Jeannette Davis, BSN, RN1 , Amy Hequembourg, PhD1, and Pamela Paplham, DNP, FNP-BC, AOCNP, FAANP1
The Journal of School Nursing2023, Vol. 39(4) 321–331© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211017125journals.sagepub.com/home/jsn
School-based nurse practitioners (NPs) can reduce health disparities for transgender and gender nonconforming (TGNC) adolescents. However, research is limited regarding their understanding of TGNC health. This study aimed to explore schoolbased NPs’ perceptions of the health needs of TGNC adolescents. A qualitative, descriptive analysis utilizing a demographic survey and semi-structured interview questionnaire was conducted. School-based NPs (N = 6) were recruited via the New York School-Based Health Alliance listserv and through clinical networking. An essentialist, reflexive approach utilizing inductive thematic analysis was utilized. Four key themes and an overarching theme were identified. The overarching theme was the following: School-based NPs are primary resources—or “point people”—for TGNC adolescents seeking support, safety, and accessibility to health care. Findings identified the need for improvements in the areas of TGNC advocacy and education.
Keywordstrans youth, transgender, gender nonconforming, school-based clinics, nurse practitioners, health/wellness
Transgender and gender nonconforming (TGNC) adolescents are more susceptible to health disparities such as increased rates of depression, suicide, and substance abuse when compared to cisgender adolescents (Gilbert et al., 2018; Johns et al., 2019; Staples et al., 2018). Meyer (2015) explains in the minority stress model that TGNC individuals face additional stressors related to their TGNC identity that can negatively impact their health. Schoolbased nurse practitioners (NPs) are in a unique position to provide health and structural interventions for TGNC adolescents, thereby improving their overall health (Menkin & Flores, 2019). However, there is a lack of research regarding school-based NPs’ understanding and awareness of TGNC adolescents’ specific health needs.
In recent years, TGNC individuals have gained more public visibility in mainstream media (Andone, 2019). The presence of transgender individuals in cinema and television has changed the current social landscape, creating more acceptance of this marginalized group. Consequently, this has created increased awareness of TGNC health disparities and has instigated public policy initiatives to support this population (Andone, 2019). Despite these advances, TGNC people continue to face structural- and individual-level discrimination within the United States. Furthermore, there is continued confusion about basic terminology associated with TGNC individuals.
TGNC terminology is evolving and can change over time. It is critical to understand the accurate terminology when caring for TGNC individuals to provide safe and sensitive care. Sex is typically assigned as male or female based on external genitalia; however, sex can also be determined by an individual’s chromosomes, sex hormones, and internal genitalia (National LGBTQIA Health Education Center, 2020a). A person’s gender identity is their internal sense of self and can be classified as being a man, woman, both, neither, or another gender (National LGBTQIA Health Education Center, 2020a). The philosophy that there are only two genders, man and woman, and that they must match an individual’s sex characteristics has changed over time (National LGBTQIA Health Education Center, 2020a). A gender nonconforming individual is a person whose gender expression does not conform to societal expectations about their gender identity based on the sex they were assigned at birth (National LGBTQIA Health Education Center, 2020b). A cisgender individual is a person whose gender identity corresponds with their sex assigned at birth (National LGBTQIA Health Education Center, 2020a, 2020b). A transgender individual is a person whose gender identity does not correspond to their sex assigned at birth (National LGBTQIA Health Education Center, 2020a, 2020b).
