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Ralph J. Klotzbaugh, PhD (Assistant Professor)1, Suha Ballout, RN, PhD (PhDAssistant Professor)2, & Gale Spencer, RN, PhD (Distinguished Teaching Professor)3

ABSTRACT Nursing literature has recognized deficits in lesbian, gay, bisexual, transgender, queer-specific care. Of particular concern is lack of knowledge about genderminorities. Lack of knowledge remains despite this populations’ increased health disparities. This pilot study investigates pre- and post-knowledge of medical guidelines, disparities, policies, and attitudes specific to gender minorities among advanced practice nursing students attending a gender minority health module. All participants in this pilot study completed a questionnaire on content and a transphobia scale to evaluate its effect on attitudes. Students were also surveyed on previous experience with gender minority patients. Students indicated sex and gender identity as female, with a mean age of 33.5 years. Twenty-seven percent of the students reported experience with gender minority patients. Wilcoxon signed rank test indicated statistically sig- nificant improvement in knowledge and improved scores on transphobia. This study demonstrated a module on the health of gender minorities is an effective method for increasing student knowledge of gender minority health care. Keywords: Advance practice education; cultural competency; gender minority; transgender.

Journal of the American Association of Nurse Practitioners 32 (2020) 332–338, © 2019 American Association of Nurse Practitioners

DOI# 10.1097/JXX.0000000000000249

Background Nursing literature has recognized deficits in knowledge of lesbian, gay, bisexual, transgender, queer (LGBTQ)- specific care needs and considerations among nursing students, educators, and care providers (Cornelius, Enweana, Alston, & Baldwin, 2017; Lim, Johnson, & Eliason, 2015). In their study on perspectives of provider behaviors among LGBTQ-identified clients, Rounds, Mcgrath, and Walsh (2013) determined that although antidiscrimina- tion laws have gradually improved attitudes and accep- tance of LGBTQ individuals, knowledge related to the LGBTQhealth needs continues to be lacking. This deficit is particularly true of point-of-care providers, such as physicians and nurse practitioners (Rounds et al., 2013; Yingling, Cotler, & Hughes, 2017). Of particular concern is lack of knowledge specific to transgender and gender nonconforming populations. In their study of advanced

practice nurses’ knowledge and attitudes on caring for transgender and gender nonconforming clients, Paradiso and Lally (2018) found that all participants agreed that both personal and professional deficits in knowledge can nega- tively affect patient care. Participants also acknowledged that improvement in advanced practice nursing curriculum specific to the needs of genderminority health is necessary. In fact, both the Institute of Medicine (2011) and the U.S. Department of Health and Human Services (2016) have called for prioritization in addressing gender minority health disparities. Both institutions have cited lack of training in gender minority health among health care pro- viders as a critical barrier to health care delivery and well- ness for this population. Lack of competent, knowledgeable providers have accounted for gender minorities avoiding health care services altogether. This avoidance contributes to ongoing health care disparities and associated negative health outcomes faced by gender minority populations.

In the interest of appropriate terminology and mean- ing, transgender and gender nonconforming people are those whose gender identity differs from the sex on their birth certificate. This might include those who have made or are making the transition from one gender identity to the other. It might also include those who are questioning their gender identity, those who identify with more than one gender, or those who express their gender in ways that might not typically be associated with that sex.

1College of Nursing, University of New Mexico, Albuquerque, New Mexico, 2Department of Nursing, College of Nursing and Health Sciences, University of Massachusetts, Boston, Massachusetts, 3Decker School of Nursing, Binghamton University, State University of New York, Binghamton, New York Correspondence: Ralph J. Klotzbaugh, PhD, College of Nursing, University of New Mexico, MSCO7 4380 Box 9, Albuquerque, NM 87131. Tel: 505272 0733; 607 761 1800; Fax: 505.272.9345; E-mail: [email protected] salud.unm.edu Received: 10 January 2019; revised: 22 April 2019; accepted 24 April 2019

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Although there are a number of acceptable terms for this group of individuals, the term gender minority (minori- ties) will be used throughout in the interest of consistency and inclusion.

