Sharing the Journey of a Transgender Patient

Joe was referred to me by a colleague in a women’s care clinic who knew of my interest in transgender health. He greeted me with, “I heard you’re interested in transgender care—I can be your guinea pig!”

Joe told me about his long-held desire to transition from being a woman to a man and asked me to be his partner in this journey. His honesty and openness about striving for an authentic life was the beginning of my own story about how a special patient can broaden understanding and change the way you practice.

Several years ago at the American Association of Nurse Practitioners National Conference, an NP from Connecticut spoke about her extensive experience with transgender patients. Her presentation was an excellent summary of the basics of gender identity and health implications. This topic seemed important to learn about, an area in which I could make a difference in my practice. Since becoming a nurse, I have felt drawn to helping the most vulnerable populations, and transgender persons experience marginalization in our society.

I never thought I could become an expert, but the speaker said that didn’t matter. She noted that her transgender patients usually teach her more than she teaches them. What is important is including transgender care in your primary care knowledge base,¹ since it has been recommended that primary care providers, at the frontlines in patient-centered care, coordinate and partner with transgender patients.²

I was so fortunate to meet Joe. He was open to answering my questions about his interest in a female-to-male (FTM) transition and what the process would entail. Despite my eagerness to help, I was admittedly nervous about portraying myself as a professional, knowing that my experience with transgender issues was limited. I didn’t want to say the wrong thing or use the wrong pronoun. What I discovered is that it’s OK to feel like a novice. It just takes practice to get the wording right, but your patients will appreciate your efforts.

Joe proved to be an excellent guide on this journey; at our first visit, he offered me resources, including information about an upcoming local transgender conference, evidence-based materials, and supportive readings. As I reviewed the literature to educate myself, I discovered that despite a paucity of research, there is a growing understanding of transgender issues and an increasing body of evidence to study.

One of the keys for many people, but especially for transgender persons, is psychological support. Often, transgender people have had a tough road, struggling with gender identity, isolation from friends and family, rejection issues, discrimination, and violence. Depression and suicide are all too common in this patient population.

The Endocrine Society’s Clinical Practice Guidelines recommend that patients secure a good working relationship with a mental health provider for their journey before moving forward with hormonal treatments and surgical interventions.³ Mental health professionals can also help families of transgender persons work through difficult psychosocial issues.

Joe was already regularly meeting with a psychologist and had an excellent support network in place. He was ready for the next step, and I was onboard to help him take it. I did some research to identify professionals in my community who were accepting transgender patients, as well as community resources available for this population. In speaking with colleagues, I was able to find a local endocrinologist who would prescribe hormones, a gynecologist who was comfortable with FTM transition, and a local plastic surgeon who was experienced with FTM chest reconstruction.

During my search for appropriate referrals, I would simply call the office and leave my name and a general question about whether the practice provided transgender care. If I received a “yes” response, I would then follow up with more personal contact with the provider. I did encounter some providers who were not comfortable providing transgender health care. I don’t know if this was an individual or organizational decision, or if it reflected personal beliefs or a lack of experience—but it has affected my further referrals to those offices.

I facilitated referrals for Joe to the endocrinologist, gynecologist, and plastic surgeon. He confirmed after the visits that these providers were professional, prepared, and welcoming, so they could be referral sources for other transgender persons in the future. And for those who might not be as far along their journey as Joe was when we met, several psychiatric NP colleagues directed me to a group of qualified and experienced counselors and therapists with expertise in gender-identity issues. I also discovered that the local university has a great support group for transgender people, as well as their friends and families. With these resources, I am equipped to help my transgender patients navigate their transitions.

As Joe’s primary care provider, though, my role is about more than just providing appropriate referrals. Some of the most important conversations we had addressed the implications of his transition for future preventive health screenings. These include breast exams, which are recommended after an FTM chest reconstruction, and pelvic exams, which are recommended if the uterus and cervix remain in place.⁴ The World Professional Association for Transgender Health has established standards of care that are helpful for providers and patients navigating this journey.⁵

Together, Joe and I developed a plan of care for the transition, with Joe making informed decisions. For example, we agreed that endocrinology would initiate hormone therapy, but I would manage it after a certain point.