Gender affirmation is the process an individual takes to make medical, social, and/or legal changes to recognize, accept, and express one’s gender identity (National LGBTQIA Health Education Center, 2020b). It is critical to provide gender-affirming care for adolescents, particularly between ages 12 and 18, when many TGNC youth are experiencing puberty (Kaltiala-Heino et al., 2018). The physical body changes that occur during this time of life may exacerbate and heighten levels of psychological distress among some TGNC adolescents, resulting in gender dysphoria (Kaltiala-Heino et al., 2018). Prior to initiating any gender-affirming interventions, it is recommended that the adolescents seek evaluation from a mental health professional (Hembree et al., 2017). Gender-affirming medical changes include the use of gender-affirming hormone therapy or surgery (National LGBTQIA Health Education Center, 2020b). Many, but not all, adolescents may want gender-affirming hormone or surgical intervention (Coleman et al., 2012). Guidelines recommend initiating gender-affirming hormone therapy for requesting adolescents that are diagnosed with gender dysphoria and exhibit physical changes of puberty (Hembree et al., 2017). Adolescents who meet these criteria can be referred to an endocrinologist for evaluation. It is recommended for adolescents to first undergo pubertal suppression, a noninvasive, reversible process that uses gonadotropin-releasing hormone analogs to suppress puberty (Coleman et al., 2012; Panagiotakopoulos, 2018). Adolescents who request gender-affirming hormone treatment with sex hormones must follow a gradually increasing dose schedule after a multidisciplinary team of medical and mental health professionals has confirmed the persistence of gender dysphoria with the mental capacity to give informed consent, which is typically reached by age 16 (Hembree et al., 2017). Gender-affirming surgery is recommended only after a mental health provider and the clinician responsible for hormone therapy both agree that surgery is medically necessary and would benefit the adolescent’s overall health. However, gender-affirming surgery is typically only initiated after the completion of at least one year of compliant hormone treatment, unless it is not desired or contraindicated (Hembree et al., 2017). Additionally, guidelines recommend delaying gender-affirming genital surgery involving gonadectomy and/or hysterectomy until the patient is 18 years old, although this is often evaluated on a case-by-case basis (Hembree et al., 2017). Social gender-affirmation is the process an individual undergoes to change their name, pronouns, clothing, and/or hairstyle to more accurately reflect their gender identity (National LGBTQIA Health Education Center, 2020b). Schools can use the person’s chosen name and pronouns on attendance rosters, student identification, yearbook, and report cards. If the student chooses to undergo gender-affirming legal changes, they can change their name, sex designation, and gender markers on all legal documents, including school transcripts (National LGBTQIA Health Education Center, 2020b). Overall, it is important to implement mental health treatment and consult with families, schools, and other health care professionals in order to support the health of TGNC adolescents (National LGBTQIA Health Education Center, 2020a).
The number of TGNC people living in the United States is difficult to estimate, given that questions related to gender identity are typically not included in population-based surveys, and if they are, most do not include gender identity choices beyond male or female (Rowe et al., 2019). Recent studies have estimated that approximately 1.4 million transgender adults live within the United States (Flores et al., 2016; Meyer et al., 2017). Additionally, Herman et al. (2017) note that 0.73% of young adults ages 13–17 identify as transgender as well. Yet, these numbers are largely underestimated due to the discrimination and prejudice experienced by this population, causing under-reporting (Cicero & Wesp, 2017; Flores et al., 2016). This discrimination can start as early as youthhood. School-related bullying during middle and high school has a notorious prevalence in the adolescent population ages 12–18 (Centers for Disease Control and Prevention [CDC], 2019). Bullying is particularly detrimental during adolescence, as it often leads to poor academic performance, substance abuse, depression, and anxiety (CDC, 2019). Societal expectations about gender expression and identity may create a hostile school environment for TGNC adolescents that can impact their health across the life span (Herek, 2016; Meyer, 2015; National Public Radio [NPR] et al., 2017). Significantly, TGNC adolescents experience higher rates of discrimination than lesbian, gay, and bisexual [LGB] cohorts (Cicero & Wesp, 2017). As a result of this discrimination, TGNC students have disproportionately high rates of substance use, depression, and suicide (Gilbert et al., 2018; Herek, 2016; Johns et al., 2019; Staples et al., 2018). Notably, Johns et al. (2019) found that 35% of transgender high school students attempted suicide in the past year. Day et al. (2017) found that alcohol misuse was 1.5 times more prevalent in TGNC middle school and high school students compared to cisgender students. Overall, TGNC students report fewer preventative health appointments and more visits to the nurse’s office than cisgender students (Rider et al., 2018), perhaps due to depression, alcohol use, or other health risk behaviors. Therefore, school-based NPs are well-positioned to provide safe, gender-affirming school environments while initiating the necessary health interventions for this population.