Lack of knowledge among medical professionals remains despite gender minorities’ increased health dis- parities related to risk behaviors, chronic health complica- tions, social factors, and access to quality health care. Risk behaviors and chronic health complications are related to much higher rates of substance abuse, HIV, and other sex- ually transmitted infections, as well as psychological dis- tress and attempted suicide. The 2015 US Transgender Survey showed rates of HIV among gender minority pop- ulations as nearly five times greater than in the general US population. In addition, attempted suicide rates among gender minorities are nearly nine times the rate in the general US population (James et al., 2016).

In terms of social factors contributing to health dis- parities among gender minorities, gender minority indi- viduals experience higher rates of unemployment, housing discrimination, and homelessness. Gender minorities also face pervasive violence and harassment, including verbal harassment, physical attack, and sexual assault.

Finally, gender minorities face multiple difficulties accessing health care that is knowledgeable, welcoming, and appropriate. Gender minorities often put off seeking necessary health care for fear of mistreatment. Those who do seek medical care report negative experiences related to refusal of treatment or harassment (Kosenko, Rintamaki, Raney, & Maness, 2013). In many reported cases, gender minorities often have to teach their pro- viders about transgender-specific health care needs to obtain appropriate care (James et al., 2016).

Research has demonstrated that high levels of pro- vider knowledge and the quality of their communication continues to contribute toward improvements in patient experiences and perceptions of care within the general population with the potential to improve patient out- comes (Mohammed et al., 2016). However, existing re- search related to the health care of gender minority populations has consistently demonstrated that in- sufficiency of specific provider knowledge and competent communication among health care providers continues to play a significant role in the persistent health dis- parities experienced by genderminorities (Kosenko, et al., 2013; Park & Safer, 2018). It should therefore be of par- ticular importance in nursing education to address these disparities by familiarizing students with gender minority health care needs. This knowledge can simultaneously improve student behaviors and comfort levels to posi- tively affect meaningful interventions for gender minority populations (Rounds et al., 2013). Meaningful inter- ventions might include (but not be limited to) in- corporating considerations of the gender minority client in existing courses such as advanced health assessment,

risk prevention, pharmacology, reproductive health, and health policy. In their study on practicing nurses’ knowl- edge of transgender patient needs, Carabez, Eliason, and Martinson (2016) determined that most nurses have insecurities and/or misconceptions related to gender minority patients and their specific health care needs. Despite the need to educate nurses on health care spe- cific to gender minorities, findings from a national survey of 1,000 nursing faculty show that nursing lags behind other disciplines in terms of LGBTQ-related curricular content (Lim et al., 2015). Specifically, findings demon- strated an allotted mean of 2.12 hours of LGBTQ-related content in nursing versus a mean of 5 hours of LGBTQ- related content allotted by undergraduate medical edu- cation (Lim et al., 2015; Obedin-Maliver et al., 2011). Addressing gender minority health care needs within nursing education is in keeping with the current position statement by the American Nurses Association (2018) that specifically encourages nurses to deliver culturally competent care and advocacy for transgender clients.

Considering that much of the discrimination faced by gender minorities has occurred with point-of-care pro- viders, it might be especially critical to integrate gender minority–specific health care content in advanced practice nursing programs to begin to mitigate some of the dis- crimination and negative experiences faced by gender mi- nority clients in the health care environment. To date, even less research on lesbian, gay, bisexual, transgender-in- clusive curricular content is available specific to advanced practice nursing (Manzer, O’Sullivan, & Doucet, 2018).

In this study, we sought to determine the knowledge of medical guidelines, health disparities, and policies spe- cific to gender minorities both before and after attending a module on gender minority health among advanced practice nursing students in an advanced pharmacology course. In addition, we sought to de- termine what effect attending the same module might have on transphobia scores both before and after the module presentation. Although there have been a num- ber of studies examining attitudes and beliefs of students enrolled in various health professions related to homo- phobia, very few have looked at student attitudes and beliefs regarding transphobia. In addition, there are very few studies about students in health care professions being exposed to gender minority content during their formal education (Acker, 2017). Therefore, we sought to address the educational needs evidenced in existing lit- erature to determine whether advanced practice nursing students’ knowledge, attitudes, and beliefs about gender minorities might improve after participating in a gender minority health care module.

