GENDER TRANSITION: ONE NURSE’S STORY

By Ellen Martin, PhD, RN, TNA Director of Practice

GENDER TRANSITIONS involve navigating the fragmented healthcare and legal systems. Given that 0.6% of the population is transgender it follows that about 1,700 of the 284,000 nurses in Texas are transgender. We recently had the opportunity to visit with one nurse who shared her story.

She (her preferred pronoun) began her transition two years ago, and overall her experience was mostly positive. Well-supported by her family, her coworkers, and her boss, she started with six to eight months of hormone therapy. The World Professional Association for Transgender Health (WPATH) has practice guidelines and protocols for hormone treatments. Making healthcare decisions, such as whether or when to have surgery, are deeply personal.

Legal issues add a level of complexity. Changing one’s name is fairly easy. Changing one’s gender marker is a more complicated process that involves changing the gender on a government document such as a passport then obtaining a court order to amend the birth certificate. The decision on when to change legal documents is also individual. In this case, she wanted to have an updated driver’s license prior to taking a long road trip. Having a different appearance than the gender noted on the driver’s license can be an issue of personal safety. Things can get even more complicated when the individual is a licensed professional.

Updating one’s nursing license is a straightforward procedure. Nurses have 10 days to change their name with the Board of Nursing. The nurse provides the Texas Board of Nursing with the supporting court documents to update the license record to reflect the new name and gender marker. As a case manager with a caseload of long-term clients, she and her employer had planned to notify patients over time after her transition was complete.

In an effort to make sure all the “i’s were dotted and t’s were crossed” she spoke with a BON staff member about her situation and shared the plan. The staff member she spoke with insisted that all her patients must be informed within 30 days, emphasizing that the nurse’s practice is built on trust. The nurse tried to explain that patients don’t have the right to know about a nurse’s personal life such as a name change from a divorce. In addition, gender transitions may take longer than 30 days depending on hormonal effects, and it is difficult (if not impossible) to perfectly time changes in personal appearance with the legal name change and license change.

Despite the nurse’s efforts, the BON staff member stood by the opinion, stating that this change was different because of the physical change in appearance, citing the “patient’s right to know.” The staff member emphasized the potential consequences of actions against a licensee if the name on the name badge did not match the nurse’s legal name on file. While the information from the staff member was appreciated, it was disheartening that the staff member interjected her personal opinions into the situation. Not wanting to make the situation worse, the nurse did not further question the staff member or ask to speak to a supervisor.

There are no provisions in the Nurse Practice Act or board rules requiring transgender nurses to notify clients. Kristin Benton, MSN, RN, Director of Nursing at the BON emphasized that the BON expects staff to treat everyone with respect and encourages nurses who do not feel they are getting accurate or complete information to speak to a supervisor.

To protect her license, the nurse spoke to her employer, and they agreed that the safest plan was to push up the notification plan. This short notification window put an unexpected burden on the nurse’s workload and affected her employer and coworkers. It was an awkward situation not only because it is deeply personal but because the plan had been to notify clients after her transition was complete, not before. She was able to notify over 140 clients within 30 days and most were very supportive. Only a handful responded that they were “too old-fashioned” or felt uncomfortable and asked to change case managers. However, this rapid time frame also created a boundary issue for patients who expressed support of her transition and were curious “how the transition was going.” This was the reason why they had originally planned to wait to notify patients. Because nursing encounters are supposed to be about the patients and not the nurse, she ultimately decided to transfer to a new role.

Reflecting on her experience, the nurse noted that this a good time to be transgender with increased visibility and advocacy. She is also working to use her experience to improve care for others.

“Transgender is who we are, not a problem on a problem list,” she said. “It’s a consideration.”

The nurse is currently working with her organization and electronic health record vendor to make changes to support better care for transgender patients. For example, one of the barriers to patient-centered care is that electronic health records are not designed to capture preferred pronouns. She is also working to ensure that guidelines and protocols for transgender patients are incorporated into the software and clinical practice.

A fundamental aspect of nursing is treating patients, colleagues, families, and students with respect. That should not occur as a burden, but rather as a gift — a gift that you are able to share as a nurse.