In summary, little is known about school-based NPs’ perceptions of TGNC adolescents. Current research in this field has primarily focused on lesbian, gay, bisexual, and transgender (LGBT) populations broadly (Brown et al., 2020; Garbers et al., 2018, Manzer et al., 2018; Reisner et al., 2020; Schweiger-Whalen et al., 2019; Willging et al., 2016). Consequently, TGNC individuals have been historically subsumed under the LGBT umbrella within health care research, thus overlooking their unique experiences and health care needs. However, a growing body of research has begun to recognize the need for individualized health care for TGNC individuals (Brown et al., 2020; Carabez et al., 2016; Paradiso & Lally, 2018). This literature has focused on school health professionals in general, such as school nurses, school psychologists, social workers, and guidance counselors (Garbers et al., 2018; Reisner et al., 2020). School-based NPs have been notably absent from this body of research. It is essential to investigate school-based NP’s awareness of TGNC health to better assess the preparedness of current school-based health clinics to treat diverse adolescents.
The minority stress model was first proposed by Meyer (2003) to identify factors contributing to mental health disparities among sexual minority individuals (LGB). He theorized that this population reported greater health disparities due to the unique forms of stress resulting from their experiences of discrimination and prejudice. Meyer’s minority stress model has been subsequently extended and adapted to account for the experiences of transgender, gender nonconforming, and other gender minority populations (Hendricks & Testa, 2012; Meyer, 2015). Meyer (2015) suggests that TGNC individuals experience everyday stressors, similar to the general population, in addition to unique distal and proximal stressors related to their gender identity or gender presentation. Distal stressors such as prejudice, discrimination, and stigma coupled with proximal stressors such as expectations of rejection, identity concealment, and internalized transphobia can lead to adverse health outcomes such as depression, anxiety, substance use disorders, and suicide (Gilbert et al., 2018; Johns et al., 2019; Meyer, 2015; Staples et al., 2018). Moreover, minority stress can cause TGNC adolescents to have higher rates of absenteeism and poor academic success (Day et al., 2018). School-based NPs play a critical role in cultivating an affirming and supportive school environment that nurtures TGNC adolescents who are at risk for minority stress resulting health disparities. However, to date, little is known about the preparedness of school-based NPs to fulfill this important role. Therefore, the purpose of the current study is to explore the perceived health needs of TGNC adolescents among school-based NPs.
To fulfill our study purpose of gaining an in-depth understanding of school-based NPs knowledge about the health needs of TGNC adolescents, we utilized a qualitative, descriptive approach, gathering demographic characteristics and in-depth responses to semi-structured interview questions from participants (N = 6). Interview questions covered participants’ knowledge of TGNC-specific terminology, previous TGNC education, and their past experiences caring for TGNC students. Participants also were asked to share their perceptions of TGNC-specific physical and mental health needs, gender-affirming interventions, and the role they believe school-based NPs play in caring for this population.
School-based NP participants were primarily recruited based on voluntary response sampling from the New York School-Based Health Alliance (NYSBHA) listserv with secondary recruitment via convenience sampling from the first author’s clinical network. Support for this study was established with the executive director of the NYSBHA, who served as the community partner in participant recruitment efforts. The NYSBHA (2020) is a professional organization that advocates for the 272 school-based health centers within New York state. Recruitment emails described the study, indicated general eligibility criteria, the nature of participation, and provided contact information for participation. To be eligible for participation in the study, participants had to be at least 18 years of age, hold current New York licensure as an NP, understand and speak English, and practice in a school-based health setting that cares for adolescents ages 12–18 in New York state.
Study procedures were reviewed and approved by the University at Buffalo’s Institutional Review Board (IRB). Each participant was interviewed once for approximately 1 hour by Zoom video or phone conference call. The first author conducted interviews in a private, quiet, and secure location, and participants were asked to select an interview location that was equally as conducive to open dialogue. Interviews took place from September 2020 to November 2020 and were audio-recorded via Zoom. Verbal consent was obtained from the participants prior to the interview. The verbal consent statement explained that the interviews were audio-recorded and that participants’ confidentiality would be honored with all their information de-identified. The participants were notified that audio recordings were only retained until transcription was completed. Additionally, the participants were informed that they could withdraw from the study at any time, and they could refuse to answer any question without penalty. After providing verbal consent, participants were asked to verbally respond to a series of demographic questions. Demographic data included age, gender, race, ethnicity, years of clinical practice, board certification status, and practice location within NY. Following the demographic survey, the first author began the semi-structured interview. Interview questions were developed by the first author based on the study’s objective and findings from the literature review. Audio recordings were de-identified, transcribed, and thoroughly read to confirm accuracy by the first author. After transcription, the audio recordings were deleted per the IRB protocol.