The support and care that I can provide to my transgender patients is obvious. But what working with them does for me is equally invaluable. On any given day in the clinic, I can feel a little deflated and think, “Did I really help anyone today?” My experiences with transgender patients are refreshing, because I know they appreciate my support whether I am an expert or not; it is truly a gift to work with them. The experience has taught me that I can put new information I learn into practice, that I am an expert in preventive care and complex case coordination, and that I can be a competent and caring part of a health care team for transgender persons.

A transition is a process—a different journey for each individual. It is also a journey for each health care provider. Other health care professionals, like myself, can educate themselves about transgender issues and even become champions for this population in their communities. I hope to assist my colleagues in becoming more educated about transgender issues in the future. Please consider sharing your thoughts with me by writing to NPEditor@frontlinemedcom.com.

REFERENCES
1. Alegria CA. Transgender identity and health care: implications for psychological and physical evaluation. J Am Acad Nurse Pract. 2011;23(4):175-182.
2. Deutsch MB, Feldman JL. Updated recommendations from the World Professional Association for Transgender Health standards of care. Am Fam Phys. 2013;87(2):89-93.
3. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009;94(9):3132-3154.
4. University of California, San Francisco Center of Excellence for Transgender Health. Primary care protocol for transgender patient care (2011). http://transhealth.ucsf.edu/protocols. Accessed August 24, 2015.
5. World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people (7th version; 2015). www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351. Accessed August 24, 2015.

Joe was referred to me by a colleague in a women’s care clinic who knew of my interest in transgender health. He greeted me with, “I heard you’re interested in transgender care—I can be your guinea pig!”

Joe told me about his long-held desire to transition from being a woman to a man and asked me to be his partner in this journey. His honesty and openness about striving for an authentic life was the beginning of my own story about how a special patient can broaden understanding and change the way you practice.

Several years ago at the American Association of Nurse Practitioners National Conference, an NP from Connecticut spoke about her extensive experience with transgender patients. Her presentation was an excellent summary of the basics of gender identity and health implications. This topic seemed important to learn about, an area in which I could make a difference in my practice. Since becoming a nurse, I have felt drawn to helping the most vulnerable populations, and transgender persons experience marginalization in our society.

I never thought I could become an expert, but the speaker said that didn’t matter. She noted that her transgender patients usually teach her more than she teaches them. What is important is including transgender care in your primary care knowledge base,¹ since it has been recommended that primary care providers, at the frontlines in patient-centered care, coordinate and partner with transgender patients.²

I was so fortunate to meet Joe. He was open to answering my questions about his interest in a female-to-male (FTM) transition and what the process would entail. Despite my eagerness to help, I was admittedly nervous about portraying myself as a professional, knowing that my experience with transgender issues was limited. I didn’t want to say the wrong thing or use the wrong pronoun. What I discovered is that it’s OK to feel like a novice. It just takes practice to get the wording right, but your patients will appreciate your efforts.

Joe proved to be an excellent guide on this journey; at our first visit, he offered me resources, including information about an upcoming local transgender conference, evidence-based materials, and supportive readings. As I reviewed the literature to educate myself, I discovered that despite a paucity of research, there is a growing understanding of transgender issues and an increasing body of evidence to study.

One of the keys for many people, but especially for transgender persons, is psychological support. Often, transgender people have had a tough road, struggling with gender identity, isolation from friends and family, rejection issues, discrimination, and violence. Depression and suicide are all too common in this patient population.

The Endocrine Society’s Clinical Practice Guidelines recommend that patients secure a good working relationship with a mental health provider for their journey before moving forward with hormonal treatments and surgical interventions.³ Mental health professionals can also help families of transgender persons work through difficult psychosocial issues.

Joe was already regularly meeting with a psychologist and had an excellent support network in place. He was ready for the next step, and I was onboard to help him take it. I did some research to identify professionals in my community who were accepting transgender patients, as well as community resources available for this population. In speaking with colleagues, I was able to find a local endocrinologist who would prescribe hormones, a gynecologist who was comfortable with FTM transition, and a local plastic surgeon who was experienced with FTM chest reconstruction.

