination against this population is discomfort, resulting from lack of understanding, or prior interaction with transgender people or sex workers. If a nurse has never knowingly interacted with a transgender person, the experience can leave the nurse at a loss. Meeting someone who does not follow the traditional gender roles for that society—for example, a biological man who wears clothing that is typically reserved solely for women, or acting in a manner typically expected only of women—can cause feelings of discomfort for some people. In this case, exposure
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to a new situation (i.e. dealing with someone who has had life experiences that one has not considered before) can result in the nurse feeling unclear on what to say—for example, by which gendered words to address the patient (sir or madam?) and how to act. Lack of knowledge is another challenge for nurses: not knowing what resources are available to these individuals in each community, or what their specific needs may be, can easily lead to frustration and avoidance (Foster and Richmond, 2003).
Unexplored prejudice Some nurses may perceive themselves as open-minded and supportive of all people’s differences, but then are presented with a situation that challenges their openness to nontraditional views of gender. Perhaps on a purely cognitive level, they believe that everyone is entitled to live as they wish, but when put in the situation of working with a TSW, they experience a surprising emotional reaction and find themselves unable to support the patient adequately or quell their own judgements. In this situation, it is very important for nurses to reflect on why they are uncomfortable or what in their lives has contributed to the development of these feelings. Exploring this through self-reflection can help nurses to understand their own reactions, and what can be done about them. It can be helpful for the nurse to engage in discussions with someone they trust and feel comfortable with, in order to gain a deeper insight into the reasons for their negative feelings. Doing even a small amount of research on the challenges TSW face in society can also help nurses to become more empathetic to the struggles and humanity of their TSW patients.
Fear Fear of being ‘hurt’ by the patient is one reason why nurses stigmatise marginalised or disenfranchised populations (Maze, 2005). The prevalence of HIV for TSWs is higher than it is for other sex workers, and significantly higher than it is in the general population (Operario et al, 2008). There are many reasons for this. Inconsistent use of condoms is one, due in part to a saturated sex market (where, if the TSW insists on wearing a condom, the client may simply go to another sex worker who does not). Another reason is the sharing of needles used for injection drugs, silicone injections (Slamah et al, 2010), or hormones that may be either prescribed by a physician or bought on the black market (Thornhill and Klein, 2010). Although needle exchanges are funded by provincial governments and are common in Canadian cities, rural communities sometimes do not have them at all or have exchanges that are only open on certain days of the week and at certain times, thereby limiting access. Lack of knowledge of Canadian law with regard to drug use also prevents people from accessing needle-exchange services. Although purchase and possession of clean needles is legal in Canada, possession of drug ‘paraphernalia’ is illegal, and the fact that the law does not include needles in its definition of paraphernalia is not known by many drug users (Klein, 2007). One final reason for increased HIV rates among TSWs is that the risk of HIV transmission while receiving
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Perceived difficulty of providing care Some nursing and healthcare staff have stigmatised sex workers (especially if they are also drug users) by labelling them ‘difficult patients’. This is due in part to their sometimes complex medical or psychosocial challenges and ‘special needs’, their perceived levels of motivation, and their general attitudes (Mulia, 2002).TSWs may be perceived by healthcare workers as having more complex needs than the general population, both physically and psychosocially. Perceptions about how motivated the patient is to take care of her own health, to access community resources, to leave sex work and to adhere to medical advice or treatment, can lead to frustration and judgement on the nurse’s part (Mulia, 2002). General attitudes of the patient toward the healthcare system, healthcare workers, or self-care practices, can also be seen by nurses as contributing to making the patient more difficult to work with (Mulia, 2002).
Enactment of stigmatisation One serious problem with stigmatisation is that the person being stigmatised is often looked at as though any problems that arise have been brought on himself or herself (Halter, 2008). When nurses have these feelings towards a patient, it can result in devaluation of the patient as an individual and inequitable treatment or suboptimal care. According to the National Transgender Discrimination Survey (Grant et al, 2011), the statistics of transgender people experiencing discriminatory treatment by medical professionals are substantial: 11% of participants in the survey reported being given unequal treatment in a mental-health clinic; 13% were treated unequally in an emergency department; 24% reported experiencing unequal treatment in a hospital or doctor’s office; and 19% of people taking part in the survey reported being refused medical care due to their gender status.
Implications for nurses Reserving judgement The preceding discussion points to the need for all nurses to support and advocate for the rights of TSWs who need health care. Establishing a therapeutic and trusting relationship with individuals who have experienced a large amount of discrimination in their lifetimes can be challenging, but is of the utmost necessity in order to provide optimal care. Part of developing a trusting relationship is being non-judgemental and open to the patient. In the words of Zunner and Grace (2012: 62), the most important thing to remember when treating any patient is to ask oneself, ‘Who is this person in front of me? What has brought her to these circumstances?’ While moving past one’s own opinions, values and biases is not always an easy task, it is a nurse’s professional responsibility to provide optimal care
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for each and every patient, no matter what the nurse thinks of the patient’s experiences and characteristics. It is crucial not to make assumptions when working with TSWs, and to recognise that TSWs have as many unique experiences as every other human being, and come from all walks of life. Some are IV drug users, but many do not touch drugs or alcohol, or use them only rarely. Some work on the streets, some work in ‘agencies’ or in their own home; some may have dropped out of secondary school, while others might hold university degrees. While nurses need to understand at least some of the social and health issues that TSWs face, they also need to recognise that these factors are not ‘one size fits all’. Each person has her own experiences; assuming that everyone in a group has the same experiences can be as condemnatory as not knowing anything about the issues to begin with. Because human communication is so much more than simply verbal, nurses must be aware of their body language and facial expressions, and try to avoid expressions that could be interpreted as judgemental or uncomfortable. It has been estimated that up to 80% of human communication relies on non-verbal communication (Roberson, 2010). This includes body language, facial expression and gestures; plus tone, volume, speed and inflection of voice. Making eye-contact, giving occasional affirmative nods, and avoiding bored or nervous gestures such as fidgeting or allowing one’s eyes to wander the room can help show patients that you are interested in what they are trying to communicate (Preston, 2005). While this is important when dealing with all patients, it has an especially strong effect when working with patients who belong to marginalised groups. According to the Canadian Mental Health Association, gay, lesbian, bisexual and transgender youth are 14 times more likely than heterosexual youth to develop substance abuse issues (Canadian Mental Health Association, 2014). For transgender patients who are struggling with addiction, or who have a prior history of substance dependence, it is important to be aware that increased tolerance to pain medication is a possibility. In addition, those on methadone treatment are likely to be even more difficult to treat for pain. According to Hines et al (2008: 1), patients on methadone maintenance programmes are sometimes given less opioid analgesia than the typical patient who is experiencing acute pain, ‘due to requests for analgesia being misinterpreted as craving for drugs’, but pain studies have shown that patients on methadone maintenance have hyperalgesic responses to pain, and that the potential for cross-tolerance to other opioids may exist. This suggests that patients on a methadone programme, or who have a long history of opioid use, do indeed require higher doses of analgesia to achieve adequate pain relief. Hines et al (2008) also showed that for patients on methadone maintenance, insufficient pain relief can be a large factor in behavioural problems and early discharge.
