Nurse Educator
Nurse Educator Vol. 40, No. 5, pp. 244-248 Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Meeting the Needs of the Transgender Nursing Student Pamela Levesque, DNP, APRN-BC, FNP, CNE Student success has been linked to a supportive academic environment and faculty involvement. The college experience can be stressful for any nursing student. Transgender nursing students experience the additional stress of being in the gender minority. This article focuses on the needs of the transgender nursing student and suggests interventions to support academic and social success. Keywords: gender identity; LGBTQ; nursing faculty; nursing students; transgender persons
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ransgender and trans are often used as umbrella terms referring to people whose gender identity and/or gender expression does not match their gender assigned at birth (natal gender). More recently, TGNC, an abbreviation for trans and gender nonconforming, is being used as it more broadly identifies the numerous identities within transgender communities.1,2 People who identify as transgender are increasing their visibility in society as a greater number are coming out and proclaiming their transgender identity.3,4 Societal visibility includes college campuses where diversity is more prevalent today than ever. Census data for the transgender student are sparse, limited to individual studies, and not done at the national level. In a 2003 study by The Policy Institute of the National Gay & Lesbian Task Force, of 1000 students who responded, 68 self-identified as transgender.5 It is not known if these figures are representative of the total population of transgender college students. Other studies examined did not provide data on the number of transgender students.3,6 While the literature pertaining to transgender issues at colleges and universities is scarce, their needs are gaining greater attention, as more campuses include gender identity and gender expression in their nondiscrimination and mission statements.7 What does exist in the literature suggests a lack of resources and little support. Colleges have a duty to provide a safe educational setting to all students. The American College Health Association (ACHA) and the National Education Association (NEA) have cultural competency statements, both of which refer to cultural competency as a lifelong Author Affiliation: Assistant Professor, Department of Nursing, University of North Carolina–Wilmington. The author declares no conflicts of interest. Correspondence: Dr Levesque, 211 Hillside Dr, Portsmouth, NH 03801 ([email protected]). Accepted for publication: February 17, 2015 Published ahead of print: April 15, 2015 DOI: 10.1097/NNE.0000000000000163
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journey.8,9 The ACHA extends this description by stating that cultural competency is a developmental process going beyond awareness and knowledge to expanding one’s horizons, thinking critically about power and oppression, and behaving appropriately. In the ACHA online guidelines, cultural competency represents the ‘‘capacity for an individual, an organization, or an institution to respond to the unique needs of populations whose cultures are different from that which might be referred to as ‘dominant’.’’8 The NEA suggests that the ability to successfully teach students from a culture or cultures other than our own depends on having cultural competence.9 As part of the gender minority, transgender persons face greater risk to their health and well-being than do their heterosexual age peers. These risks include alienation, high dropout rates, suicide, verbal and physical harassment, substance abuse, sexually transmitted diseases, homelessness, prostitution, and declining school performance.10,11 Nurse educators are in a key position to facilitate transition to and success in academic life for transgender nursing students by ensuring there is a safe environment for learning. This article focuses on the needs of the transgender nursing student and suggests interventions for the nursing education program and nurse educators when working with transgender nursing students.
Review of the Literature An initial search with no period-of-time limitation conducted using Ovid, CINAHL, Health Source Plus, and EBSCO databases using the keywords transgender, nursing, student, college, qualitative research, and experiences yielded no publications specifically on the experience of the transgender nursing student. The only limitation to the search was English-language availability. The search produced 10 articles related to transgender students, of which 8 were related to transgender college students. A later search including keywords heteronormativity and nursing yielded 88 articles, 4 of which
Volume 40 & Number 5 & September/October 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Nurse Educator
related to nursing or nursing education programs and transgender students.
College Environment Blumenfeld et al examined lesbian, gay, bisexual, transgender, and queer (LGBTQ) experiences on campuses across the United States.12 A total of 5149 students, staff, faculty, and administrators who identified as belonging to the queer spectrum (lesbian, bisexual, gay, same-sex loving, pansexual, asexual, questioning, and along the trans spectrum) participated. Participants comprised all 50 states and all institutions included in the Carnegie Basic Classification of Institutions of Higher Education. LGBTQ individuals on college and university campuses were found to be at a significantly higher risk for harassment as compared with the study’s control group of their heterosexual and gender normative counterparts. Thirty-one percent experienced a difficult or hostile campus and climate, 21% experienced some form of harassment related to their sexual identity or gender expression; and 43% of the trans spectrum feared for their physical safety.12 Pusch,3 Goodrich,6 and McKinney13 conducted the only 3 identified studies that specifically examined the experiences of transgender college students. They found that gender and sexual minority college students were increasing their visibility and faced college-related stressors connected to being in a minority, which may impact their experience and success. In all of the studies, students reported that their schools lacked resources such as support groups and gender-specific counseling or health care. In addition, participants stated that they experienced a lack of safety where issues of prejudice, discrimination, or a hostile campus climate were concerned. Pusch3 also found that gender binary assumptions are predominant on college campuses. Those college students who do not conform to the gender binary fear how friends and family will react when they come out and fear ridicule and physical harm within the college campus environment. Research themes from Furrow10 suggested a lack of safety through harassment, bullying, and threats while on campus. Some students connected safety with academic history. They believed that achieving high grades protected them from ‘‘professors’ homophobic treatmentI good grades were my safety.’’10(p150) High grades kept them from being singled out for any unnecessary reason. Other aspects of safety were related to exposure or suddenly being in a situation where a person is ‘‘being outed,’’ with one interviewee stating, ‘‘For me personally, safety is as simple as acknowledging my gender correctly.’’10(p150) In Furrow’s10 research, course content and structure were significant themes. Students described class discussions and the assumption that all participants who had not come out as LGBTQ were indeed straight, ‘‘there was always the straight assumption.’’10(p151) Heteronormativity is a societal hierarchical system that privileges and approves individuals based on presumed binaries of gender and sexuality.14 It is a belief that everyone is, or should be, heterosexual.15 This heteronormative belief, as opposed to a ‘‘queer’’ framework that allows for the presence of ‘‘other’’ identities (queer, gender queer, queer sexuality), limits identity expression and as such perpetuates the gender binary that isolates the transgender student on campus. Faculty participating in Furrow’s10 study indicated that they were responsible for creating a safe learning enviNurse Educator
ronment through awareness of LGBTQ issues facing students on campus. Establishing a positive climate in the early days of a course, confronting conflict quickly and thoroughly when it arises, and personal coming out as LGBTQ or as an ally also were reported by faculty as ways they could support the sexual and gender minority student.
