NURS 355: Ch. 6- Diverse Population

Biologic Sex

Sex assigned at birth

-external genitalia, internal reproductive organs, and chromosomes

Biologically male

Born with a penis, testicles, XY chromosomes

Biologically female

Born with a vagina, uterus, ovaries, XX chromosomes

Intersex

Born with genitalia or chromosomes that are not clearly categorized

Gender Identity

Self-perceived gender

Cisgender

gender identity aligns (same) with sex assigned at birth

Transgender

gender identity or expression is different (opposite) than sex assigned at birth

Gender

Socially-constructed idea based on cultural standards

Traditional Western culture

binary construct – male or female

Gender Expression

Expression of gender in outward appearance, behavior, mannerisms, interests that can change over time

Non-binary, gender fluid, gender queer

Describe someone who does not define themselves as completely one gender or the other

Cross-dressing

-Men (usually heterosexual) who wear women’s clothing for pleasure or performance

-May not be a permanent or full-time change

Gender Dysphoria

diagnostic classification - mental health disorder with defined criteria

-distress from conflict between a person’s gender identity and sex assigned at birth

Gender Non-Conformity

Gender identity, role or expression differs from expected cultural norms

-Not categorized as a mental health disorder

Sexual Orientation

How one identifies based on sexual or romantic attraction to others

-3 aspects (behavior, attraction, identity)

-aspects my or may or may not be tied together

Behavior

who are you attracted to sexually

Attraction

who are you attracted to emotionally

Identity

gay, lesbian, bisexual, or heterosexual

Asexual

Not feeling sexual attraction or desire for partnered sexuality

Bi, Bisexual

A person who is emotionally, sexually, or affectionally attracted to more than one gender

Cis, Cisgender

Term to describe persons whose gender identity matches their physical sex assigned at birth

Gay male

A male who is sexually, romantically, or relationally attracted to other men

Gender Queer/Gender Non-Conforming

A person whose gender identity or expression falls outside the traditional male/female binary

Heterosexual or “straight”

Implies a person who has sex with or is attracted to persons of the opposite gender

Homosexual (an offensive term)

“Gay man” or “lesbian” – preferred term describing persons who have sex with or are attracted to persons of the same gender

Intersex

A person who has biologic or secondary sex traits that are inconsistent with what is typically considered male or female

Lesbian

A woman who is sexually, romantically, or relationally attracted to other women

LGBTQ+, LGBTQI+, LGBTQIA+

Abbreviation for Lesbian, Gay, Bisexual, Queer/Questioning (LGBTQ), Intersex (LGBTQI), Ally/Asexual (LGBTIA)

The plus (+) acknowledges that there are more identities that exist

MSM

Men who have sex with men

Non-Binary

Refers to a spectrum of gender and not being in 1 of 2 categories. Typically, the 2 gender categories are male and female

Omnigender

Term that describes possessing all genders

Poly (Polyamorous)

Having more than 1 romantic relationship at the same time

Queer

A term that can mean people who identify as lesbian, gay, bisexual, transgender, or who identify outside of the traditional societal definitions of gender or sexual orientation

Some consider term offensive as it was previously used as a slur

Members of the LGBTQ+ community have taken back this term as a form of empowerment

Questioning

Persons who are in the process of examining or understanding their gender identity or sexual orientation

Same Gender Loving

Term to describe persons who are attracted physically, romantically, or relationally to persons of the same gender

Trans, Transgender

An umbrella term for people whose gender identity differs from their sex assigned at birth

Two Spirit

A term used by Native American and Canadian First Nation people to describe persons who identify with a 3rd gender that has both masculine and feminine qualities

Health Inequities

Stigma and discrimination are often based on cultural, political, legal and historic contexts

-Creates a hostile culture

Homosexuality was identified as a mental illness until 1973

Some religions do not acknowledge or accept same sex behaviors or feelings

Same sex marriage legalized by U.S. Supreme Court in 2015 changed

Pervasive discrimination by healthcare providers is felt by

Poverty

Stems from stigma and discrimination

-Leads to poor health outcomes

Other Health Disparities- Higher rates of

Substance use, including alcohol & tobacco

- twice as high

Depression & anxiety

Violence & victimization

LGBTQ+ Youth

report feeling down or hopeless

Rate of mental health disorders are higher

considered suicide

Social & Health Issues- Disproportionately higher rates of

Violence and victimization

Cancer

Obesity and overweight

HIV and STIs

Health Care Providers have

Limited training in providing culturally appropriate care to the LGBTQ+ community contribute to challenges and barriers

Gerontologic Considerations- Limited network of support

higher rates of isolation

Intolerance in the older age groups (65 years+) - go “back in the closet” in fear of negative & violent reactions from residents & staff in long-term care facilities

Inclusive Environments

Non-discrimination

Inclusive

Welcoming Environments

Begin the moment a patient enters our facilities - even before we have contact

-Inclusive bill of rights displayed

-Safe space signage or visual cues for all

Intake Process

Use inclusive communication strategies

Establish the patient’s preferred name, gender identity and use of pronouns

Social History

Use gender neutral terms when asking about relationship status or living situation until you are clear

-ask if unsure, never assume

Ethical/Legal Considerations

Advance Directives

Make decision-making documents available to patients

Health History

Include non-judgmental language

sensitivity in regard to patient choices

Be aware of your own discomfort

Consider starting conversations with basic questions about fertility, pregnancy, family planning, STIs

Preventive Health

Standard guidelines for preventive health screenings

Educate on PrEP and PEP strategies to prevent HIV when indicated

Do not assume that a transgender patient has had gender affirming surgery

Tobacco use screening, education and assistance

Gender Affirming Hormone Therapy (GAHT)

Provides the opportunity to transition to the gender of choice

Aligns hormones and physical attributes with affirmed gender

Testosterone therapy is used for those choosing to become male

Estrogen and anti-androgen therapy is used for those choosing to become female

Changes occur over an extended period of time (months to years)

GAHT

●Standards of care for transgender persons

●Ask patients about desire for future fertility and reproductive health

●Teach about side effects and the importance of adherence to the treatment regimen

Non-Surgical Gender Affirming Interventions

●Chest binding of breasts or tucking the penis

●Cosmetic fillers to feminize facial features

●Vocal therapy to feminize voices

Gender Affirming Surgery

●Gender reconstructive surgery is not a choice of all transgender persons

●Range and type of surgery is primarily driven by patient desires and goals

●May include a series of procedures over time

Chest Masculinization Surgery

Breast tissue is removed

Nipples are repositioned

Patient anatomy and surgical preference help determine exact technique

Testosterone therapy is not a pre-requirement

Feminizing Breast Augmentation

GAHT may not produce the desired results

May require a minimum of 12 months of hormone therapy before surgery

Gel or saline implants

Fat transfer - patient is the donor

Nursing Management for Gender Affirming Surgery: Assessment

Documentation of persistent gender dysphoria

Capacity and ability to provide informed consent

Age of majority

Well-controlled co-occurring medical or mental health problems

Interprofessional collaboration

Nursing Management for Gender Affirming Surgery: Implementation

Acute care

-General post-op care

-Drain care including amount and type of drainage

-Chest binder or other supportive dressings and associated care

-Pain management

Ambulatory Care

-Assess for complications – seromas, hematomas, infection

-Manage limited range of motion (usually lasts for several weeks post-op)

-Ongoing regular screening for breast cancer – the length of exposure to feminizing hormones increases the risk of breast cancer