Establish an environment of safety Establishing an environment of safety for marginalised patients is a critical factor for offering supportive care. This contributes to developing trust and helping the patient to
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anal intercourse from an infected person is approximately 18 times higher than receiving vaginal intercourse from the same (Dotinga, 2012). Due to the increased risk of developing a blood-borne virus as a result of sex work, nurses may fear transmission when working with these patients, even without knowing the individual’s HIV or hepatitis status.
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PROFESSIONAL ISSUES feel that she can be honest and open with her healthcare providers. One of the best ways to achieve this is to include the patient in her own care, and to ask her how she can best be supported. For example, gender pronouns are something in transgender people’s lives that can make them feel excluded and disrespected if used improperly. According to author and trainer on transgender issues, Matt Kailey, generally it is appropriate to use the pronoun that fits with the gender the person is ‘presenting’ (Kailey, 2014). For example, if the person is wearing a dress or is clearly dressed in clothes traditionally thought to belong to women, it should be assumed that this person would prefer to be referred to as ‘she’. However, the very best thing is to ask the patient directly. Some transgender individuals prefer male pronouns; some prefer female; others prefer lesser-used, non-binary pronouns such as ‘ze’ or ‘zir’ in place of ‘s/he’ or ‘his/her’. Non-binary pronouns (i.e. neither definitively male nor female) can be especially preferred by transgender people who do not present in gender-normative ways. If other patients are around, bring the patient to a private place to avoid making her feel uncomfortable during the discussion. For the majority of transgender people, being asked which pronoun they prefer shows respect for the individual, and it shows them that they have an ally among the staff, or at least someone with whom they can feel safe (Kailey, 2014).
face when accessing health care and other resources, can help to broaden nurses’ understanding of the challenges this population faces and help them to see things from a compassionate standpoint. Knowledge of some of the resources that are available in a particular community to transgender people and to sex workers is another important tool that can assist each nurse in being able to connect TSW patients with the support they need. Finally, if a nurse finds herself unable for whatever reason to provide compassionate and non-judgemental care to TSW patients, it is important that she knows when it is time to get another nurse to take over care of that patient.
Discrimination or inappropriate staff comments
Bauer G, Scheim A, Deutsch M, Massarella C (2013) Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. Ann Emerg Med 63(6): 713–20.e1. doi: 10.1016/j.annemergmed.2013.09.027. Epub 2013 Nov 1 Blanchard J, Lurie N (2004) R-E-S-P-E-C-T: Patient reports of disrespect in the healthcare setting and its impact on care. J Fam Pract 53(9): 721–30 Canadian Mental Health Association (2014) Lesbian, gay, bisexual and transgender people and mental health. http://tinyurl.com/oruqhq4 (accessed 6 November 2014) Chapman R, Nicol P, Shields L, Watkins R, Zappia T (2011) Nursing and medical students’ attitude, knowledge and beliefs regarding lesbian, gay, bisexual and transgender parents seeking healthcare for their children. J Clin Nurs 21(7–8): 938–45. doi: 10.1111/j.1365-2702.2011.03892.x Dotinga R (2012) Biology Leaves Gay Men Highly Vulnerable to HIV: Study. US News and World Report, 20 July. http://tinyurl.com/ctgmfs7 (accessed 6 November 2014) European Network for HIV/STI Prevention and Health Promotion among Migrant Sex Workers (2009) Sex work in Europe: a mapping of the prostitution
According to the Ethical Nursing Care of Transgender Patients, if you witness discrimination or inappropriate comments made by other staff or patients in front of the patient, there are several things that can be done. The first option is to speak privately with that staff member later in the day and raise your concerns. If this is not possible, or you do not feel confident addressing the other staff about it, the unit manager should be asked to discuss the importance of treating all patients with respect. Equally imperative, if not even more so, is to discuss it with the patient, if she is willing. Explain that you saw what happened, that it was inappropriate, what you are going to do about it, and that you are sorry it happened. Ask her what she needs to feel safe, what you can do for her. Be sure to remind her to let you know if she experiences anything else like that while there. If this type of behaviour becomes a regular problem on the unit, it is important to speak to the nurse manager of the unit, or to the governing body of nursing in your province, state or county (Zunner and Grace, 2012).