Nursing LGBTQ nurses are frequently found to be invisible in the nursing workforce, absent from discourses of professional nursing organizations, and ignored or pathologized in the nursing curriculum and have historically been absent from nursing journals.1,7 It has been suggested that nursing education, practice, and administration do not reflect the cultural diversity of populations they serve.16,17 Studies investigating nursing’s knowledge and attitudes toward LGBTQ persons suggest a gap.18-21 Although there is a beginning shift in medical and nursing education to include the gender and sexual minorities, heteronormativity remains dominant.21,22 Benkert et al23 assessed cultural competency among 122 nurse practitioner students. Students reported high levels of comfort with people who are different from themselves but fairly low scores on engaging in community-related, culturally relevant behaviors. An early study by Randall24 surveyed baccalaureate nurse educators (n = 95) from 13 schools to assess their knowledge and attitudes about lesbians. The results of the study indicated educators were not personally fearful of sexual advances from lesbians but had concern about lesbians molesting and caring for children and being in the role of an educator. More than half of the respondents believed that ‘‘lesbianism’’ was not a natural expression of human sexuality. This study was published in 1989, and there are no recent studies for comparison. Using the Transcultural Self-efficacy Tool, Hoyer17 examined the transcultural self-efficacy of nursing education leaders and faculty related to nonbinary sexual identities, referring to those individuals who identify outside the male/ female binary. Findings of the survey of 535 nurse leaders and faculty in 5 Midwestern states indicated that nursing education administrators were more transculturally confident than nursing education faculty in their personal attitudes, values, and beliefs (affective).17 Two studies exploring nursing student experiences in general are mentioned here to bring insight into the student experience regarding minority culture and the nursing learning environment. Coleman’s25 qualitative research explored the experiences of 14 African American nursing students from a predominantly white, 2-year program. Themes uncovered were difference (alienation), coping and survival, supports systems, and institutional context (‘‘This is a white environment. We’re left out’’), similar to themes identified in transgender college student studies. A study by Hinchberger26 in 2009 explored the question of violence against female nursing students (n = 126). All respondents reported witnessing or experiencing violence in their clinical placements. Perpetrators were staff members (50% of the time), followed by patients (25%) and visitors or others (25%). While direct correlations of these 2 nursing student studies cannot be made to the transgender nursing student population, they provide context to the potential environment transgender nursing students may face during their education. Volume 40 & Number 5 & September/October 2015
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Nursing Education Implications College students in general struggle for peer approval and self-acceptance.13 Transgender students face the issues associated with college life, financial, academic, and social, with the additional turmoil of developing a positive self-image related to gender identity. Zubernis and Snyder27 suggested that destructive attitudes absorbed from society can be internalized, and this may leave students feeling like outsiders influencing their ability to successfully complete their education. While nursing has addressed culturally competent care for the LGBTQ patient, disparities still remain. In an effort to promote positive educational and social engagement for all students, it is essential that academic institutions and nursing education programs develop awareness of and sensitivity to the gender minorities. This may take courage on the part of the nurse educator and nursing administration. Courage in nursing can be linked to ethical and moral risk taking where one takes actions despite fear for self and of others with the intent to ensure safety.28 There must be a commitment to creating an environment that is accepting, welcoming, and supportive and that offers integration into the academic and social milieu.25 Nationally, there are standards that guide for the provision of culturally appropriate health and health care. These standards, known as Culturally and Linguistically Appropriate Services in Health and Health Care, were developed in 2000 and enhanced in 2013 as a response to a change in health disparities, shifting demographics, and legal and accreditation requirements.29 Fueled by the Institute of Medicine’s publication, Unequal Treatment, culturally and linguistically appropriate services gained recognition as a key way to address a changing cultural health landscape within the United States.30 The National League for Nursing and the American Association of Colleges of Nursing (AACN) provide statements that support a nursing education climate of diversity and inclusion.31,32 AACN data show that in 2013 more than 30% of students at each level (baccalaureate, masters, and doctoral) represented minority populations.32 No nursing student population data exist for the gender minority population. The ACHA and NEA provide cultural competency guidelines for the academic setting. The NEA guidelines include a diversity toolkit for educators, which is adapted from Diller and Moule’s ‘‘Cultural Competence: A Primer for Educators.’’9 The 5 basic cultural competence skills areas are (1) valuing diversity, (2) being culturally self-aware, (3) understanding dynamics of differences, (4) having knowledge of students’ culture, and (5) institutionalizing cultural knowledge and adapting to diversity. Strategies within the categories are adapted to nursing education.
Valuing Diversity Transgender college students are diverse across race and ethnicity, age, sexual preference, class, family composition, geographic location, religion, disability, and immigrant status.33 Building a nursing unit that visibly embraces diversity begins with assessing and modifying departmental policies and practices by the entire nursing unit: leadership, nursing faculty, and administrative support staff. Defining ‘‘valuing diversity’’ is an essential component of the conversation in which the school of nursing creates core statements that demonstrate 246
what this ‘‘looks’’ like in their school any given day. Statements of a culturally sensitive environment, such as the mission statement and policies, should be transparent and included in all written materials including the Internet and recruitment literature. Creating a culturally diverse climate goes beyond documenting the school’s philosophy and policies to include the appearance of the school. It is suggested this appearance include photographs, art work, and diversity statements on the walls of the school, which set a tone and acknowledge the practice environment and belief system. Encouraging the diversity community, both college and community-at-large, to display their artwork bridges the divide and may help to facilitate a larger and more inclusive picture of diversity awareness.