During my search for appropriate referrals, I would simply call the office and leave my name and a general question about whether the practice provided transgender care. If I received a “yes” response, I would then follow up with more personal contact with the provider. I did encounter some providers who were not comfortable providing transgender health care. I don’t know if this was an individual or organizational decision, or if it reflected personal beliefs or a lack of experience—but it has affected my further referrals to those offices.

I facilitated referrals for Joe to the endocrinologist, gynecologist, and plastic surgeon. He confirmed after the visits that these providers were professional, prepared, and welcoming, so they could be referral sources for other transgender persons in the future. And for those who might not be as far along their journey as Joe was when we met, several psychiatric NP colleagues directed me to a group of qualified and experienced counselors and therapists with expertise in gender-identity issues. I also discovered that the local university has a great support group for transgender people, as well as their friends and families. With these resources, I am equipped to help my transgender patients navigate their transitions.

As Joe’s primary care provider, though, my role is about more than just providing appropriate referrals. Some of the most important conversations we had addressed the implications of his transition for future preventive health screenings. These include breast exams, which are recommended after an FTM chest reconstruction, and pelvic exams, which are recommended if the uterus and cervix remain in place.⁴ The World Professional Association for Transgender Health has established standards of care that are helpful for providers and patients navigating this journey.⁵

Together, Joe and I developed a plan of care for the transition, with Joe making informed decisions. For example, we agreed that endocrinology would initiate hormone therapy, but I would manage it after a certain point.

The support and care that I can provide to my transgender patients is obvious. But what working with them does for me is equally invaluable. On any given day in the clinic, I can feel a little deflated and think, “Did I really help anyone today?” My experiences with transgender patients are refreshing, because I know they appreciate my support whether I am an expert or not; it is truly a gift to work with them. The experience has taught me that I can put new information I learn into practice, that I am an expert in preventive care and complex case coordination, and that I can be a competent and caring part of a health care team for transgender persons.

A transition is a process—a different journey for each individual. It is also a journey for each health care provider. Other health care professionals, like myself, can educate themselves about transgender issues and even become champions for this population in their communities. I hope to assist my colleagues in becoming more educated about transgender issues in the future. Please consider sharing your thoughts with me by writing to NPEditor@frontlinemedcom.com.

REFERENCES
1. Alegria CA. Transgender identity and health care: implications for psychological and physical evaluation. J Am Acad Nurse Pract. 2011;23(4):175-182.
2. Deutsch MB, Feldman JL. Updated recommendations from the World Professional Association for Transgender Health standards of care. Am Fam Phys. 2013;87(2):89-93.
3. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009;94(9):3132-3154.
4. University of California, San Francisco Center of Excellence for Transgender Health. Primary care protocol for transgender patient care (2011). http://transhealth.ucsf.edu/protocols. Accessed August 24, 2015.
5. World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people (7th version; 2015). www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351. Accessed August 24, 2015.

Joe was referred to me by a colleague in a women’s care clinic who knew of my interest in transgender health. He greeted me with, “I heard you’re interested in transgender care—I can be your guinea pig!”

Joe told me about his long-held desire to transition from being a woman to a man and asked me to be his partner in this journey. His honesty and openness about striving for an authentic life was the beginning of my own story about how a special patient can broaden understanding and change the way you practice.

Several years ago at the American Association of Nurse Practitioners National Conference, an NP from Connecticut spoke about her extensive experience with transgender patients. Her presentation was an excellent summary of the basics of gender identity and health implications. This topic seemed important to learn about, an area in which I could make a difference in my practice. Since becoming a nurse, I have felt drawn to helping the most vulnerable populations, and transgender persons experience marginalization in our society.

I never thought I could become an expert, but the speaker said that didn’t matter. She noted that her transgender patients usually teach her more than she teaches them. What is important is including transgender care in your primary care knowledge base,¹ since it has been recommended that primary care providers, at the frontlines in patient-centered care, coordinate and partner with transgender patients.²

I was so fortunate to meet Joe. He was open to answering my questions about his interest in a female-to-male (FTM) transition and what the process would entail. Despite my eagerness to help, I was admittedly nervous about portraying myself as a professional, knowing that my experience with transgender issues was limited. I didn’t want to say the wrong thing or use the wrong pronoun. What I discovered is that it’s OK to feel like a novice. It just takes practice to get the wording right, but your patients will appreciate your efforts.

