DiversityNursing Blog

By Carina Storrs

CNN 

Jenner's story, and others', is indeed bringing gender transitioning, which can involve surgery, hormonal therapy and behavioral changes, into the mainstream. "There's certainly a growing acceptance of gender diversity and understanding of how important [affirming internal gender] is," said Dr. Timothy Cavanaugh, medical director of the Transgender Health Program at Fenway Health.

It is estimated that one in 10,000 people who are born male feel their true identify is female or have a strong desire to be female. There are approximately 100 to 500 genital surgeries every year in the United States as part of gender transition, according to the Encyclopedia of Surgery. But that number could be growing. 

In the older generation, the demographic to which Jenner belongs, "I think many people thought their only option was to hide their internal gender or repress it [because] there wasn't a lot of social support or acceptance," Cavanaugh said. "With growing awareness, people in their 40s, 50s and up are coming to a place where they can do something about it," he added. 

But what does it mean to have gender transition procedures, particularly hormonal therapies and invasive genital and facial surgeries, for this older group, compared with transgender people in their 20s and 30s (which Cavanaugh says is the other common demographic)? Are there health concerns, or benefits, with undergoing physical changes later in life? 

Many transgender people take lifelong hormone therapy, and for transwomen (transitioning from male to female) hormones are estrogens and anti-androgens that block their body's testosterone. Jenner reported undergoing hormone therapy, along with a 10-hour facial feminization surgery and breast augmentation. The Olympic gold medalist and former husband of Kris Kardashian said she has not had genital surgery and it's unclear whether she will.

However, as people age, their bodies become less responsive to hormones, and estrogen's effects. Primarily, breast development and weight redistribution will probably be less dramatic in older transwomen compared with younger, Cavanaugh said. At the same time, doctors tend to prescribe a lower dose of estrogen in older women because of concerns of blood clots, and consequent heart attacks and strokes. 

"It may mean that it takes a little longer, that the feminization is not as vigorous, or the effects may not be as satisfactory in older transwomen," Cavanaugh said. However, physical changes do still occur, and they have clear psychological benefits for these women. (In transmen, or people transitioning from female to male, testosterone therapy is generally viewed as safer than estrogen and more effective, Cavanaugh added.)

Facial surgery can be part of gender transitioning for transwomen who have manly features, such as sagging brows that develop with age, said Dr. David Alessi, facial plastic surgeon and owner and director of the Alessi Institute in Beverly Hills, California. (He added that transwomen who have effeminate faces may not need surgery.)

It is possible to make the face look younger and more feminine at the same time, Alessi said. For example, lifting the brow makes it less saggy and removes wrinkles. But there are limits. "I can make a 60-year-old male look like a 50-year-old woman, but not like a 20-year-old girl," he said. 

The more difficult surgery, for all ages, is genital, and older transgender people have special challenges, Alessi said. In particular, surgeons create a vagina, typically using tissue from the penis. However, that tissue may die in its new location if it does not have good circulation, as is more common in older people, and the surgery would have to be repeated to graft tissue from the colon or mouth, Alessi said. "The goal is to do the genital surgery in one surgery, but more likely it takes two or three surgeries, and that is more likely in older patients," he said. 

There are also general problems with any surgery in people in their 60s and 70s. "Often they develop chronic medical conditions, such as high blood pressure and cardiovascular disease, that makes surgery a little bit more risky" because it could exacerbate these conditions, Cavanaugh said

Gender transitioning does not always involve hormone therapy and surgery, however. Among people in their 20s and 30s, who may have more access to information online and to support groups, "we see a number of younger patients who say, 'I just need my identity affirmed,'" Cavanaugh said. They can sometimes achieve this goal through dress and social behavior and finding groups of like-minded people. 

"[Yet] there are always going to be people who really feel a disconnect between internal gender and anatomy, especially when interacting with the world, that it makes more sense and is really beneficial for them to masculinize or feminize the body," Cavanaugh said.

Jonathan Winston Jones

The disconcerting news was the doctor had to Google the issue first to figure out the best medical advice.

"My provider just did a Web search to figure out what dose of hormones I should be on, and put me on the highest dose," Sallans said. That could have been a dangerous choice. "Starting too high of a dose too quickly can cause a lot of health problems, particularly to cardiovascular health."