Being Culturally Self-aware Cultural competency is the capacity for an individual (and organization) to respond to the many needs of various cultures different from what may be seen as dominant.8 The ACHA list of culturally competent characteristics at the individual level can be found at its website. Nursing administrators should assist faculty in the development of cultural awareness, which includes the needs of nursing students who are of the gender minority.25 Diversity workshops, panel presentations, and webinars that integrate knowledge and vocabulary specific to the minority group should be considered essential components of the program. Including attitude self-assessment tools that are selfadministered allows for faculty to have privacy with their findings and aids in creating a safe culture for all. Support for the growth of culturally competent nurse educators is demonstrated through ongoing diversity initiatives, by including selfawareness assessments as part of the annual self-evaluation, and by requiring professional development continuing education the area of cultural awareness and competence. Dynamics of Differences It is well documented in the literature that most nursing curricula are devoid of a representation of the gender minority (and sexual minority). Further steps include crafting a developmentally organized curriculum that clearly integrates health care for the gender (and sexual) minority in all courses, for both prelicensure and graduate programs. Carefully developing such a diverse and rich cultural curriculum includes the selection of textbooks or supplemental materials that are LGBTQ inclusive. Textbooks that are not inclusive of the gender minority can be supplemented with evidence-based resources, lay press writings, and film. Commitment to the mission of a culturally diverse curriculum can initially mean extra time and work for faculty, but faculty members working together on the mission, as opposed to in course-situated silos, are essential for the school of nursing. Faculty working together can also mean classroom support. Coteaching unfamiliar content or having guest speakers are ways that faculty can support one another to provide open and diverse classroom content. No one person can be the holder of all culturally targeted knowledge. The creation of a caring diverse culture includes the care faculty have for one another where being able to ask for help is embraced without judgment but with a spirit of collegiality and cohesion.
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Faculty in Furrow’s10 study addressed the importance of faculty role modeling. Examples included modeling acceptance during classroom discussion, confronting conflict when it occurred in the classroom, monitoring homophobic language used in the classroom, and consulting with available campus resources to educate oneself.10 The NEA suggests that ‘‘knowing what can go wrong in cross-cultural communication’’ is inherent to understanding the dynamics of differences in a classroom. Knowing how to facilitate the dialogue, whether it is online or in person, takes personal comfort and forethought on the part of the educator. Research findings also recognize the importance of establishing a safe setting for LGBTQ students.3,6,10 Gender differences may include the use of legal or birth name versus the student’s preferred name and pronoun with which they identify. This may be incorporated into the first day of the nursing program when students introduce themselves. How can nurse educators create a safe space for all students including the transgender nursing student? Setting the stage (environment) is important. The educator can frame the exercise by asking students to include in their introduction their preferred name and pronoun and begin the exercise by presenting their preferred name and pronoun as well. Rules for communication and expectations for classroom behavior should be discussed. Civility as a concept should be made tangible in relation to cultural sensitivity. Inviting a speaker from campus diversity may also provide an opportunity for open conversation. Including these components in the beginning of the nursing program and with each course provides opportunities for role modeling by faculty and setting a standard for collegial behavior that does not tolerate prejudices or heteronormativity.
Knowledge of Students’ Culture Culturally responsive teaching includes student-centered instruction.32 Student-centered instruction in a culturally responsive environment takes into consideration the impact of the teaching and learning strategies on the learner and respects and builds on the diverse experiences of the student group.9,32 An example for a culturally responsive learning environment is the instruction of physical assessment techniques. It is common for students to be paired for practice. However, establishing a safe personal boundary space for learning is critical. Imagine you are transgender and actively transitioning; your chest may be bound, your body may feel foreign because of hormones, or you might have had recent surgery as part of the reassignment process. Stress is inevitable, and learning potentially thwarted. Informing nursing students about class content and structure prior to class can prepare students for potentially uncomfortable situations. For example, sending an e-mail to students prior to the first physical assessment class should outline learning activities and expectations and invite students to contact the course faculty member with any issues. Another area of attention for the culturally responsive nurse educator is the learning laboratory. It is not unusual for a manikin to have an upper torso of 1 gender with interchangeable sexual genitalia (male/female). Manikins may be referred to as ‘‘he/she’’ by students who are unfamiliar with this situation, which can be insensitive to transgender persons. Faculty who address this reference at the outset of the Nurse Educator
course and whenever it is overheard are establishing a safe learning environment for all. Integrating gender and sexual health assessment into the nursing curriculum should be a priority for nursing programs. Health assessment interviewing and forms should be inclusive of the gender (and sexual) minority. Students who are exposed to inclusivity from the beginning of their programs are more likely to integrate this practice as the norm. Heteronormativity and gender biases in the clinical setting exist and present another situation in which faculty members need cultural awareness. Potential clinical issues could involve staff nurses, patient, and family comments or reactions to the transgender student’s appearance. Issues of personal safety related to gender-assigned bathrooms and changing areas for clinical experiences need to be addressed proactively by clinical faculty. Faculty who are aware of potentially stressful situations can take the initiative to assess the clinical environment for potential conflicts.
Institutionalizing Cultural Knowledge and Adapting to Diversity Some colleges and universities in an attempt to implement congruent diversity policies and practices have made systemic administrative changes. For example, the University of Vermont updated its nondiscrimination policies and made modifications to the student-information system. The university created a software path that puts students’ preferred names and pronouns on class rosters and identification cards but retains their legal names on financial and medical forms. The university also stopped dividing students by gender during orientation.34 Changes such as these protect students from ‘‘outing themselves’’ as transgender, which should be a personal decision. Other interventions to be considered at the campus level include gender-neutral housing and bathrooms, campusbased culturally sensitive health care services with private patient changing rooms, and support services for transgender students including counseling.13,34,35 A peer support group establishing a community of peers allows for a social environment where identities are not stigmatized. These supports offer opportunity for transgender students to complete their education in a safe and supportive learning environment free from fear of minority stress-associated ridicule, harassment, or rejection.36 Nurses seek to create a world where all people receive and have a voice in competent, compassionate, and respectful care in their communities.37 Congruent with this mission is the mindful nursing education of those of the gender minority, transgender nursing students.
Conclusion Nursing faculty are charged with the responsibility of crafting a curriculum that is inclusive of the gender (and sexual) minority. In keeping with this culturally congruent curriculum, educators have the responsibility of creating a nursing education unit where those in the gender minority can learn safely and become the next generation of professional nurses, free from harm and prejudice.
