Chronic Disease, LGBTQ, Mental Health, Provider Communication Skills, Substance Use, Suicide Prevention 06.30.2021

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Clinical Training in Gender-Affirming Care: A Q&A

We sat down with Nathan Levitt, FNP-BC, MSN, RN, BSN, MA, Nurse Practitioner and Director of LGBTQ and Gender Justice Learning at Yale University. Nathan has been teaching LGBTQ healthcare to nursing and medical schools for over 20 years and is serving as a subject matter expert on Kognito’s upcoming gender-affirming care simulation.

Clinical Training in Gender-Affirming Care

Nathan, tell us about yourself.

Nathan Levitt: Clinical training in gender-affirming care
Nathan Levitt, FNP-BC, MSN, RN, BSN, MA

I’ve been a nurse practitioner for about five years, and before that, I was a registered nurse. I’ve been in the field of lesbian, gay, bisexual, and transgender care for something like 20 years now, with a focus on trans care. I myself am a trans-identified man, and I’ve been doing trans healthcare as an educator and as a nurse practitioner and clinician for over ten years.

I’m also the Director of LGBTQ and Gender Justice Learning at Yale University within the graduate nursing program. I’m going to be focusing specifically on teaching nurses and doing telemedicine care at FOLX Health for trans patients around hormones and sexual healthcare.

What is gender-affirming care?

It can encompass a few different things. Many people think gender-affirming care is only focused on making sure clinicians know about hormones and surgery. Certainly, that’s a part of it, but it’s also all-encompassing in holistic care.

Gender-affirming care is what is it like for a transgender, gender non-binary person to walk into a clinic, a hospital, or health center and receive affirming care —being called the right name, the right pronoun, chosen name, chosen pronoun. Having forms representing who they are, asking questions about their body that are affirming and sensitive to hormone care, gender-specific care, or trans-specific care if they’re interested in transitioning with hormones or surgery. Care that is not only affirming but educated and informed on what that means.

There’s also gender-affirming care related to other things‑ like trans and non-binary people might come in for a cold or a cough. Something that is maybe not related to their trans identity but may still need that gender-affirming care that’s not assuming that someone is cis-gender or non-transgender and is asking the right questions. The patient will feel that this will be a comfortable place where they can be all of who they are. They can talk about their partner, their body, their transition needs, their primary care needs.

What aspects of the patient-provider relationship are unique when it comes to gender-affirming care?

I do focus a lot on the front desk and receptionists because often, they are the first faces that a trans or non-binary person would see. It can go from that fear that a trans patient has over their ID not matching the way they look, their name, or their gender marker. Not using ma’am or sir, not assuming a certain gender or sexual orientation for that matter. That sensitivity is so important and that’s very specific to the trans and non-binary community.

Then just think about the different steps that a patient walks through, from the call that they might get to make the appointment, to the front desk, to maybe a triage nurse if there is one, a social worker, or a medical assistant. Then the clinician billing is a big part of it, too. So if I’m a transgender male, for example, I’m male on my health insurance and my other documents and if I need to come in for a pap smear, that often will flag as a billing issue, because someone male is getting a vaginal pap smear. Or it could be a trans woman getting a prostate screening. Anything where the gender marker doesn’t match what is considered a gendered procedure or visit will often pop up as a billing issue. So, it shows that every aspect of a health center or hospital/clinic needs to be educated and informed on gender-affirming care on the correct language to use, on not making assumptions.

What is the current state of provider training in gender-affirming care?

It’s certainly come a long way. When I was in nursing school, there was nothing. There was maybe a little bit on lesbian and gay health, but really nothing on bisexual or transgender health, and so there was a big need there in nursing school, and I know also in medical schools and social work schools.

I have been doing trainings for a while now at nursing schools and medical schools and health centers and hospitals. I always lead these trainings with: “how many of you have had any training on trans care?” It’s usually zero to maybe three people who raise their hand.

A study on medical schools showed that there were four hours on LGBT health, and it wasn’t even specific to trans health. So, four hours within the many years that med students are in school amounts to very little. There have been a few studies on nursing schools showing similar data.