Methods Before presenting the module and collecting data, this pilot study was submitted to the university’s institutional

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review board and was qualified as exempt from review because of educational settings and practices. Eleven students (representing one of a number of advanced pharmacology course sections for students enrolled in the advanced practice nursing program) participated in a module on gender minority health as part of the ad- vanced pharmacology course for advanced practice nursing students. The module was approximately 90 minutes long and included gender minority–specific content related to medical knowledge and health dis- parities, as well as local and national policies. The ap- proach to the module content was informed by current studies reflecting themajor health issues, disparities, and concerns among genderminorities. Themodule beganwith an introduction to appropriate terminology, as well as a discussion regarding the difference between sexual ori- entation and gender identity. The importance of providing a gender affirmative clinical practice such as intake forms that include both sex assigned at birth and gender identity, use of a clients preferred pronouns, and the provision of gender neutral bathrooms was also discussed. In addition, background related to gender minority health disparities were also presented as a way to stress the importance of a gender minority-specific health module. Both local and national policies were also discussed, particularly because they relate to insurance coverage or lack of insurance coverage for transgender health-related services.

Given the focus of the course, however, the majority of the presentationwas related to initiation and appropriate management of gender affirmation hormone therapy for the gender minority client. After presenting an overview of gender affirmation therapy, students participated in three different case studies to review, consider, and dis- cuss. The module concluded with an open dialogue for students to address any questions or particular concerns about any of the content including the provision of gen- der affirmation therapy. It is important that students were provided with a copy of the presentation and suggested further readings and appropriate online resources.

Participating students were enrolled in either the family or adult-gerontology concentration. Students in this section were all enrolled part-time in a program located in a large urban area with a focus on the health of urban populations. All of the students had previous experience working as registered nurses before entering the advance practice nursing program of study. To evaluate student learning, all participants completed a questionnaire on the module content both before and after attending the presentation. The questionnaire covered concepts related to each gender minority–specific content area. In addition, all participants completed a transphobia scale both before and immedi- ately after themodule presentation to evaluate its effect on attitudes and beliefs about gender minorities. Finally, all students were initially surveyed to obtain information re- lated to their previous experience with gender minority

patients and whether they felt their curriculum adequately covered gender minority health.

The questionnaire was an adaptation from an existing questionnaire by Braun, Garcia-Grossman, Quiñones- Rivera, and Deutsch (2017). Validity and reliability were not reported for the questionnaire. The questionnaire was adapted in part to reflect appropriate local health policies for gender minorities. Maximum scores in medical knowledge, health disparities, and local and national policies were 11, 2, and 3, respectively, with 1 point given for each correct response in each of the domains. Higher scores indicated greater knowledge in each module domain (Table 1). The transphobia scale, which is a 9-item scale developed by Nagoshi et al. (2008) to measure prejudice against gender minorities, was also used. Items were scored on a scale of 1 (dis- agree) to 3 (agree), with 2 indicating neutrality. The transphobia scale was selected for this study because it demonstrated high internal consistency, with a re- liability coefficient of 0.82 and a test-retest stability correlation of 0.88. Lower scores indicated less trans- phobia (Table 2).

Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) 25.0 for Macintosh (IBM, Armonk, NY). Nonparametric paired samples sta- tistical analyses were used to analyze pretest and post- test medical knowledge, health disparity, and policy knowledge, as well as attitudes and beliefs about gender minorities. Nonparametric tests were chosen because of the small sample size.

Results Demographic data collected for this sample were limited to sex assigned at birth, gender identity, age, and previous experience with gender minority patients. All students indicated their sex and gender identity as female, with a mean age of 33.5 years. Three students (27.3%) reported having had previous experience with gender minority patients, whereas 8 (72.7%) indicated they did not. Two students (18.2%) indicated that the program had ade- quately covered the topic, whereas 9 (81.8%) indicated that the program had not.

The Wilcoxon signed rank test was conducted to evaluate whether students showed improved medical knowledge after participating in the gender minority health module. Results indicated a significant difference (Z = 22.98; p = .003). The mean of the ranks for pretest medical knowledge was 4.73, whereas the mean for posttest knowledge was 7.55.