References 1. Johnson M, Yucha C. Methodological quality of quantitative nursing lesbian, gay, bisexual, and transgender research from 2000 to 2010. Adv Nurs Sci. 2012;35(2):154-165. Volume 40 & Number 5 & September/October 2015
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2. Erickson-Schroth L, ed. Trans Bodies, Trans Selves: A Resource for the Transgender Community. New York: Oxford University Press; 2014. 3. Pusch RS. Objects of curiosity: transgender college students’ perceptions of the reactions of others. J Gay Lesbian Issues Educ. 2005;3(1):45-61. 4. Alegria AC. Transgender identity and health care: implications for psychosocial and physical evaluation. J Am Acad of Nurse Pract. 2010;23(4):175-182. 5. Rankin RS. Campus Climate: for gay, lesbian, bisexual, and transgender people: a national perspective. National LGBTQ Task Force Web Site. Available at http://www.thetaskforce.org/ static_html/downloads/reports/reports/CampusClimate.pdf. Published April 2003. Accessed November 11, 2014. 6. Goodrich MK. Lived experiences of college-age transsexual individuals. J Coll Counse. 2012;18:215-232. 7. Broido ME. Understanding diversity in millennial students. New Dir Stud Serv. 2004;106:73-85. 8. ACHA guidelines: cultural competency statement. Available at http://www.acha.org. Updated February 2011. Accessed November 11, 2014. 9. NEA Diversity Toolkit: Cultural Competence for Educators. Available at http://www.nea.org/tools/30402.htm. Published 2002. Accessed November 11, 2014. 10. Furrow H. LGBT students in the college composition classroom. J Ethnogr Qual Res. 2012;6:145-159. 11. MuDoz-Plaza C, Quinn CS, Rounds AD. Lesbian, gay, bisexual and transgender students: perceived social support in the high school environment. High School J. 2012;85(4):52-63. 12. 2010 State of Higher Education for Lesbian, Gay, Bisexual & Transgender People. Campus Pride. Available at http://www. campuspride.org/store/products/2010-state-of-higher-educationfor-lgbt-people/. Accessed November 27, 2014. 13. McKinney SJ. On the margins: a study of the experiences of transgender college students. J Gay Lesbian Issues Educ. 2005; 3(1):63-75. 14. Toomey BR, McGuire KJ, Russell TS. Heteronormativity, school climates, and perceived safety for gender nonconforming peers. J Adolesc. 2012;35:187-196. 15. Morrison S, Dinkel S. Heterosexism and health care: a concept analysis. Nurs Forum. 2012;47(2):123-130. 16. Kardong-Edgren S, Campinha-Bacote J. Cultural competency of graduating US bachelor of science nursing students. Contemp Nurse. 2008;28:37-44. 17. Hoyer G. Transcultural self-efficacy of nursing education leaders and faculty related to non-binary sexual identities. 2013. Master’s Thesis and Doctoral Dissertations. 2013. PaperS65. Digital Commons@EMU. Available at www.http://commons.emich.edu/these. Accessed December 9, 2014. 18. Chapman R, Watkins R, Zappia T, Nicol P, Shields L. Nursing and medical students’ attitudes, knowledge and beliefs regarding lesbian, gay, bisexual and transgender parents seeking health care for their children. J Clin Nurs. 2011;21(7-8):938-945. 19. Eliason JM, Raheim S. Experiences and comfort with culturally diverse groups in undergraduate pre-nursing students. J Nurs Educ. 2000;39(4):161-165.
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20. Levesque P. Nurse practitioners knowledge, attitudes, and self-efficacy for working with transgender patients. Clin Nurs Stud. 2013;1(4):93-100. 21. Rondahl G. Students’ inadequate knowledge about lesbian, gay, bisexual and transgender persons. Int J Nurs Educ Scholarsh. 2009:6(1). doi: 10.2202/1548-923X.1718. 22. Rondahl G. Heteronormativity in health care education programs. Nurse Educ Today. 2011;31(4):345-349. 23. Benkert R, Tanner C, Guthrie B, Oakley D, Pohl MJ. Cultural competence of nurse practitioner students: a consortium’s experience. J Nurs Educ. 2005;44(5):225-232. 24. Randall EC. Lesbian phobia among BSN educators: a survey. J Nurs Educ. 1989;28(7):302-306. 25. Coleman DL. Experiences of African American students in a predominantly White, two-year nursing program. Assoc Black Nurs Faculty J. 2008;winter:8-13. 26. Hinchberger AP. Violence against female student nurses in the workplace. Nurs Forum. 2009;44(1):37-46. 27. Zubernis L, Snyder M. Considerations of additional stressors and developmental issues for gay, lesbian, bisexual, and transgender college students. J Coll Stud Psychother. 2007;22(1):75-79. 28. Hawkins S, Morse J. The praxis of courage as a foundation for care. J Nurs Scholarsh. 2014;46(4):263-270. 29. National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care. Think Cultural Health Web site. Available at www.http://thinkculturalhealth.hhs.gov/Content/ clas.asp. Accessed November 11, 2014. 30. National Academy of Sciences Web site. Institute of Medicine: Unequal Treatment: What HealthCare Providers Need to Know About Racial and Ethnic Disparities in Health Care. Available at https://www.iom.edu/~/media/Files/Report%20Files/2003/ Unequal-Treatment-Confronting-Racial-and-Ethnic-Disparitiesin-Health-Care/Disparitieshcproviders8pgFINAL.pdf. Accessed November 11, 2014. 31. A Commitment to Diversity in Nursing and Nursing Education. National League for Nursing Web site. Available at www.nln.org. aboutnln/reflection_dialgoue/refl_dial_3html. Accessed November 11, 2014. 32. The Changing Landscape: Nursing Student Diversity on the Rise. American Association of Colleges of Nursing Web site. Available at www.aacn.nche.edu/diversity-in-nursing. Accessed November 11, 2014. 33. Harley AD, Nowak MT, Gassaway JL, Savage AT. Lesbian, gay, bisexual, and transgender college students with disabilities: a look at multiple cultural minorities. Psychol Sch. 2002;39(5):525-538. 34. Tisley A. New policies accommodate transgender students. Chron High Educ. 2010;56(39):19-20. 35. Beemyn GB, Dominque A, Pettit J, Smith T. Suggested steps to make campuses more trans-inclusive. J Gay Lesbian Issues Educ. 2008;3(1):89-94. 36. Bockting DW, Miner HM, Romine Swinburne ER, Hamilton A, Coleman E. Stigma, mental health, and resilience in an online sample of the US transgender population. Am J Public Health. 2013;103:943-951. 37. Shattell MM, Chinn LP. Nursing silent on LGBTQ health: rebel nurses provide hope. Arch Psychiatr Nursi. 2014;28(1):76-77.