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Know the issues Awareness of the high rate of domestic and partner abuse, as well as other forms of abuse, is key. Assessments for abuse and for mental health should be conducted. Nurses should discuss violence-prevention strategies with the patient and, if the patient is suspected to have been abused, the nurse may discuss it with the patient and, if appropriate, notify the on-staff social worker if one is available. Having at least a preliminary understanding of the issues mentioned in this article, and other issues that relate to TSWs, as well as being aware of the barriers that TSWs
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Conclusions Working with TSWs does not need to be difficult, but it does require sensitivity, empathy and an interest in providing optimal care to a population that has in the past been (and continues to be) treated with prejudice and ignorance. Nurses are in an excellent position to create positive, therapeutic relationships with their TSW patients. Success in this area can have an impact not only on short-term health outcomes, but on relationships between the health profession and BJN marginalised populations as a whole. Conflict of interest: none
KEY POINTS n Stigmatisation of transgender sex workers (TSWs) contributes to illness and poorer health outcomes for this population n Nurses, as leaders and as frontline staff, are in a unique and powerful position to improve the quality of life and health outcomes for their clients n Due to complex reasons including lack of opportunities and discrimination, a higher proportion of transgender individuals are attracted to sex work compared with other genders n Not all transgender individuals involved in sex work are ‘victims’. Many are highly-educated, have high self-esteem, and choose sex work as their career. Reserving judgement is key to providing supportive nursing care to these populations n Knowing the issues facing transgender people and sex workers can help health professionals provide competent care that meets the particular needs of these populations
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scene in 25 European countries. http://tinyurl.com/khcp673 (accessed 6 November 2014) Foster J, Richmond I (2003) Negative attitudes toward people with co-morbid mental health and substance misuse problems: an investigation of mental health professionals. J Ment Health 12(4): 393–403 Gates G (2011) How many people are gay, lesbian, bisexual, and transgender? The Williams Institute. http://tinyurl.com/77bdant (accessed 6 November 2014) Gender Equity Resource Center (2014) Transgender. http://tinyurl.com/ qblhrrp (accessed 6 November 2014) Grant J, Mottet L, Tanis J (2011) Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. National Gay and Lesbian Taskforce. http:// www.thetaskforce.org/static_html/downloads/reports/reports/ntds_full.pdf (accessed 6 November 2014) Halter M (2008) Perceived characteristics of psychiatric nurses: stigma by association. Arch Psychiatr Nurs 22(1): 20–6. doi: 10.1016/j.apnu.2007.03.003 Hartney E (2010) What is Stigma? About.com. http://addictions.about.com/ od/glossar1/g/stigma.htm (accessed 6 November 2014) Hines K,Theodorou S,Williamson A, Fong D, Curry K (2008) Management of acute pain in methadone maintenance therapy in-patients. Drug Alcohol Rev 27(5): 519–23. doi: 10.1080/09595230802245519 Houston A (2011) Trans sex workers still most vulnerable. http://tinyurl.com/ plkqgew (accessed 6 November 2014) Kailey M (2014) Trans etiquette for non-trans people. http://tinyurl. com/697glgh (accessed 6 November 2014) Klein A (2007) Sticking Points: Barriers to Access to Needle and Syringe Programs in Canada. Canadian HIV/AIDS Legal Network (Réseau juridique canadien VIH/sida), Toronto Langille J (2014) Reducing stigma in health-care settings. http://tinyurl.com/
ldwhsfs (accessed 6 November 2014) Maze CD (2005) Registered Nurses’ personal rights vs professional responsibility in caring for members of underserved and disenfranchised populations. J Clin Nurs 14(5): 546–54 Merriam-Webster (2014) Stigma. http://www.merriam-webster.com/ dictionary/stigma?show=0&t=1415014435 (accessed 6 November 2014) Mulia N (2002) Ironies in the pursuit of well-being: the perspectives of lowincome, substance-using women on service institutions. Contemporary Drug Problems 29(4): 711–48 Operario D, Soma T, Underhill K (2008) Sex work and HIV status among transgender women: Systematic review and meta-analysis. J Acquir Immune Defic Syndr 48(1): 97–103. doi: 10.1097/QAI.0b013e31816e3971 Overs C (2012) Sex workers: Part of the solution. World Health Organization. http://www.who.int/hiv/topics/vct/sw_toolkit/115solution.pdf (accessed 6 November 2014) Preston P (2005) Nonverbal communication: Do you really say what you mean? J Healthc Manag 50(2): 83–6 Roberson C (2010) Nonverbal communication. Alabama Nurse 3(13): 13–18 Slamah K, Winter S, Ordek K (2010) Stigma and Violence Against Transgender Sex Workers. RH Reality Check. http://tinyurl.com/2c4he3j (accessed 6 November 2014) Thornhill L, Klein P (2010) Creating environments of care with transgender communities. J Assoc Nurses AIDS Care 21(3): 230–9. doi: 10.1016/j. jana.2009.11.007 Tucker E (2011) Job training programs on the rise for transgender workers. Prince George Citizen, 7 October Zunner B, Grace P (2012) The ethical nursing care of transgender patients: An exploration of bias in health care and how it affects this population. Am J Nurs 112(12): 61-4. doi: 10.1097/01.NAJ.0000423514.58585.a3
Critiquing Nursing Research 2nd edition About the book
The fundamentals of the book, however, remain the same. It focuses specifically on critiquing nursing research and the increasing requirement for nurses to become conversant with research and understand its link with the use of evidence to underpin practice.
This second edition retains all the successful Having read this book, nurses should be more familiar with the approaches and techniques involved in critiquing nursing research and be able to utilise some of these skills and techniques in their own efforts to critique. Accordingly, they will be better placed to make informed judgements regarding the quality of the research paper and the value of the evidence reported.
features of the first, plus additional material on psychiatric research and critiquing nursing research when writing a dissertation. As nurse education around the world increasingly moves towards an all-graduate discipline, it is vital for nurses to have the ability to critique research in order to benefit practice. This book is the perfect tool for those seeking to gain or develop precisely that skill and is a must-have for all student nurses, teachers and academics.
About the authors
Dr John R. Cutcliffe holds the as ‘David G.students Braithwaite’ Professor ofhave Very suitable toChairundertake Nursing Endowed at the University of Texas (Tyler); he is also an Adjunct Professor of Psychiatric Nursing at Stenberg College International School of Nursing, Vancouver, Canada and a Visiting Professor at the University of Ulster, United Kingdom. He is an Associate Editor for the Journal of Psychiatric and Mental Health Nursing and an Assistant Editor for the International Journal of Nursing Studies. John’s clinical background is in psychiatric and general nursing, having worked as a clinician and then as an educator in the United Kingdom. He is an international scholar having worked in universities in four different countries: England, Northern Ireland, Canada and the United States. Martin Ward is an Independent Mental Health Nursing Consultant; he is also Co-ordinator of Mental Health Nursing Studies at the University of Malta and Chair of the Expert Panel of Horatio - European Psychiatric Nurses, based in the Netherlands. From 1995 to 2000 he held the post of Director of Mental Health for the Royal College of Nursing. Martin has been a Trustee of the English Health Advisory Service (HAS) and a member of the HAS Inspectorate and has also been involved with work with the World Health Organisation. In 1997, both authors were instrumental in designing and launching the NPNR National Journal Club.