A Wilcoxon signed rank test showed a significant dif- ference in health disparity knowledge after participating in the module (Z =22.74; p = .006). The mean of the ranks for pretest health disparity knowledge was 0.55, whereas themean posttest was 1.82. In terms of policy, a significant difference was again indicated (Z = 22.98; p = .003). The

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Table 1. Questionnaire items by domain of knowledge Medical considerations

1. Match the following medications with the correct population next to each drug. Populations codes are as follows: M = female-to-male F = male-to-female N = not used a. Spironolactone (F) b. Estradiol (F) c. Testosterone (M) d. Antiestrogens (N) e. Progestogens (F) f. Premarin (N)

2. Which of the following statements regarding the medical care of transgender patients is true? a. After vaginoplasty, transgender women no longer need prostate exams b. Oral estrogen use among nonsmoking transgender women still places them at high risk for DVT c. Elevated cholesterol in transgender men should have their testosterone immediately discontinued d. Cervical cancer screening recommendations apply to transgender men e. Transgender women are at increased risk for breast cancer and should be screened annually while on estrogen

3. What professional organization publishes the standards of care of transgender and gender-nonconforming people for the use by primary care providers?

a. Institute of Medicine b. World Health Organization c. US Preventative Services d. World Professional Association for Transgender Health

4. Which of the following are terms used to describe gender identity? a. Trans man b. Lesbian c. Male d. Gay e. Trans female

5. All transgender people have at least some surgery to alter their bodies. a. True b. False c. Uncertain

6. Which one of the following is a contraindication to estrogen therapy? a. Any ongoing mental health condition b. Any history of migraine headache c. An active estrogen-sensitive cancer d. A personal history of DVT

Health disparities

1. According to findings from the US Transgender Survey 2015, which one of the following statements is true regarding the prevalence of HIV in transgender populations?

a. HIV Rates are highest among transgender men b. Nearly one in seven black transgender women were living with HIV c. Transgender women were least likely to be tested for HIV d. Rate of transgender respondents living with HIV was more than four times as high as the general US population

2. According to findings from theUS Transgender Survey 2015, which of the following statements regarding treatment by health care providers as a transgender person are true (select all that apply)

a. 33% who have seen a provider reported at least one negative experience related to being transgender b. Transgender men are less likely to report negative experiences with health care providers than transgender women c. Nearly one quarter reported that they avoided seeking healthcare due to fear of beingmistreated as a transgender person d. Six percent reported that their routine care provider knew almost everything about caring for transgender people

(continued)

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mean of the ranks for pretest policy knowledge was 0.82, whereas the mean posttest was 2.73.

To determine the effect of the gender minority health module on student attitudes and beliefs about gender minorities, a Wilcoxon signed rank test was performed. A significant difference was demonstrated (Z = 22.414; p = .016). The mean of ranks for pretransphobia scores was 13.55, whereas the mean for posttransphobia scores was 12.36 (Table 3).

Discussion This study demonstrated that a module dedicated to the health of gender minorities is an effective method for

increasing student knowledge of gender minority health care. Knowledge was related not just to medical consid- erations and management in cross-sex hormone therapy but also to disparities and increased health risks among gender minorities. In addition, the knowledge of specific local and national policies related to the care of gender minorities was improved. This study also demonstrated that the same module significantly improved attitudes and beliefs about gender minorities among participants, as evidenced by scores from the transphobia scale.

Although there is no current evidence to support where gender minority health care content should be introduced in the curriculum, the specific medical

Table 1. Questionnaire items by domain of knowledge, continued Health policy

1. Which one of the following is current recommended best practice for collecting gender identity data? a. Asking a single question “what is your sex/gender?” b. Asking a single question “what is your sexual orientation” c. Asking two questions “what sex were you assigned at birth” and “what is your current gender identity” d. Current recommended best practices do not advise collecting data on sex and gender identity

2. Which of the following are true? (select all that apply) a. Guidelines fromMeaningful Use havemandated that Electronic Health Records collect gender identity in addition to birth

sex b. Most current electronic health record systems include the ability to collect preferred patient pronouns c. Failure to use the preferred name or pronoun when referring to a transgender patient can have drastic consequences on

patient satisfaction d. All of the above are true e. None of the above are true

3. Which one of the following statements are true in the state of xxx regarding transgender individuals? (select all that apply) a. xxx passed a law requiring all insurers licensed or authorized to operate in xxx to cover all transgender care b. xxx passed a law requiring some insurers licensed or authorized to operate in xxx to cover all transgender care c. xxx has declared that surgery is no longer a prerequisite to getting a new birth certificate d. xxx passed a law requiring all insurers licensed or authorized to operate in xxx to cover all transgender care except