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Nurse Educator
Nurse Educator Vol. 40, No. 5, pp. 244-248 Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Meeting the Needs of the Transgender Nursing Student Pamela Levesque, DNP, APRN-BC, FNP, CNE Student success has been linked to a supportive academic environment and faculty involvement. The college experience can be stressful for any nursing student. Transgender nursing students experience the additional stress of being in the gender minority. This article focuses on the needs of the transgender nursing student and suggests interventions to support academic and social success. Keywords: gender identity; LGBTQ; nursing faculty; nursing students; transgender persons
T
ransgender and trans are often used as umbrella terms referring to people whose gender identity and/or gender expression does not match their gender assigned at birth (natal gender). More recently, TGNC, an abbreviation for trans and gender nonconforming, is being used as it more broadly identifies the numerous identities within transgender communities.1,2 People who identify as transgender are increasing their visibility in society as a greater number are coming out and proclaiming their transgender identity.3,4 Societal visibility includes college campuses where diversity is more prevalent today than ever. Census data for the transgender student are sparse, limited to individual studies, and not done at the national level. In a 2003 study by The Policy Institute of the National Gay & Lesbian Task Force, of 1000 students who responded, 68 self-identified as transgender.5 It is not known if these figures are representative of the total population of transgender college students. Other studies examined did not provide data on the number of transgender students.3,6 While the literature pertaining to transgender issues at colleges and universities is scarce, their needs are gaining greater attention, as more campuses include gender identity and gender expression in their nondiscrimination and mission statements.7 What does exist in the literature suggests a lack of resources and little support. Colleges have a duty to provide a safe educational setting to all students. The American College Health Association (ACHA) and the National Education Association (NEA) have cultural competency statements, both of which refer to cultural competency as a lifelong Author Affiliation: Assistant Professor, Department of Nursing, University of North Carolina–Wilmington. The author declares no conflicts of interest. Correspondence: Dr Levesque, 211 Hillside Dr, Portsmouth, NH 03801 ([email protected]). Accepted for publication: February 17, 2015 Published ahead of print: April 15, 2015 DOI: 10.1097/NNE.0000000000000163
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journey.8,9 The ACHA extends this description by stating that cultural competency is a developmental process going beyond awareness and knowledge to expanding one’s horizons, thinking critically about power and oppression, and behaving appropriately. In the ACHA online guidelines, cultural competency represents the ‘‘capacity for an individual, an organization, or an institution to respond to the unique needs of populations whose cultures are different from that which might be referred to as ‘dominant’.’’8 The NEA suggests that the ability to successfully teach students from a culture or cultures other than our own depends on having cultural competence.9 As part of the gender minority, transgender persons face greater risk to their health and well-being than do their heterosexual age peers. These risks include alienation, high dropout rates, suicide, verbal and physical harassment, substance abuse, sexually transmitted diseases, homelessness, prostitution, and declining school performance.10,11 Nurse educators are in a key position to facilitate transition to and success in academic life for transgender nursing students by ensuring there is a safe environment for learning. This article focuses on the needs of the transgender nursing student and suggests interventions for the nursing education program and nurse educators when working with transgender nursing students.
Review of the Literature An initial search with no period-of-time limitation conducted using Ovid, CINAHL, Health Source Plus, and EBSCO databases using the keywords transgender, nursing, student, college, qualitative research, and experiences yielded no publications specifically on the experience of the transgender nursing student. The only limitation to the search was English-language availability. The search produced 10 articles related to transgender students, of which 8 were related to transgender college students. A later search including keywords heteronormativity and nursing yielded 88 articles, 4 of which
Volume 40 & Number 5 & September/October 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Nurse Educator
related to nursing or nursing education programs and transgender students.
College Environment Blumenfeld et al examined lesbian, gay, bisexual, transgender, and queer (LGBTQ) experiences on campuses across the United States.12 A total of 5149 students, staff, faculty, and administrators who identified as belonging to the queer spectrum (lesbian, bisexual, gay, same-sex loving, pansexual, asexual, questioning, and along the trans spectrum) participated. Participants comprised all 50 states and all institutions included in the Carnegie Basic Classification of Institutions of Higher Education. LGBTQ individuals on college and university campuses were found to be at a significantly higher risk for harassment as compared with the study’s control group of their heterosexual and gender normative counterparts. Thirty-one percent experienced a difficult or hostile campus and climate, 21% experienced some form of harassment related to their sexual identity or gender expression; and 43% of the trans spectrum feared for their physical safety.12 Pusch,3 Goodrich,6 and McKinney13 conducted the only 3 identified studies that specifically examined the experiences of transgender college students. They found that gender and sexual minority college students were increasing their visibility and faced college-related stressors connected to being in a minority, which may impact their experience and success. In all of the studies, students reported that their schools lacked resources such as support groups and gender-specific counseling or health care. In addition, participants stated that they experienced a lack of safety where issues of prejudice, discrimination, or a hostile campus climate were concerned. Pusch3 also found that gender binary assumptions are predominant on college campuses. Those college students who do not conform to the gender binary fear how friends and family will react when they come out and fear ridicule and physical harm within the college campus environment. Research themes from Furrow10 suggested a lack of safety through harassment, bullying, and threats while on campus. Some students connected safety with academic history. They believed that achieving high grades protected them from ‘‘professors’ homophobic treatmentI good grades were my safety.’’10(p150) High grades kept them from being singled out for any unnecessary reason. Other aspects of safety were related to exposure or suddenly being in a situation where a person is ‘‘being outed,’’ with one interviewee stating, ‘‘For me personally, safety is as simple as acknowledging my gender correctly.’’10(p150) In Furrow’s10 research, course content and structure were significant themes. Students described class discussions and the assumption that all participants who had not come out as LGBTQ were indeed straight, ‘‘there was always the straight assumption.’’10(p151) Heteronormativity is a societal hierarchical system that privileges and approves individuals based on presumed binaries of gender and sexuality.14 It is a belief that everyone is, or should be, heterosexual.15 This heteronormative belief, as opposed to a ‘‘queer’’ framework that allows for the presence of ‘‘other’’ identities (queer, gender queer, queer sexuality), limits identity expression and as such perpetuates the gender binary that isolates the transgender student on campus. Faculty participating in Furrow’s10 study indicated that they were responsible for creating a safe learning enviNurse Educator
ronment through awareness of LGBTQ issues facing students on campus. Establishing a positive climate in the early days of a course, confronting conflict quickly and thoroughly when it arises, and personal coming out as LGBTQ or as an ally also were reported by faculty as ways they could support the sexual and gender minority student.