Fortunately, Sallans didn't have any health complications.

But his experience left him with a mission. He volunteers to speak with medical institutions, as well as with businesses and colleges, to urge them to be more LGBT inclusive. 

While a growing number of medical schools are teaching future doctors how to address health concerns that can be specific to the lesbian, gay, bisexual and transgender communities, studies show current doctors only get about five hours of training, if they get any at all.

For members of the LGBT community who live in more rural and conservative areas like Nebraska, the struggle to get good, or at least up-to-date, medical care may be even more difficult. 

In general, legal protections and institutional supports for LGBT Nebraskans are already thin, spotty or nonexistent.

On March 2, the United States District Court struck down Nebraska's ban on marriage for same-sex couples, but that ruling is on appeal. 

Without the legal institution of marriage, LGBT Nebraskans typically lack family health benefits, unless their employers provide them to same-sex partners.

A 2014 study from the Williams Institute at the University of California Los Angeles found that states without LGBT legal protections in place see lower rates of health insurance coverage for LGBT residents than states with protections.

That plays out in Nebraska. 

A 2014 study from researchers at the University of Nebraska Omaha found that LGBT residents in the rural parts of the state have lower rates of health insurance coverage than their counterparts in urban areas. 

Even when LGBT Nebraskans have health insurance, they struggle to find providers versed in lesbian, gay, bisexual and transgender heath care needs. 

Research shows that LGBT individuals often experience health issues linked to being regular targets of discrimination or social stigma. Discrimination has been linked to higher rates of substance abuse, suicide and stress-related illnesses, which can include heart problems, obesity, eating disorders and cancer. 

If the available doctors are not familiar with the increased rates of these issues, they may provide inadequate care.

Patients who find their doctors do not understand their issues may also delay treatment, often with bad health outcomes, said Jay Irwin, an assistant professor of sociology at the University of Nebraska-Omaha and a researcher in LGBT health. 

Sometimes patients are turned away by providers who don't want to treat LGBT patients, particularly if there are no laws to prohibit such discrimination. 

Irwin has completed studies that focus on the health care challenges of lesbians in rural areas and found that many people feel isolated and are afraid to come out -- or risk discrimination in the medical office.

Nebraska's sheer size doesn't help. Sixteenth largest in the nation by geography, members of its LGBT community often live far from large cities with significant LGBT populations and with teaching hospitals with staff members who have experience working with members of that community.

The Human Rights Campaign's 2014 Healthcare Equality Index named four Nebraska health care facilities, all in Omaha, as leaders in LGBT health care equality. 

Omaha is on the state's eastern border with Iowa. LGBT residents in western Nebraska -- for instance, places like North Platte -- have to travel 270 miles in either direction, to Omaha or Denver, Colorado, to reach facilities designated as leaders by the Human Rights Campaign. 

People who work within the health care system have seen some improvement when it comes to treating members of the LGBT community. 

Jill Young is the client services manager at Nebraska AIDS Project's Scottsbluff, Nebraska, office in the western part of the state.

She recalled when she started working there in the late 1990s she saw medical staff refuse care to LGBT people with HIV/AIDS. 

"We had nurses, for example, who said they wouldn't serve patients with HIV/AIDS," Young said. "But we've come a long way since then." 

Young has seen more hospitals in the region adopting policies that are supportive of LGBT residents, including one that just started recognizing same-sex partners' wills as legal documents that will allow them access to their partners when they are being cared for in areas restricted to immediate family only.

But she said she still sees too many LGBT residents traveling great distances to get care and she still sees too many patients who don't seek medical care until it is too late. 

"We still go to the hospital," she said, "and see people who are days away from dying."

Eric Yarwood, 44, has more experience than he would like with Nebraska's health care facilities. 

He spent over 100 days last year at hospitals in Omaha for complications related to germ cell cancer.

He had nine rounds of chemotherapy, three stem cell transplants, his third surgery two weeks ago and five more days for followup last week. 

For all but four of the days he was in the hospital, his partner, Aaron Persen, 36, was at his side every evening. "Aaron and I are a unit," Yarwood said. "I can count on my fingers the number of times he didn't come." 

While the couple has found the overwhelming majority of physicians and medical staff to be "genuinely supportive" of their relationship, there still were a few instances when they felt uncomfortable and unaccepted, once with a physician and another time with a nurse. 