Transgender surgeries

Table 2. Items for the validated transphobia scale 1. I don’t like it when someone is flirting with me and I can’t tell if they are a man or woman

2. I think there is something wrong with a person who says they are neither a man nor a woman

3. I would be upset if someone I’d known a long time revealed to me that they used to be another gender

4. I avoid people on the street whose gender is unclear to me

5. When I meet someone, it is important for me to be able to identify them as a man or a woman

6. I believe the male/female dichotomy is natural

7. I am uncomfortable around people who don’t conform to traditional gender roles, for example, aggressive women or emotional men

8. I believe that a person can never change their gender

9. A person’s genitals define what gender they are, for example, a penis defines a person as being aman, a vagina defines a person as being a woman

Note: Agreement on 5-point Likert scale, 1-strongly disagree to 5-strongly agree.

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concerns related to gender minority care seemed ap- propriate in an advanced pharmacology course. This of course is not to suggest that questions and concerns related to gender minority health should be reduced to medical management. Many components of this module could be expanded and explored more in depth in courses such as health promotion and advanced health assessment, as well as professional role development and health policy. Indeed, gender minority health could appropriately be integrated across the entire advanced practice nursing curriculum.

Although this study is focused on advanced practice nursing students, results suggest that it may be worth exploring the integration of gender minority care in on- going continuing education among advanced practice nurse clinicians and educators. One serious consider- ation is the readiness and willingness of nursing faculty to invest the time to integrate concepts of gender mi- nority health into their coursework. However, given the complicated situation of unprepared providers, coupled with a critical need to provide competent care to gender minorities, advanced practice nurses need to engage their patient advocacy to avoid perpetuating existing disparities faced by gender minorities.

Limitations Findings from this pilot study demonstrated positive student learning outcomes from a cultural competency module specific to gender minority health needs in- tegrated into an advanced practice nursing pharmacol- ogy course. There are, however, some limitations that need to be addressed. First, this was a pilot study con- ducted with a small sample of advanced practice nursing students and would be worth replicating with larger numbers of students in the future. Although one might expect increased knowledge from an immediate pretest/posttest knowledge assessment, what was par- ticularly encouraging to the researchers was the signifi- cance in reduced transphobia among participants. It would be interesting to assess retention of information and improved attitudes among students with a second

posttest administered no less than 6 months after par- ticipation. Moreover, it would be interesting to follow up and assess how this knowledge translates into clinical practice over time.

In addition, this module was delivered as part of an advanced pharmacology course. However, content re- lated to gender minority health disparities and policy could be integrated more seamlessly into other courses throughout advanced practice nursing curriculum. Fi- nally, findings from this study are difficult to generalize because the course was presented to students attending a university in the northeast region of the United States, with state laws and policies that have been protective and inclusive of gender minorities. Repeating this module in universities located in states or regions without similar protective and inclusive state laws and policies should be considered.

Conclusion This study is one of very few in the field of nursing in- vestigating gender minority–inclusive health education within an advanced practice nursing program. More studies investigating othermethods of integrating gender minority health care in nursing education would be of benefit. Consideration of gender minorities, in addition to existing cultural competence and diversity modules within advanced practice nursing curriculum, will better prepare advanced practice nurses to be at the forefront of decreasing health disparities and eliminating inequi- ties in health care.

Authors’ contributions: R. Klotzbaugh developed the pilot project and performed all analyses and wrote the initial draft of the manuscript. S. Ballout conducted the litera- ture review and helped with sections of the initial draft, G. Spencer assisted in development of the research project and participated in final revisions to the manuscript for submission.

Competing interests: The authors report no conflicts of interest.

Table 3. Pretest and posttest scores and Wilcoxon signed rank test Z scores Measure Pretest Posttest Change Z Significance

Medical knowledge 4.73 (1.3) 7.55 (1.4) 2.82 22.98 .003

Disparities 0.55 (.69) 1.82 (.41) 1.27 22.74 .006

Policy 0.82 (.98) 2.73 (.47) 1.91 22.98 .003

Transphobia 13.55 (4.37) 12.37 (3.64) 21.18 22.41 .016

Note: SDs are in parentheses.

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References Ac

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