Nursing LGBTQ nurses are frequently found to be invisible in the nursing workforce, absent from discourses of professional nursing organizations, and ignored or pathologized in the nursing curriculum and have historically been absent from nursing journals.1,7 It has been suggested that nursing education, practice, and administration do not reflect the cultural diversity of populations they serve.16,17 Studies investigating nursing’s knowledge and attitudes toward LGBTQ persons suggest a gap.18-21 Although there is a beginning shift in medical and nursing education to include the gender and sexual minorities, heteronormativity remains dominant.21,22 Benkert et al23 assessed cultural competency among 122 nurse practitioner students. Students reported high levels of comfort with people who are different from themselves but fairly low scores on engaging in community-related, culturally relevant behaviors. An early study by Randall24 surveyed baccalaureate nurse educators (n = 95) from 13 schools to assess their knowledge and attitudes about lesbians. The results of the study indicated educators were not personally fearful of sexual advances from lesbians but had concern about lesbians molesting and caring for children and being in the role of an educator. More than half of the respondents believed that ‘‘lesbianism’’ was not a natural expression of human sexuality. This study was published in 1989, and there are no recent studies for comparison. Using the Transcultural Self-efficacy Tool, Hoyer17 examined the transcultural self-efficacy of nursing education leaders and faculty related to nonbinary sexual identities, referring to those individuals who identify outside the male/ female binary. Findings of the survey of 535 nurse leaders and faculty in 5 Midwestern states indicated that nursing education administrators were more transculturally confident than nursing education faculty in their personal attitudes, values, and beliefs (affective).17 Two studies exploring nursing student experiences in general are mentioned here to bring insight into the student experience regarding minority culture and the nursing learning environment. Coleman’s25 qualitative research explored the experiences of 14 African American nursing students from a predominantly white, 2-year program. Themes uncovered were difference (alienation), coping and survival, supports systems, and institutional context (‘‘This is a white environment. We’re left out’’), similar to themes identified in transgender college student studies. A study by Hinchberger26 in 2009 explored the question of violence against female nursing students (n = 126). All respondents reported witnessing or experiencing violence in their clinical placements. Perpetrators were staff members (50% of the time), followed by patients (25%) and visitors or others (25%). While direct correlations of these 2 nursing student studies cannot be made to the transgender nursing student population, they provide context to the potential environment transgender nursing students may face during their education. Volume 40 & Number 5 & September/October 2015
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Nursing Education Implications College students in general struggle for peer approval and self-acceptance.13 Transgender students face the issues associated with college life, financial, academic, and social, with the additional turmoil of developing a positive self-image related to gender identity. Zubernis and Snyder27 suggested that destructive attitudes absorbed from society can be internalized, and this may leave students feeling like outsiders influencing their ability to successfully complete their education. While nursing has addressed culturally competent care for the LGBTQ patient, disparities still remain. In an effort to promote positive educational and social engagement for all students, it is essential that academic institutions and nursing education programs develop awareness of and sensitivity to the gender minorities. This may take courage on the part of the nurse educator and nursing administration. Courage in nursing can be linked to ethical and moral risk taking where one takes actions despite fear for self and of others with the intent to ensure safety.28 There must be a commitment to creating an environment that is accepting, welcoming, and supportive and that offers integration into the academic and social milieu.25 Nationally, there are standards that guide for the provision of culturally appropriate health and health care. These standards, known as Culturally and Linguistically Appropriate Services in Health and Health Care, were developed in 2000 and enhanced in 2013 as a response to a change in health disparities, shifting demographics, and legal and accreditation requirements.29 Fueled by the Institute of Medicine’s publication, Unequal Treatment, culturally and linguistically appropriate services gained recognition as a key way to address a changing cultural health landscape within the United States.30 The National League for Nursing and the American Association of Colleges of Nursing (AACN) provide statements that support a nursing education climate of diversity and inclusion.31,32 AACN data show that in 2013 more than 30% of students at each level (baccalaureate, masters, and doctoral) represented minority populations.32 No nursing student population data exist for the gender minority population. The ACHA and NEA provide cultural competency guidelines for the academic setting. The NEA guidelines include a diversity toolkit for educators, which is adapted from Diller and Moule’s ‘‘Cultural Competence: A Primer for Educators.’’9 The 5 basic cultural competence skills areas are (1) valuing diversity, (2) being culturally self-aware, (3) understanding dynamics of differences, (4) having knowledge of students’ culture, and (5) institutionalizing cultural knowledge and adapting to diversity. Strategies within the categories are adapted to nursing education.
Valuing Diversity Transgender college students are diverse across race and ethnicity, age, sexual preference, class, family composition, geographic location, religion, disability, and immigrant status.33 Building a nursing unit that visibly embraces diversity begins with assessing and modifying departmental policies and practices by the entire nursing unit: leadership, nursing faculty, and administrative support staff. Defining ‘‘valuing diversity’’ is an essential component of the conversation in which the school of nursing creates core statements that demonstrate 246
what this ‘‘looks’’ like in their school any given day. Statements of a culturally sensitive environment, such as the mission statement and policies, should be transparent and included in all written materials including the Internet and recruitment literature. Creating a culturally diverse climate goes beyond documenting the school’s philosophy and policies to include the appearance of the school. It is suggested this appearance include photographs, art work, and diversity statements on the walls of the school, which set a tone and acknowledge the practice environment and belief system. Encouraging the diversity community, both college and community-at-large, to display their artwork bridges the divide and may help to facilitate a larger and more inclusive picture of diversity awareness.