Joe proved to be an excellent guide on this journey; at our first visit, he offered me resources, including information about an upcoming local transgender conference, evidence-based materials, and supportive readings. As I reviewed the literature to educate myself, I discovered that despite a paucity of research, there is a growing understanding of transgender issues and an increasing body of evidence to study.

One of the keys for many people, but especially for transgender persons, is psychological support. Often, transgender people have had a tough road, struggling with gender identity, isolation from friends and family, rejection issues, discrimination, and violence. Depression and suicide are all too common in this patient population.

The Endocrine Society’s Clinical Practice Guidelines recommend that patients secure a good working relationship with a mental health provider for their journey before moving forward with hormonal treatments and surgical interventions.³ Mental health professionals can also help families of transgender persons work through difficult psychosocial issues.

Joe was already regularly meeting with a psychologist and had an excellent support network in place. He was ready for the next step, and I was onboard to help him take it. I did some research to identify professionals in my community who were accepting transgender patients, as well as community resources available for this population. In speaking with colleagues, I was able to find a local endocrinologist who would prescribe hormones, a gynecologist who was comfortable with FTM transition, and a local plastic surgeon who was experienced with FTM chest reconstruction.

During my search for appropriate referrals, I would simply call the office and leave my name and a general question about whether the practice provided transgender care. If I received a “yes” response, I would then follow up with more personal contact with the provider. I did encounter some providers who were not comfortable providing transgender health care. I don’t know if this was an individual or organizational decision, or if it reflected personal beliefs or a lack of experience—but it has affected my further referrals to those offices.

I facilitated referrals for Joe to the endocrinologist, gynecologist, and plastic surgeon. He confirmed after the visits that these providers were professional, prepared, and welcoming, so they could be referral sources for other transgender persons in the future. And for those who might not be as far along their journey as Joe was when we met, several psychiatric NP colleagues directed me to a group of qualified and experienced counselors and therapists with expertise in gender-identity issues. I also discovered that the local university has a great support group for transgender people, as well as their friends and families. With these resources, I am equipped to help my transgender patients navigate their transitions.

As Joe’s primary care provider, though, my role is about more than just providing appropriate referrals. Some of the most important conversations we had addressed the implications of his transition for future preventive health screenings. These include breast exams, which are recommended after an FTM chest reconstruction, and pelvic exams, which are recommended if the uterus and cervix remain in place.⁴ The World Professional Association for Transgender Health has established standards of care that are helpful for providers and patients navigating this journey.⁵

Together, Joe and I developed a plan of care for the transition, with Joe making informed decisions. For example, we agreed that endocrinology would initiate hormone therapy, but I would manage it after a certain point.

The support and care that I can provide to my transgender patients is obvious. But what working with them does for me is equally invaluable. On any given day in the clinic, I can feel a little deflated and think, “Did I really help anyone today?” My experiences with transgender patients are refreshing, because I know they appreciate my support whether I am an expert or not; it is truly a gift to work with them. The experience has taught me that I can put new information I learn into practice, that I am an expert in preventive care and complex case coordination, and that I can be a competent and caring part of a health care team for transgender persons.

A transition is a process—a different journey for each individual. It is also a journey for each health care provider. Other health care professionals, like myself, can educate themselves about transgender issues and even become champions for this population in their communities. I hope to assist my colleagues in becoming more educated about transgender issues in the future. Please consider sharing your thoughts with me by writing to NPEditor@frontlinemedcom.com.

REFERENCES
1. Alegria CA. Transgender identity and health care: implications for psychological and physical evaluation. J Am Acad Nurse Pract. 2011;23(4):175-182.
2. Deutsch MB, Feldman JL. Updated recommendations from the World Professional Association for Transgender Health standards of care. Am Fam Phys. 2013;87(2):89-93.
3. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009;94(9):3132-3154.
4. University of California, San Francisco Center of Excellence for Transgender Health. Primary care protocol for transgender patient care (2011). http://transhealth.ucsf.edu/protocols. Accessed August 24, 2015.
5. World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people (7th version; 2015). www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351. Accessed August 24, 2015.