An inductive, reflexive approach utilizing the six phases of Braun and Clarke’s (2006) thematic analysis was utilized to analyze the transcripts from the interviews and create themes that encapsulated the data set. An inductive thematic analysis ensured that the identified themes were directly linked to the data itself (Braun & Clarke, 2006). Therefore, the data are presented as itself, rather than as a preconceived notion. Reflexivity allowed for self-awareness of personal experiences and how they may impact the data collection and analysis process (Braun & Clarke,2019). Finally, an essentialist approach presented the participant’s motivations and experiences in a simple and direct way (Braun & Clarke, 2006). This approach allowed for a unidirectional relationship to develop between meaning and experience. According to Braun and Clark (2006), the six phases that the analysis must follow are (1) familiarizing yourself with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing potential themes, (5) defining and naming the themes, and (6) producing the report.
The six phases of Braun and Clarke’s (2006) analysis were carried out during the data analysis of the study. In Phase 1, the first author actively read and reread the data after transcription by noting patterns and meaning in the data. This phase provided a basis for the analysis. In Phase 2, initial codes were created from the interviews that were used to organize the data and ultimately create themes. Phase 3 involved creating main themes and subthemes based on the initial codes. A codebook was used to visualize and arrange codes into these themes. In Phase 4, the first author polished and refined the themes. The first author reviewed the themes in relation to their coded data and to the data set as a whole. If the themes did not fit with their codes, the theme was revised, recreated, or the code placed under another theme. If the themes did not fit within the dataset, the first author continued reviewing and refining the codes until a satisfactory codebook was created. Phase 5 defined and named the themes. The second and third authors independently reviewed the data and coding schema before meeting with the first author in Phase 5 to reach a group consensus about the final codes and themes. In the sixth and final phase of Braun and Clarke’s (2006) analysis, the final themes were utilized to create a coherent and succinct written analysis of the data.
Six school-based NPs voluntarily participated in this study (see Table 1). Two participants were recruited from the NYSBHA listserv, while the remaining four participants were recruited from the first author’s clinical network. All the participants self-reported as female Caucasians. The participants’ ages ranged from 42 to 65 years old, with an average age of 54.7. The NPs averaged 18.5 years of practice. All school-based NPs practiced in school health clinics in New York State, with three NPs practicing from Buffalo, two from New York City, and one from Batavia, NY. Findings from the semi-structured interviews revealed an overarching theme: School-based NPs are point people who provide support, safety, and accessibility to health care for TGNC adolescents and four key themes: It’s so confusing, education is beginning to become mainstream but overall remains deficient, TGNC adolescents have unique mental health needs, and all adolescents require the same fundamental physical health needs.
Participants expressed their confusion regarding the topic of TGNC health. The complexity of the terminology and the ambiguity of laws regarding adolescent surgical and hormonal treatment are concerns to school-based NPs. These findings indicate a need for education. Participant 4 states, “It’s so confusing! But I get it. I don’t know all the categories, so I try to be careful with what I say.” Participant 6 further supports this concept,
We had a lawyer come in and again address the whole situation—the whole legal aspect of it. And it’s very confusing. Cause even they aren’t sure of some of the things that they were presenting ....
Specific to confidentiality laws, Participant 1 maintains, “I am still unclear about confidentiality laws with hormone treatments ....” Participant 2 also voiced concern of confidentiality, “I don’t know the law—if it’s changed. It’s difficult in terms of actual treatment.”
School-based NPs identified a need to understand the meaning of the terminology. Regarding gender nonconforming, Participant 1 voiced,
My understanding is not identify as either male or female or even, like, wanting to identify as ...just ...yeah. Well actually that’s not true ...gender nonconforming is ...well now I don’t know. I’ve confused myself.
Participant 4 reaffirms,
I am really not sure ...gender nonconforming .... I guess that would be it if a female student ...if she may not conform with all of the attributes of a female ...that may be kind of mixed .... I am not positive.
Participant 3 mirrored this misunderstanding with cisgender terminology stating, “The terminology ...like I’ve never heard of cis ...cis ...? [Laughing] whatever you said.” Participant 6 corroborates, “C-I-S? ...I don’t know.”