Being Culturally Self-aware Cultural competency is the capacity for an individual (and organization) to respond to the many needs of various cultures different from what may be seen as dominant.8 The ACHA list of culturally competent characteristics at the individual level can be found at its website. Nursing administrators should assist faculty in the development of cultural awareness, which includes the needs of nursing students who are of the gender minority.25 Diversity workshops, panel presentations, and webinars that integrate knowledge and vocabulary specific to the minority group should be considered essential components of the program. Including attitude self-assessment tools that are selfadministered allows for faculty to have privacy with their findings and aids in creating a safe culture for all. Support for the growth of culturally competent nurse educators is demonstrated through ongoing diversity initiatives, by including selfawareness assessments as part of the annual self-evaluation, and by requiring professional development continuing education the area of cultural awareness and competence. Dynamics of Differences It is well documented in the literature that most nursing curricula are devoid of a representation of the gender minority (and sexual minority). Further steps include crafting a developmentally organized curriculum that clearly integrates health care for the gender (and sexual) minority in all courses, for both prelicensure and graduate programs. Carefully developing such a diverse and rich cultural curriculum includes the selection of textbooks or supplemental materials that are LGBTQ inclusive. Textbooks that are not inclusive of the gender minority can be supplemented with evidence-based resources, lay press writings, and film. Commitment to the mission of a culturally diverse curriculum can initially mean extra time and work for faculty, but faculty members working together on the mission, as opposed to in course-situated silos, are essential for the school of nursing. Faculty working together can also mean classroom support. Coteaching unfamiliar content or having guest speakers are ways that faculty can support one another to provide open and diverse classroom content. No one person can be the holder of all culturally targeted knowledge. The creation of a caring diverse culture includes the care faculty have for one another where being able to ask for help is embraced without judgment but with a spirit of collegiality and cohesion.
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Faculty in Furrow’s10 study addressed the importance of faculty role modeling. Examples included modeling acceptance during classroom discussion, confronting conflict when it occurred in the classroom, monitoring homophobic language used in the classroom, and consulting with available campus resources to educate oneself.10 The NEA suggests that ‘‘knowing what can go wrong in cross-cultural communication’’ is inherent to understanding the dynamics of differences in a classroom. Knowing how to facilitate the dialogue, whether it is online or in person, takes personal comfort and forethought on the part of the educator. Research findings also recognize the importance of establishing a safe setting for LGBTQ students.3,6,10 Gender differences may include the use of legal or birth name versus the student’s preferred name and pronoun with which they identify. This may be incorporated into the first day of the nursing program when students introduce themselves. How can nurse educators create a safe space for all students including the transgender nursing student? Setting the stage (environment) is important. The educator can frame the exercise by asking students to include in their introduction their preferred name and pronoun and begin the exercise by presenting their preferred name and pronoun as well. Rules for communication and expectations for classroom behavior should be discussed. Civility as a concept should be made tangible in relation to cultural sensitivity. Inviting a speaker from campus diversity may also provide an opportunity for open conversation. Including these components in the beginning of the nursing program and with each course provides opportunities for role modeling by faculty and setting a standard for collegial behavior that does not tolerate prejudices or heteronormativity.
Knowledge of Students’ Culture Culturally responsive teaching includes student-centered instruction.32 Student-centered instruction in a culturally responsive environment takes into consideration the impact of the teaching and learning strategies on the learner and respects and builds on the diverse experiences of the student group.9,32 An example for a culturally responsive learning environment is the instruction of physical assessment techniques. It is common for students to be paired for practice. However, establishing a safe personal boundary space for learning is critical. Imagine you are transgender and actively transitioning; your chest may be bound, your body may feel foreign because of hormones, or you might have had recent surgery as part of the reassignment process. Stress is inevitable, and learning potentially thwarted. Informing nursing students about class content and structure prior to class can prepare students for potentially uncomfortable situations. For example, sending an e-mail to students prior to the first physical assessment class should outline learning activities and expectations and invite students to contact the course faculty member with any issues. Another area of attention for the culturally responsive nurse educator is the learning laboratory. It is not unusual for a manikin to have an upper torso of 1 gender with interchangeable sexual genitalia (male/female). Manikins may be referred to as ‘‘he/she’’ by students who are unfamiliar with this situation, which can be insensitive to transgender persons. Faculty who address this reference at the outset of the Nurse Educator
course and whenever it is overheard are establishing a safe learning environment for all. Integrating gender and sexual health assessment into the nursing curriculum should be a priority for nursing programs. Health assessment interviewing and forms should be inclusive of the gender (and sexual) minority. Students who are exposed to inclusivity from the beginning of their programs are more likely to integrate this practice as the norm. Heteronormativity and gender biases in the clinical setting exist and present another situation in which faculty members need cultural awareness. Potential clinical issues could involve staff nurses, patient, and family comments or reactions to the transgender student’s appearance. Issues of personal safety related to gender-assigned bathrooms and changing areas for clinical experiences need to be addressed proactively by clinical faculty. Faculty who are aware of potentially stressful situations can take the initiative to assess the clinical environment for potential conflicts.
Institutionalizing Cultural Knowledge and Adapting to Diversity Some colleges and universities in an attempt to implement congruent diversity policies and practices have made systemic administrative changes. For example, the University of Vermont updated its nondiscrimination policies and made modifications to the student-information system. The university created a software path that puts students’ preferred names and pronouns on class rosters and identification cards but retains their legal names on financial and medical forms. The university also stopped dividing students by gender during orientation.34 Changes such as these protect students from ‘‘outing themselves’’ as transgender, which should be a personal decision. Other interventions to be considered at the campus level include gender-neutral housing and bathrooms, campusbased culturally sensitive health care services with private patient changing rooms, and support services for transgender students including counseling.13,34,35 A peer support group establishing a community of peers allows for a social environment where identities are not stigmatized. These supports offer opportunity for transgender students to complete their education in a safe and supportive learning environment free from fear of minority stress-associated ridicule, harassment, or rejection.36 Nurses seek to create a world where all people receive and have a voice in competent, compassionate, and respectful care in their communities.37 Congruent with this mission is the mindful nursing education of those of the gender minority, transgender nursing students.
Conclusion Nursing faculty are charged with the responsibility of crafting a curriculum that is inclusive of the gender (and sexual) minority. In keeping with this culturally congruent curriculum, educators have the responsibility of creating a nursing education unit where those in the gender minority can learn safely and become the next generation of professional nurses, free from harm and prejudice.