Critiquing Nursing Research
John Cutcliffe and Martin Ward
This second edition of Critiquing Nursing Research retains the features which made the original book a best-seller while incorporating new material in order to expand its applicability. In addition to reviewing and updating the material of the original text, the authors have added two further chapters: the first focuses on how to critique research as part of the work of preparing a dissertation; and the second on mental health research agendas throughout Europe.
Critiquing Nursing Research 2nd edition
a dissertation where they critique three pieces of nursing research.
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Foreword by Professor Kevin Gournay
John Cutcliffe and Martin Ward
ISBN 978-1-85642-316-8
John Cutcliffe and Martin Ward
The new and updated edition of the best-selling book
CritiquingNRes3.indd 1 25/03/2011 09:41
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ISBN-13: 978-1-85642-316-8; 234 x 156 mm; paperback; 244 pages; publication November 2006; £25.99
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How stigma affects healthcare access for transgender sex workers Kirsten Roche and Corey Keith
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here has been recognition that stigmatisation is a major contributor to physical and emotional illness among transgender sex workers (TSWs) (Mulia, 2002; Slamah et al, 2010; Grant et al, 2011; Houston, 2011; Zunner and Grace, 2012). Likewise, it is well-known among health professionals that nurses are in a unique and powerful position as leaders and as frontline healthcare workers to improve the quality of life and health outcomes for many clients, including TSWs. Despite this, the unique needs and experiences of the TSW population are largely overlooked in nursing education curricula and in the continuing education of nursing graduates. It is not surprising, therefore, that according to some researchers, TSWs often report that nurses discriminate against them, largely because of a lack of understanding and knowledge of TSWs’ needs and experiences (Mulia, 2002; Slamah et al, 2010; Thornhill and Klein, 2010; Zunner and Grace, 2012). The purpose of this article is to draw on published literature to highlight what nurses need to know and understand about TSWs to provide respectful, sensitive care to this population. The article will begin by providing an overview of transgender sex work, including why the proportion of transgender people who have experience working in the sex industry is so high compared with that of the general population, and how the stigmatisation of TSWs among nurses can compromise their health and wellbeing. The article will then discuss the research findings: how TSWs feel healthcare workers stigmatise them; the various reasons that have been proposed why stigmatisation of TSWs is so prevalent; and how the stigmatisation of TSWs by nurses negatively affects their access to, and willingness to engage in, the healthcare system. In conclusion, the article will identify the implications of this literature for nursing practice and education.
Definitions of terms Transgender people Transgender people are:
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‘Those whose psychological self (“gender identity”) differs from the social expectations for the physical sex they were born with’ (Gender Equity Resource Center, 2014). The individual may or may not have undergone sexual reassignment surgery (formerly called ‘a sex change’) or choose to live daily as a member of the sex s/he identifies with. The term ‘transgender’ can encompass a wide variety of lifestyles and ideas of self, and whether one identifies with the term depends on personal circumstances and individual ideas about gender identity.
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Abstract
Stigmatisation of transgender sex workers (TSWs) has been recognised as contributing to illness and poorer health outcomes for this population. It could be argued that part of this stigma comes from nurses. With their frequent face-to-face interactions with their clients, nurses come from a unique place of power to influence the health outcomes and the feelings and thoughts that transgender sex workers have about the healthcare system in general, and whether or not they feel safe accessing it. Because there is very limited literature that explores stigmatisation of TSWs on the part of nurses, the needs of TSWs are scarcely being addressed. This article addresses why a higher proportion of transgender people participate in sex work compared with people in the general population; how stigmatisation by nurses affects access to healthcare resources for TSWs; why nurses experience stigmatising thoughts and beliefs; and how nurses can create a positive impact on TSW clients. The authors have found that, although there are a number of complex reasons for bias and stigma, it is extremely important for the health of these clients that nurses put empathy, sensitivity and compassion at the forefront of their practice. Key words: Transgender ■ Stigma ■ Health care ■ Stigmatisation
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Sex work
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Sex workers
Sex worker A sex worker is a person who receives money or goods in exchange for sexual services (Overs, 2012).
Stigma Stigma can be defined as: ‘The process of marginalising a group or class of people by others in a more powerful position by labelling them as different and understanding them in terms of stereotypes. This results in the loss of social status and discrimination, and affects many areas of life for those who are stigmatised’ (Hartney, 2010: 1).
Kirsten Roche, Fourth Year Nursing Student, Thompson Rivers University; Corey Keith, Postgraduate Candidate in Education, Thompson Rivers University, British Columbia, Canada Accepted for publication: October 2014
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He or she? Although TSWs may be of different genders and sexes, for the purposes of readability, TSWs will be referred to by the feminine subject pronoun ‘she’. At the time of writing, the authors were unable to find any literature that addressed female-to-male TSWs.
Sex work and transgender individuals It is estimated that 6% of the world’s sex workers are transgender (European Network for HIV/STI Prevention and Health Promotion Among Migrant Sex Workers, 2009). In contrast, while it is extremely difficult to determine what percentage of the world’s population is transgender (due to variable ‘self-labelling’ practices among individuals and to the fact that so many transgender people hide that part of their identity out of fear of discrimination or violence), it has been estimated that in the USA, only about 0.3% of the population is transgender (Gates, 2011). A 2013 study found that 16% of transgender people from Ontario, Canada, reported having engaged in sex work or exchange sex at least once (Bauer et al, 2013). There are a number of reasons why sex work attracts such a high proportion of transgender people. The most commonly reported reason is the lack of job opportunities for people who identify as, or especially live as, a member of their non-biological sex. Many transgender (also referred to as ‘trans’ for short) people leave school early as a result of bullying, limiting both job and post-secondary education prospects (Slamah et al, 2010;Tucker, 2011). A survey of 6450 transgender people released in 2011 by the National Center for Transgender Equality and the National Gay and Lesbian Task Force in the USA found that ‘90% of respondents had reported harassment or discrimination on the job’, and ‘47% said they had been fired, not hired or denied a promotion because of being transgender’ (Grant et al, 2011: 3). Self-esteem and self-concept also play a major role in the decision to enter into sex work (Tucker, 2011). In all countries, from India and Russia to Kenya and Canada, there are TSWs. However, there are few positive role models or roles in society for this population—at times, the only obvious trans people that can be seen are indeed sex workers. Not only that, but people who use their services are often ashamed to be found engaging in sexual relationships with TSWs, so may outwardly reject the advancement of rights for these populations. This objectification, sexualisation and depersonalisation of transgender people has a very negative effect on the self-worth of the group as a whole, and individuals may see sex work as their only viable option (Slamah et al, 2010). Finally, some transgender people come to North America from places such as Latin America and Southeast Asia in search of work, or to escape the violence against them in their home countries. Some arrive with a low level of
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formal education or with language barriers, and are forced to resort to sex work (Slamah et al, 2010). This group is triply stigmatised—being trans, sex workers and immigrants or from ethnic minorities—and has the added risk of being uninformed about Canadian law and unaware of available health care, language, educational and legal resources available to them (Slamah et al, 2010).