What happens is that these students come out and start practicing and have little to no knowledge of this population. Of how to ask the right questions, what names and pronouns to use, to actually more clinical care like: what are some of the health issues in this community? How would you provide medical transition? If someone’s on hormones and they need different kinds of care or different medications? Any of those things, there’s so little information and it’s just so important for people to feel comfortable.

One of the biggest things is not having a first interaction or education on trans health issues. I certainly know firsthand, being a trans patient, for a primary care appointment that is 15 to 20 minutes, I remember spending 19 to 20 minutes of that time educating my provider on what is trans, what are trans health issues. I feel like I should have gotten paid for that visit instead of the provider.

I’m someone who can advocate for myself, but I think many patients either will leave, never come back, and/or lie. A lot of patients feel like, “I can’t be myself, so I’m going to pretend I am not trans or pretend I’m not lesbian, gay or bisexual, because this provider is not inclusive or understanding or affirming.” You never want your patient to lie or to leave, right? And a lot of people in the trans community have so many chronic health issues because they experienced harassment or discrimination in healthcare. That’s why it’s just so important that that education is there in schooling and outside of school in practice.

You are a subject matter expert working with Kognito on a new solution for clinical training in gender-affirming care. What has your role been?

HRSA Behavioral Health Workforce Grant
Try a demo here

I’ve been helping and guiding what these patient-provider simulations should look like. It’s been a great experience to think through what a student or clinician will need to think about before they have that first interaction with a trans or non-binary person.

In terms of learning objectives, it can be how do I, as a clinician or a student, think about this person coming in the door? What are the assumptions I’m making about them before they even walk in the door? For situations like someone dealing with depression or smoking or diabetes, how do I interact with that patient to make them feel affirmed and safe and also deal with their clinical issues?

With the case scenarios and how Kognito uses technology, you really feel like you’re interacting with this patient. You get to see what happens when you say certain things and how that patient may react to it, and then react to that. There are ways that you can read about it, but it’s not the same. You have to have that experience where you say the wrong thing because it’s going to happen.

Also I’ve been able to give my perspective as a trans patient and as a nurse practitioner of trans patients and suggest things that might come up. For example, for a trans woman who is a smoker and on estrogen, a lot of clinicians will just say that estrogen really increases risks associated with smoking. So when you approach a patient like that, you’re not going to use the same language that you might use with another patient around smoking, because the first thought she might think is, “you want to take away my estrogen, and that hormone is life-saving for me.”

That is what a lot of patients walk in the door assuming – that the clinician is not going to understand why they’re on hormones, try to take it away, or not have an awareness of how important it is. It’s so important to build that trust. The example of saying the wrong thing so that you can experience what that might be like is so important to patient simulations, so that you have that experience of, “I remember that situation I had, and I said the wrong thing, and now I know how to say the right thing, and now I know why too.” Having those options of different responses is important.

Some states are passing legislation to ban gender-affirming care for youth. How can providers in these states continue to support these young trans and gender diverse patients?

If you don’t see yourself represented in a positive way, in particular within healthcare, or see providers that understand you and validate you and give you affirming messages, then you’re not going to take care of your own health very well. These messages that people are getting can be so detrimental to mental health and physical health. Clinicians and providers can help by leading with this affirming positive feedback for trans patients.

In my experience in primary care, I’ve observed that trans patients of any age, once they were being called the right name, the right pronoun, being asked their pronouns and names in their visits, being asked really appropriate and inclusive language…they were taking better care of asthma, diabetes, their sexual health, all these other things, because they were feeling these messages of “I’m worthy. I’m worthy of my own healthcare, of taking care of myself.”

It sounds like a small thing, but it can go a long way for clinicians just to give this affirming messaging around people’s healthcare and help empower trans patients to take control of their health and connect them to resources and referrals that are affirming. Having a positive experience with your healthcare provider in all aspects of the clinic, again, from that front desk to the provider, communicates that you’re worthy of taking care of yourself. I think that that can go a long way.


Want to learn more about clinical training in gender-affirming care? A new simulation from Kognito is coming soon! Read more here, or try a demo here.

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