School-based NPs also expressed their misunderstanding of the differences between sexual attraction and gender identity. Participant 5 states, “Cisgender is you’re sexually or romantically attracted to the same sex.” When Participant 4 was asked what they heard most often regarding gender identity they replied, “I am having a blank here ...I don’t know if it’s correct but gay, lesbian, and I’m not sure if that’s in the right category.”
TGNC health education is beginning to merge into nursing and health curriculums but is still incomplete. Many participants remarked that they need more comprehensive training as this field continues to develop over the years. Participant 1 acknowledges,
I go to conferences whether they are adolescent reproductive or school-based health conferences. There are small breakout groups ...but they tend to be short and kind of very base level which, you know, isn’t super helpful. I feel like I kind of know the basics. I need to know more.
Participant 2 states,
Not a lot. But some. Which is unusual. So, I am a relatively new practitioner. I graduated with my DNP in 2016. We had—I want to say—a handful, if that, of lectures of LGBT issues and trans issues.
Participant 3 resonates, “I think you know back in school years ago we always talked about the topic but through the years I think it definitely has progressed more.”
Participants voiced a need to educate providers on hormone maintenance therapy and surgical interventions for this group. Regarding hormone therapy, Participant 4 verifies,
I don’t know but I am assuming there is some type of waiting period where they have to be a certain age and have certain consents and etcetera to start therapy .... I don’t know I really don’t know ....
Participant 5 also voiced this uncertainty, “I don’t know a lot about it. I don’t know at what age they start.” When to begin surgical intervention is another vague topic for schoolbased NPs. Participant 6 states,
Do they do it? I don’t know! I didn’t even know they would do it. I thought you had to be transgendered for so many years and a certain age before you would be able to get surgical treatment. I don’t know the guidelines for that.
Participant 1 reiterates this lack of knowledge while remaining congruent with the overarching theme of being a point person for referrals,
Again, I don’t know much about it. I think if a student asked me about surgery I would probably start by asking them what they have heard and what they are interested in and if they have discussed it with their friends and their family members and then referring them out, unfortunately.
All participants emphasized the mental health implications for TGNC students. School-based NPs understand that stigma from society and bullying are major risk factors for depression, anxiety, and substance abuse within this population. Participant 3 assents, “...depression or suicide or that kind of thing, you know, much more mental health issues that you worry about.”
Participant 4 discusses the enhanced mental health screening involved for this population stating,
I think you might want to expand your bullying questions, substance abuse, and alcohol abuse because I know a lot of the time they have a lot of stress and get into a lot of practices that aren’t necessarily healthy for them so I think you have to delve into some of those things to ask how they are managing their transition and what is difficult for them and what we could do to help them.
Participant 1 discusses the impact of stigma on mental health,
Well, there’s stigma from school, there’s stigma from their friends, stigma from their family. People get harassed even on the subway. A lot of stigma in the media, politics, so I think there are huge mental health needs.
The school-based NPs also commented on adolescent vulnerability and bullying. Specifically, some participants mentioned the impact this can have on TGNC adolescents’ functionality and mental states.
Participant 4 states,
Well adolescents have a tough road to begin with and then if you’re going down a different road ...you are going kind of peddling upstream when everyone’s going the other direction and I think that’s gotta be very difficult for a kid ...and some of them just don’t identify with that because they are afraid of getting, you know, bullied or having people just dismiss them.
Participant 6 resonates,
They have to be very confident and empowered by however they feel because the kids at this age are very open and could be very mean, so they have to face a lot of different students ...maybe ...making comments to them.
The participants seemed overall supportive of surgical intervention but noted that TGNC adolescents’ mental status must be evaluated prior to referral. For instance, the students’ emotional and developmental maturity must be factored in prior to surgical management. Participant 3 confirms, “I think it is great in the cases where somebody’s had psychological evaluation first to make sure that’s what they want to follow through with.” Participant 5 sustains, “Just developmentally they are different. So being able to talk about their feelings and why they feel like they want—and also part of their therapy would be continued psychosocial support and assessment.”