Consequences for the health of TSWs of nurse stigmatisation Stigma, discrimination and prejudice from nurses affects access to health care in a multitude of ways, and can have significant effects on health outcomes for TSW patients. One of the primary concerns relating to the health of TSWs who have experienced discrimination in a healthcare setting is that they tend to delay seeking medical care in the future. Blanchard and Lurie (2004) found that 31% of patients who felt ‘disrespected’ by care providers delayed seeking medical care. The National Transgender Discrimination Survey in the USA found similar results, with 28% of transgender survey respondents reporting that they had postponed medical care due to fear of discrimination (Grant et al, 2011: 4). A Canadian study found that 21% of trans Ontarians reported avoiding the emergency department when emergency care was required due to fear of discrimination on grounds of their transgender status (Bauer et al, 2013). Delaying medical care until the need is urgent can mean waiting until a seemingly insignificant medical issue becomes serious and often more difficult to treat, or even lifethreatening. Localised infections may enter the bloodstream, important treatment measures for chronic conditions may be ignored, and sexually transmitted infections (STIs) or HIV testing may be postponed due to fear. This may increase the risk that the patient passes the virus or infection on to her sex-trade clients. One TSW explained: ‘I used to get tested every 3 months prior to working in the sex industry, as I believed it was always a good idea to stay safe and inform partner(s) if anything did happen. However, as a trans individual, I was hesitant to go to the clinics as you never know the criticisms you might get from staff or doctors. For one, you never know who you are going to get—one week you could get a real positive person and another you could be getting someone that is real sex negative or transphobic. Once I started sex work I put it off or avoided getting checked because I just don’t want to deal with the judgement from the staff. If I got this much grief and negative attitude just for being trans and getting an STI check, I could only imagine what would be the judgements if I told them I am a sex worker. Today, I still have not told my family doctor for the same reason’ (‘Amy’, Central Interior Region of British Columbia, Canada: personal communication, 2013) Stigmatisation by nurses can influence how much
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The Canadian Mental Health Commission (2014) describes it as ‘a complex social process that marginalises and disenfranchises people,’ while ‘prejudicial attitudes and discriminatory behaviours fuel inaccurate notions’ about them (Langille, 2014).
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PROFESSIONAL ISSUES information a patient is willing to share about their health and their life. Chapmen et al (2011) noted that when a person feels disrespected by healthcare workers, she can easily lose the sense of trust she has towards those workers, or not develop one at all. Once that has happened, she will be less likely to share information that is important in order to provide the best possible care. Employment, lifestyle and relationships affect one’s health greatly, and the less that the patient discloses about those areas of her life, the less likely the nurse is to know what kind of resources, information or support the patient needs. This could also potentially contribute to misdiagnosis. One TSW said in an interview about her healthcare experiences: ‘If you’re already transgender, often you’re going to hide the sex work part of things. Why would you want to add more stigma? Many don’t want to be in the line of work and are ashamed already—they’re self-stigmatising … they don’t want to add stigma from others as well. You’re on your guard when sharing information’ (‘Amy’, Central Interior Region of British Columbia, Canada: personal communication, 2013) Because care delays, mismanaged pain and inadequate information about patients can worsen health outcomes, nurses have a responsibility to prevent these things from happening (Zunner and Grace, 2012). Nurses are in an excellent position, with their relational skills and frequency of direct patient care, to provide support and help for this group of patients.
The reasons for stigma of TSWs among nurses There are numerous factors that contribute to nurses’ stigmatisation of TSWs. The stigma may be due to the individual’s transgender status, the type of work she is involved in, the lifestyle she lives, or other factors. According to Zunner and Grace (2012: 62), reasons for discrimination may include ‘discomfort, prior experience, unexplored prejudice, immaturity, poor self-esteem and so on’. Other reasons may include parental or family attitudes, religious and cultural beliefs, and fear. Chapman et al (2011) found that nursing students were less or more supportive of lesbian, gay, bisexual and transgender people depending on the student’s race, sex, religious beliefs, attendance at religious services, and having a friend who is openly gay, lesbian, bisexual or transgender, with Caucasian women who do not consider themselves religious being the most supportive.
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Prior experience A common reason for discrimination against this population is discomfort, resulting from lack of understanding, or prior interaction with transgender people or sex workers. If a nurse has never knowingly interacted with a transgender person, the experience can leave the nurse at a loss. Meeting someone who does not follow the traditional gender roles for that society—for example, a biological man who wears clothing that is typically reserved solely for women, or acting in a manner typically expected only of women—can cause feelings of discomfort for some people. In this case, exposure
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to a new situation (i.e. dealing with someone who has had life experiences that one has not considered before) can result in the nurse feeling unclear on what to say—for example, by which gendered words to address the patient (sir or madam?) and how to act. Lack of knowledge is another challenge for nurses: not knowing what resources are available to these individuals in each community, or what their specific needs may be, can easily lead to frustration and avoidance (Foster and Richmond, 2003).