References 1. Johnson M, Yucha C. Methodological quality of quantitative nursing lesbian, gay, bisexual, and transgender research from 2000 to 2010. Adv Nurs Sci. 2012;35(2):154-165. Volume 40 & Number 5 & September/October 2015
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2. Erickson-Schroth L, ed. Trans Bodies, Trans Selves: A Resource for the Transgender Community. New York: Oxford University Press; 2014. 3. Pusch RS. Objects of curiosity: transgender college students’ perceptions of the reactions of others. J Gay Lesbian Issues Educ. 2005;3(1):45-61. 4. Alegria AC. Transgender identity and health care: implications for psychosocial and physical evaluation. J Am Acad of Nurse Pract. 2010;23(4):175-182. 5. Rankin RS. Campus Climate: for gay, lesbian, bisexual, and transgender people: a national perspective. National LGBTQ Task Force Web Site. Available at http://www.thetaskforce.org/ static_html/downloads/reports/reports/CampusClimate.pdf. Published April 2003. Accessed November 11, 2014. 6. Goodrich MK. Lived experiences of college-age transsexual individuals. J Coll Counse. 2012;18:215-232. 7. Broido ME. Understanding diversity in millennial students. New Dir Stud Serv. 2004;106:73-85. 8. ACHA guidelines: cultural competency statement. Available at http://www.acha.org. Updated February 2011. Accessed November 11, 2014. 9. NEA Diversity Toolkit: Cultural Competence for Educators. Available at http://www.nea.org/tools/30402.htm. Published 2002. Accessed November 11, 2014. 10. Furrow H. LGBT students in the college composition classroom. J Ethnogr Qual Res. 2012;6:145-159. 11. MuDoz-Plaza C, Quinn CS, Rounds AD. Lesbian, gay, bisexual and transgender students: perceived social support in the high school environment. High School J. 2012;85(4):52-63. 12. 2010 State of Higher Education for Lesbian, Gay, Bisexual & Transgender People. Campus Pride. Available at http://www. campuspride.org/store/products/2010-state-of-higher-educationfor-lgbt-people/. Accessed November 27, 2014. 13. McKinney SJ. On the margins: a study of the experiences of transgender college students. J Gay Lesbian Issues Educ. 2005; 3(1):63-75. 14. Toomey BR, McGuire KJ, Russell TS. Heteronormativity, school climates, and perceived safety for gender nonconforming peers. J Adolesc. 2012;35:187-196. 15. Morrison S, Dinkel S. Heterosexism and health care: a concept analysis. Nurs Forum. 2012;47(2):123-130. 16. Kardong-Edgren S, Campinha-Bacote J. Cultural competency of graduating US bachelor of science nursing students. Contemp Nurse. 2008;28:37-44. 17. Hoyer G. Transcultural self-efficacy of nursing education leaders and faculty related to non-binary sexual identities. 2013. Master’s Thesis and Doctoral Dissertations. 2013. PaperS65. Digital Commons@EMU. Available at www.http://commons.emich.edu/these. Accessed December 9, 2014. 18. Chapman R, Watkins R, Zappia T, Nicol P, Shields L. Nursing and medical students’ attitudes, knowledge and beliefs regarding lesbian, gay, bisexual and transgender parents seeking health care for their children. J Clin Nurs. 2011;21(7-8):938-945. 19. Eliason JM, Raheim S. Experiences and comfort with culturally diverse groups in undergraduate pre-nursing students. J Nurs Educ. 2000;39(4):161-165.
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20. Levesque P. Nurse practitioners knowledge, attitudes, and self-efficacy for working with transgender patients. Clin Nurs Stud. 2013;1(4):93-100. 21. Rondahl G. Students’ inadequate knowledge about lesbian, gay, bisexual and transgender persons. Int J Nurs Educ Scholarsh. 2009:6(1). doi: 10.2202/1548-923X.1718. 22. Rondahl G. Heteronormativity in health care education programs. Nurse Educ Today. 2011;31(4):345-349. 23. Benkert R, Tanner C, Guthrie B, Oakley D, Pohl MJ. Cultural competence of nurse practitioner students: a consortium’s experience. J Nurs Educ. 2005;44(5):225-232. 24. Randall EC. Lesbian phobia among BSN educators: a survey. J Nurs Educ. 1989;28(7):302-306. 25. Coleman DL. Experiences of African American students in a predominantly White, two-year nursing program. Assoc Black Nurs Faculty J. 2008;winter:8-13. 26. Hinchberger AP. Violence against female student nurses in the workplace. Nurs Forum. 2009;44(1):37-46. 27. Zubernis L, Snyder M. Considerations of additional stressors and developmental issues for gay, lesbian, bisexual, and transgender college students. J Coll Stud Psychother. 2007;22(1):75-79. 28. Hawkins S, Morse J. The praxis of courage as a foundation for care. J Nurs Scholarsh. 2014;46(4):263-270. 29. National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care. Think Cultural Health Web site. Available at www.http://thinkculturalhealth.hhs.gov/Content/ clas.asp. Accessed November 11, 2014. 30. National Academy of Sciences Web site. Institute of Medicine: Unequal Treatment: What HealthCare Providers Need to Know About Racial and Ethnic Disparities in Health Care. Available at https://www.iom.edu/~/media/Files/Report%20Files/2003/ Unequal-Treatment-Confronting-Racial-and-Ethnic-Disparitiesin-Health-Care/Disparitieshcproviders8pgFINAL.pdf. Accessed November 11, 2014. 31. A Commitment to Diversity in Nursing and Nursing Education. National League for Nursing Web site. Available at www.nln.org. aboutnln/reflection_dialgoue/refl_dial_3html. Accessed November 11, 2014. 32. The Changing Landscape: Nursing Student Diversity on the Rise. American Association of Colleges of Nursing Web site. Available at www.aacn.nche.edu/diversity-in-nursing. Accessed November 11, 2014. 33. Harley AD, Nowak MT, Gassaway JL, Savage AT. Lesbian, gay, bisexual, and transgender college students with disabilities: a look at multiple cultural minorities. Psychol Sch. 2002;39(5):525-538. 34. Tisley A. New policies accommodate transgender students. Chron High Educ. 2010;56(39):19-20. 35. Beemyn GB, Dominque A, Pettit J, Smith T. Suggested steps to make campuses more trans-inclusive. J Gay Lesbian Issues Educ. 2008;3(1):89-94. 36. Bockting DW, Miner HM, Romine Swinburne ER, Hamilton A, Coleman E. Stigma, mental health, and resilience in an online sample of the US transgender population. Am J Public Health. 2013;103:943-951. 37. Shattell MM, Chinn LP. Nursing silent on LGBTQ health: rebel nurses provide hope. Arch Psychiatr Nursi. 2014;28(1):76-77.
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