"I'm not sure how often the medical staff works with gay couples or receives training on how to work with gay couples," Yarwood said. 

Yarwood's prognosis is good, and the couple looks with optimism to a future of having more access to LGBT-inclusive health care facilities and a more inclusive state overall. 

"Hopefully, by the time we get through the cancer and save a little money," Persen said, "Nebraska will follow most other states and allow our relationship to be legally recognized."

Source: www.cnn.com

From thestarpress.com By Michelle Kinsey

MUNCIE — Indiana University Health Ball Memorial Hospital wants to make sure that every person who walks through their doors gets equal treatment.

That commitment has landed the hospital at the top of a list, as the first in the state to be designated as lesbian, gay, bisexual, transgender (LGBT) friendly by the Human Rights Campaign, the nation’s largest LGBT civil rights organization.

The news came in the form of the HRC’s annual Healthcare Equality Index for 2012, which looks at how equitably healthcare facilities in the United States treat their lesbian, gay, bisexual and transgender patients and employees.

IU Health BMH was one of 234 nationwide — but the only one in the state — recognized as a “Leader in LGBT Healthcare Equality,” meeting all four core policy categories — patient non-discrimination; employment non-discrimination; equal visitation for same-sex partners and parents, and training in LGBT patient-centered care.

“We are proud of the recognition,” said IU Health BMH President and CEO Mike Haley. “It’s the result of a lot of hard work.”

That work began two years ago, after a transgender patient claimed she was mistreated in the hospital’s emergency room.

Transsexual Erin Vaught claimed she was called “it” and “he-she” and eventually denied treatment when she went to the ER on July 18, 2010, for a lung condition that was causing her to cough up blood.

Complaints were filed days later by Indiana Equality and Indiana Transgender Rights Advocacy Alliance and the incident went viral, with the hospital receiving criticism nationwide, and beyond.

Ball Memorial Hospital released a statement saying the hospital was conducting an internal review.

The result?

“We failed to meet their needs,” Haley said. “We acknowledged that openly.”

Then they went a step further.

“It’s one thing to apologize,” he said. “It’s another to say, ‘And furthermore, I want this hospital to be considered as a place anyone would want to go if they needed a hospital.’”

Haley issued a challenge to all physicians, employees and volunteers to meet every HRC key indicator.

Ann McGuire, vice president of human resources for IU Health BMH, led the hospital’s efforts. Members of the LGBT community were asked to help.

Jessica Wilch, board member and past president of Indiana Equality, an LGBT rights group, said she was a “believer in what (IU Health BMH was) trying to do” from the first meeting.

“When this went viral, my concern was that BMH would take the stand that this was an isolated incident and just pacify the process,” Wilch said. “Instead they saw it as a teachable moment.”

New policies were drafted and training was developed.

In addition to hospital leaders, anyone a patient would come in contact with was involved in the training, McGuire said, adding that it was about more than just a tutorial. It was about “eye-opening” conversations.

Wilch agreed, saying that face-to-face conversations with the LGBT community were essential.

“We could talk freely about the things we have encountered and then come up with ways, together, to handle it differently,” she said.

Overall, the HRC reports the number of American hospitals striving to treat lesbian, gay, bisexual, and transgender (LGBT) patients equally and respectfully is on the rise.

This year’s survey found a 40 percent increase in rated facilities.

Last year, IU Health BMH was short a few policy additions for the leadership HRC designation, but was still recognized for its efforts.

Wilch said she was not surprised the hospital “hit all of the marks” this year.

“They have become, essentially, one of the leading hospitals in the country, because it really started with them,” she said. “They were the ones who reached out to us and said ‘How can we make this better? How can we do the right thing?’”

Haley said he believed the training and policies developed at IU Health BMH will be used “across IU Health.”

IU Health BMH has also set out to look at other ways to expand their “best practices” when it comes to diversity, McGuire said. The hospital has been hosting Palettes of Diversity events, which have celebrated not only the LGBT community, but other cultures.

“We are making sure we are hard-wiring an environment recognizing and supporting diversity for all who come here,” Haley said.

McGuire agreed.

“It’s about relationships and dignity and respect,” she said. “It is uniqueness that each of us brings that makes us stronger as a community.”

And, McGuire would tell you, as a hospital.