Unexplored prejudice Some nurses may perceive themselves as open-minded and supportive of all people’s differences, but then are presented with a situation that challenges their openness to nontraditional views of gender. Perhaps on a purely cognitive level, they believe that everyone is entitled to live as they wish, but when put in the situation of working with a TSW, they experience a surprising emotional reaction and find themselves unable to support the patient adequately or quell their own judgements. In this situation, it is very important for nurses to reflect on why they are uncomfortable or what in their lives has contributed to the development of these feelings. Exploring this through self-reflection can help nurses to understand their own reactions, and what can be done about them. It can be helpful for the nurse to engage in discussions with someone they trust and feel comfortable with, in order to gain a deeper insight into the reasons for their negative feelings. Doing even a small amount of research on the challenges TSW face in society can also help nurses to become more empathetic to the struggles and humanity of their TSW patients.
Fear Fear of being ‘hurt’ by the patient is one reason why nurses stigmatise marginalised or disenfranchised populations (Maze, 2005). The prevalence of HIV for TSWs is higher than it is for other sex workers, and significantly higher than it is in the general population (Operario et al, 2008). There are many reasons for this. Inconsistent use of condoms is one, due in part to a saturated sex market (where, if the TSW insists on wearing a condom, the client may simply go to another sex worker who does not). Another reason is the sharing of needles used for injection drugs, silicone injections (Slamah et al, 2010), or hormones that may be either prescribed by a physician or bought on the black market (Thornhill and Klein, 2010). Although needle exchanges are funded by provincial governments and are common in Canadian cities, rural communities sometimes do not have them at all or have exchanges that are only open on certain days of the week and at certain times, thereby limiting access. Lack of knowledge of Canadian law with regard to drug use also prevents people from accessing needle-exchange services. Although purchase and possession of clean needles is legal in Canada, possession of drug ‘paraphernalia’ is illegal, and the fact that the law does not include needles in its definition of paraphernalia is not known by many drug users (Klein, 2007). One final reason for increased HIV rates among TSWs is that the risk of HIV transmission while receiving
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Perceived difficulty of providing care Some nursing and healthcare staff have stigmatised sex workers (especially if they are also drug users) by labelling them ‘difficult patients’. This is due in part to their sometimes complex medical or psychosocial challenges and ‘special needs’, their perceived levels of motivation, and their general attitudes (Mulia, 2002).TSWs may be perceived by healthcare workers as having more complex needs than the general population, both physically and psychosocially. Perceptions about how motivated the patient is to take care of her own health, to access community resources, to leave sex work and to adhere to medical advice or treatment, can lead to frustration and judgement on the nurse’s part (Mulia, 2002). General attitudes of the patient toward the healthcare system, healthcare workers, or self-care practices, can also be seen by nurses as contributing to making the patient more difficult to work with (Mulia, 2002).
Enactment of stigmatisation One serious problem with stigmatisation is that the person being stigmatised is often looked at as though any problems that arise have been brought on himself or herself (Halter, 2008). When nurses have these feelings towards a patient, it can result in devaluation of the patient as an individual and inequitable treatment or suboptimal care. According to the National Transgender Discrimination Survey (Grant et al, 2011), the statistics of transgender people experiencing discriminatory treatment by medical professionals are substantial: 11% of participants in the survey reported being given unequal treatment in a mental-health clinic; 13% were treated unequally in an emergency department; 24% reported experiencing unequal treatment in a hospital or doctor’s office; and 19% of people taking part in the survey reported being refused medical care due to their gender status.
Implications for nurses Reserving judgement The preceding discussion points to the need for all nurses to support and advocate for the rights of TSWs who need health care. Establishing a therapeutic and trusting relationship with individuals who have experienced a large amount of discrimination in their lifetimes can be challenging, but is of the utmost necessity in order to provide optimal care. Part of developing a trusting relationship is being non-judgemental and open to the patient. In the words of Zunner and Grace (2012: 62), the most important thing to remember when treating any patient is to ask oneself, ‘Who is this person in front of me? What has brought her to these circumstances?’ While moving past one’s own opinions, values and biases is not always an easy task, it is a nurse’s professional responsibility to provide optimal care
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for each and every patient, no matter what the nurse thinks of the patient’s experiences and characteristics. It is crucial not to make assumptions when working with TSWs, and to recognise that TSWs have as many unique experiences as every other human being, and come from all walks of life. Some are IV drug users, but many do not touch drugs or alcohol, or use them only rarely. Some work on the streets, some work in ‘agencies’ or in their own home; some may have dropped out of secondary school, while others might hold university degrees. While nurses need to understand at least some of the social and health issues that TSWs face, they also need to recognise that these factors are not ‘one size fits all’. Each person has her own experiences; assuming that everyone in a group has the same experiences can be as condemnatory as not knowing anything about the issues to begin with. Because human communication is so much more than simply verbal, nurses must be aware of their body language and facial expressions, and try to avoid expressions that could be interpreted as judgemental or uncomfortable. It has been estimated that up to 80% of human communication relies on non-verbal communication (Roberson, 2010). This includes body language, facial expression and gestures; plus tone, volume, speed and inflection of voice. Making eye-contact, giving occasional affirmative nods, and avoiding bored or nervous gestures such as fidgeting or allowing one’s eyes to wander the room can help show patients that you are interested in what they are trying to communicate (Preston, 2005). While this is important when dealing with all patients, it has an especially strong effect when working with patients who belong to marginalised groups. According to the Canadian Mental Health Association, gay, lesbian, bisexual and transgender youth are 14 times more likely than heterosexual youth to develop substance abuse issues (Canadian Mental Health Association, 2014). For transgender patients who are struggling with addiction, or who have a prior history of substance dependence, it is important to be aware that increased tolerance to pain medication is a possibility. In addition, those on methadone treatment are likely to be even more difficult to treat for pain. According to Hines et al (2008: 1), patients on methadone maintenance programmes are sometimes given less opioid analgesia than the typical patient who is experiencing acute pain, ‘due to requests for analgesia being misinterpreted as craving for drugs’, but pain studies have shown that patients on methadone maintenance have hyperalgesic responses to pain, and that the potential for cross-tolerance to other opioids may exist. This suggests that patients on a methadone programme, or who have a long history of opioid use, do indeed require higher doses of analgesia to achieve adequate pain relief. Hines et al (2008) also showed that for patients on methadone maintenance, insufficient pain relief can be a large factor in behavioural problems and early discharge.
Establish an environment of safety Establishing an environment of safety for marginalised patients is a critical factor for offering supportive care. This contributes to developing trust and helping the patient to
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anal intercourse from an infected person is approximately 18 times higher than receiving vaginal intercourse from the same (Dotinga, 2012). Due to the increased risk of developing a blood-borne virus as a result of sex work, nurses may fear transmission when working with these patients, even without knowing the individual’s HIV or hepatitis status.
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PROFESSIONAL ISSUES feel that she can be honest and open with her healthcare providers. One of the best ways to achieve this is to include the patient in her own care, and to ask her how she can best be supported. For example, gender pronouns are something in transgender people’s lives that can make them feel excluded and disrespected if used improperly. According to author and trainer on transgender issues, Matt Kailey, generally it is appropriate to use the pronoun that fits with the gender the person is ‘presenting’ (Kailey, 2014). For example, if the person is wearing a dress or is clearly dressed in clothes traditionally thought to belong to women, it should be assumed that this person would prefer to be referred to as ‘she’. However, the very best thing is to ask the patient directly. Some transgender individuals prefer male pronouns; some prefer female; others prefer lesser-used, non-binary pronouns such as ‘ze’ or ‘zir’ in place of ‘s/he’ or ‘his/her’. Non-binary pronouns (i.e. neither definitively male nor female) can be especially preferred by transgender people who do not present in gender-normative ways. If other patients are around, bring the patient to a private place to avoid making her feel uncomfortable during the discussion. For the majority of transgender people, being asked which pronoun they prefer shows respect for the individual, and it shows them that they have an ally among the staff, or at least someone with whom they can feel safe (Kailey, 2014).
face when accessing health care and other resources, can help to broaden nurses’ understanding of the challenges this population faces and help them to see things from a compassionate standpoint. Knowledge of some of the resources that are available in a particular community to transgender people and to sex workers is another important tool that can assist each nurse in being able to connect TSW patients with the support they need. Finally, if a nurse finds herself unable for whatever reason to provide compassionate and non-judgemental care to TSW patients, it is important that she knows when it is time to get another nurse to take over care of that patient.
Discrimination or inappropriate staff comments
Bauer G, Scheim A, Deutsch M, Massarella C (2013) Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. Ann Emerg Med 63(6): 713–20.e1. doi: 10.1016/j.annemergmed.2013.09.027. Epub 2013 Nov 1 Blanchard J, Lurie N (2004) R-E-S-P-E-C-T: Patient reports of disrespect in the healthcare setting and its impact on care. J Fam Pract 53(9): 721–30 Canadian Mental Health Association (2014) Lesbian, gay, bisexual and transgender people and mental health. http://tinyurl.com/oruqhq4 (accessed 6 November 2014) Chapman R, Nicol P, Shields L, Watkins R, Zappia T (2011) Nursing and medical students’ attitude, knowledge and beliefs regarding lesbian, gay, bisexual and transgender parents seeking healthcare for their children. J Clin Nurs 21(7–8): 938–45. doi: 10.1111/j.1365-2702.2011.03892.x Dotinga R (2012) Biology Leaves Gay Men Highly Vulnerable to HIV: Study. US News and World Report, 20 July. http://tinyurl.com/ctgmfs7 (accessed 6 November 2014) European Network for HIV/STI Prevention and Health Promotion among Migrant Sex Workers (2009) Sex work in Europe: a mapping of the prostitution
According to the Ethical Nursing Care of Transgender Patients, if you witness discrimination or inappropriate comments made by other staff or patients in front of the patient, there are several things that can be done. The first option is to speak privately with that staff member later in the day and raise your concerns. If this is not possible, or you do not feel confident addressing the other staff about it, the unit manager should be asked to discuss the importance of treating all patients with respect. Equally imperative, if not even more so, is to discuss it with the patient, if she is willing. Explain that you saw what happened, that it was inappropriate, what you are going to do about it, and that you are sorry it happened. Ask her what she needs to feel safe, what you can do for her. Be sure to remind her to let you know if she experiences anything else like that while there. If this type of behaviour becomes a regular problem on the unit, it is important to speak to the nurse manager of the unit, or to the governing body of nursing in your province, state or county (Zunner and Grace, 2012).
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Know the issues Awareness of the high rate of domestic and partner abuse, as well as other forms of abuse, is key. Assessments for abuse and for mental health should be conducted. Nurses should discuss violence-prevention strategies with the patient and, if the patient is suspected to have been abused, the nurse may discuss it with the patient and, if appropriate, notify the on-staff social worker if one is available. Having at least a preliminary understanding of the issues mentioned in this article, and other issues that relate to TSWs, as well as being aware of the barriers that TSWs
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Conclusions Working with TSWs does not need to be difficult, but it does require sensitivity, empathy and an interest in providing optimal care to a population that has in the past been (and continues to be) treated with prejudice and ignorance. Nurses are in an excellent position to create positive, therapeutic relationships with their TSW patients. Success in this area can have an impact not only on short-term health outcomes, but on relationships between the health profession and BJN marginalised populations as a whole. Conflict of interest: none
KEY POINTS n Stigmatisation of transgender sex workers (TSWs) contributes to illness and poorer health outcomes for this population n Nurses, as leaders and as frontline staff, are in a unique and powerful position to improve the quality of life and health outcomes for their clients n Due to complex reasons including lack of opportunities and discrimination, a higher proportion of transgender individuals are attracted to sex work compared with other genders n Not all transgender individuals involved in sex work are ‘victims’. Many are highly-educated, have high self-esteem, and choose sex work as their career. Reserving judgement is key to providing supportive nursing care to these populations n Knowing the issues facing transgender people and sex workers can help health professionals provide competent care that meets the particular needs of these populations
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scene in 25 European countries. http://tinyurl.com/khcp673 (accessed 6 November 2014) Foster J, Richmond I (2003) Negative attitudes toward people with co-morbid mental health and substance misuse problems: an investigation of mental health professionals. J Ment Health 12(4): 393–403 Gates G (2011) How many people are gay, lesbian, bisexual, and transgender? The Williams Institute. http://tinyurl.com/77bdant (accessed 6 November 2014) Gender Equity Resource Center (2014) Transgender. http://tinyurl.com/ qblhrrp (accessed 6 November 2014) Grant J, Mottet L, Tanis J (2011) Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. National Gay and Lesbian Taskforce. http:// www.thetaskforce.org/static_html/downloads/reports/reports/ntds_full.pdf (accessed 6 November 2014) Halter M (2008) Perceived characteristics of psychiatric nurses: stigma by association. Arch Psychiatr Nurs 22(1): 20–6. doi: 10.1016/j.apnu.2007.03.003 Hartney E (2010) What is Stigma? About.com. http://addictions.about.com/ od/glossar1/g/stigma.htm (accessed 6 November 2014) Hines K,Theodorou S,Williamson A, Fong D, Curry K (2008) Management of acute pain in methadone maintenance therapy in-patients. Drug Alcohol Rev 27(5): 519–23. doi: 10.1080/09595230802245519 Houston A (2011) Trans sex workers still most vulnerable. http://tinyurl.com/ plkqgew (accessed 6 November 2014) Kailey M (2014) Trans etiquette for non-trans people. http://tinyurl. com/697glgh (accessed 6 November 2014) Klein A (2007) Sticking Points: Barriers to Access to Needle and Syringe Programs in Canada. Canadian HIV/AIDS Legal Network (Réseau juridique canadien VIH/sida), Toronto Langille J (2014) Reducing stigma in health-care settings. http://tinyurl.com/
ldwhsfs (accessed 6 November 2014) Maze CD (2005) Registered Nurses’ personal rights vs professional responsibility in caring for members of underserved and disenfranchised populations. J Clin Nurs 14(5): 546–54 Merriam-Webster (2014) Stigma. http://www.merriam-webster.com/ dictionary/stigma?show=0&t=1415014435 (accessed 6 November 2014) Mulia N (2002) Ironies in the pursuit of well-being: the perspectives of lowincome, substance-using women on service institutions. Contemporary Drug Problems 29(4): 711–48 Operario D, Soma T, Underhill K (2008) Sex work and HIV status among transgender women: Systematic review and meta-analysis. J Acquir Immune Defic Syndr 48(1): 97–103. doi: 10.1097/QAI.0b013e31816e3971 Overs C (2012) Sex workers: Part of the solution. World Health Organization. http://www.who.int/hiv/topics/vct/sw_toolkit/115solution.pdf (accessed 6 November 2014) Preston P (2005) Nonverbal communication: Do you really say what you mean? J Healthc Manag 50(2): 83–6 Roberson C (2010) Nonverbal communication. Alabama Nurse 3(13): 13–18 Slamah K, Winter S, Ordek K (2010) Stigma and Violence Against Transgender Sex Workers. RH Reality Check. http://tinyurl.com/2c4he3j (accessed 6 November 2014) Thornhill L, Klein P (2010) Creating environments of care with transgender communities. J Assoc Nurses AIDS Care 21(3): 230–9. doi: 10.1016/j. jana.2009.11.007 Tucker E (2011) Job training programs on the rise for transgender workers. Prince George Citizen, 7 October Zunner B, Grace P (2012) The ethical nursing care of transgender patients: An exploration of bias in health care and how it affects this population. Am J Nurs 112(12): 61-4. doi: 10.1097/01.NAJ.0000423514.58585.a3
Critiquing Nursing Research 2nd edition About the book
The fundamentals of the book, however, remain the same. It focuses specifically on critiquing nursing research and the increasing requirement for nurses to become conversant with research and understand its link with the use of evidence to underpin practice.
This second edition retains all the successful Having read this book, nurses should be more familiar with the approaches and techniques involved in critiquing nursing research and be able to utilise some of these skills and techniques in their own efforts to critique. Accordingly, they will be better placed to make informed judgements regarding the quality of the research paper and the value of the evidence reported.
features of the first, plus additional material on psychiatric research and critiquing nursing research when writing a dissertation. As nurse education around the world increasingly moves towards an all-graduate discipline, it is vital for nurses to have the ability to critique research in order to benefit practice. This book is the perfect tool for those seeking to gain or develop precisely that skill and is a must-have for all student nurses, teachers and academics.
About the authors
Dr John R. Cutcliffe holds the as ‘David G.students Braithwaite’ Professor ofhave Very suitable toChairundertake Nursing Endowed at the University of Texas (Tyler); he is also an Adjunct Professor of Psychiatric Nursing at Stenberg College International School of Nursing, Vancouver, Canada and a Visiting Professor at the University of Ulster, United Kingdom. He is an Associate Editor for the Journal of Psychiatric and Mental Health Nursing and an Assistant Editor for the International Journal of Nursing Studies. John’s clinical background is in psychiatric and general nursing, having worked as a clinician and then as an educator in the United Kingdom. He is an international scholar having worked in universities in four different countries: England, Northern Ireland, Canada and the United States. Martin Ward is an Independent Mental Health Nursing Consultant; he is also Co-ordinator of Mental Health Nursing Studies at the University of Malta and Chair of the Expert Panel of Horatio - European Psychiatric Nurses, based in the Netherlands. From 1995 to 2000 he held the post of Director of Mental Health for the Royal College of Nursing. Martin has been a Trustee of the English Health Advisory Service (HAS) and a member of the HAS Inspectorate and has also been involved with work with the World Health Organisation. In 1997, both authors were instrumental in designing and launching the NPNR National Journal Club.
Critiquing Nursing Research
John Cutcliffe and Martin Ward
This second edition of Critiquing Nursing Research retains the features which made the original book a best-seller while incorporating new material in order to expand its applicability. In addition to reviewing and updating the material of the original text, the authors have added two further chapters: the first focuses on how to critique research as part of the work of preparing a dissertation; and the second on mental health research agendas throughout Europe.
Critiquing Nursing Research 2nd edition
a dissertation where they critique three pieces of nursing research.
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Foreword by Professor Kevin Gournay
John Cutcliffe and Martin Ward
ISBN 978-1-85642-316-8
John Cutcliffe and Martin Ward
The new and updated edition of the best-selling book
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© 2014 MA Healthcare Ltd
ISBN-13: 978-1-85642-316-8; 234 x 156 mm; paperback; 244 pages; publication November 2006; £25.99
British Journal of Nursing, 2014, Vol 23, No 21
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 24, 2015. For personal use only. No other uses without permission. . All rights reserved.