Interestingly, most participants stressed the need to treat all students equally regarding their physical health needs. In particular, school-based NPs acknowledged that safe sex practices and human immunodeficiency virus (HIV) prevention are routinely covered in their assessments. However, the majority of participants failed to mention the importance of using gender-affirming language or screening for certain cancers based on their anatomical body parts. For example, Participant 5 states, “...regardless of what they tell me in the physical I always go over safe sex practices ...we talk about HIV at age 13—that’s always ....” Participant 3 continues this notion, “I mean aside from maybe you know talking about things like prevention such as STD prevention and that kind of stuff I would say pretty equivocal to other physical health needs.”
Participant 6 asserts,
[You would treat them] as you would anyone. Like if they came in for any kind of medical treatment and they had to see somebody—a specialist—so they might have to go to a specialist because they want other choices as the one student did that went the hormonal treatment, but you would just refer them to people as you would anybody else.
Overwhelmingly, the school-based NPs identified that their main role in providing health for this population is to provide guidance and support in a safe way. It was evident through all six interviews that although school-based NPs may not have all the answers for their TGNC students, they understand the importance of timely referrals and when to direct their students to reliable resources for care. Participant 1 exemplified this stating, “...being a point person for counseling and some reproductive health care and helping them get connected to counseling and or surgery or hormonal therapy.”
This notion is echoed by Participant 4,
That’s where I see us as a school, as school-base ...is try to get these kids connected to stable places that they can go for appropriate and correct information, not just what they are hearing from, you know, the kids on the street and the things that are online cause we know those things are not always correct.
School-based NPs noted that support and safety are crucial for this population. Their vulnerability as adolescents and as TGNC individuals creates a need for more encouragement and assistance. Participant 2 maintains,
Kids need so much affirmation at that age and are so much questioning who they are, where they are going and what their purpose is in life. And anytime any of that is questioned, whether its internally by their friends, by their family, by their teachers, by society ...that creates a set up for loss of confidence which is unhealthy. So, I think the need to support kids relative to whoever they are and in this particular community needing more of that.
Participant 3 reinforces this stating,
Showing them somebody that is not going to have opinions or regard them in a certain way because of you know life decisions like that they are making. So being a support system for them as well.
Participant 6 reiterates the importance of making their students feel safe,
So that I make them feel comfortable and they are safe, and they aren’t feeling like people are picking on them or no one is making fun of them or anything like that. That we agree with their choices and that’s what it is.
School-based NPs also identified their ability to provide better access to health care for these students. The clinics are conveniently located within schools, allowing for students to easily come to them for advice, support, or referral.
Participant 5 states,
We see these kids every single day. So, like I said if they come down for a headache and it’s not quite a headache or presenting like a headache—I know it’s something else. I know it could be fight with their mother, brother ...whoever. We just know them in a different, more intimate way I think.
Participant 6 supports this notion of safety by providing accommodation asserting,
Accommodation is a big topic. What are you doing for them so they don’t feel uncomfortable when they have to make a choice of gender—a bathroom, a locker room a ...you know, stuff like that.
The school-based NP participants of this study shared common perceptions about potential ways to address the existing gaps in meeting the health care needs of TGNC adolescents in school-based settings in which they practice. Schoolbased NPs exemplified their compassion and respect for all their students, yet it is clear through their perceptions of TGNC terminology and physical health that TGNC adolescent health is still an unfamiliar topic to school-based NPs. It is critical for school-based providers to educate themselves about the unique physical health implications for the TGNC population so they can improve their care delivery. This study also highlights the need for TGNC education to be not only incorporated into nursing programs but also into clinical environments where it can reach providers who are currently practicing. Of note, this study inspired many of the school-based NPs to independently investigate TGNC terminology, hormone therapy, and surgical intervention guidelines after their interview was conducted. Positively, school-based NPs understand the significant mental health concerns for TGNC adolescents. As Meyer (2015) explained in the minority stress model, school-based NP participants identified through their interviews that external stressors such as adolescent development, bullying, and stigma can contribute to poor mental health outcomes of TGNC students such as anxiety, depression, and substance abuse. In particular, participants expressed the necessity to add additional mental health screening into their practices such as bullying and alcohol abuse as a result of the stress they may have from their transition. Interdisciplinary collaboration with school nurses, social workers, and psychologists are great resources for school-based NPs to utilize when evaluating these students for depression, anxiety, substance abuse, and suicidality. In summary, school-based NPs identified that their role in delivering health care to TGNC adolescents is to use their expertise and knowledge to be guides, educators, advocates, and confidants. Their versatility when caring for TGNC students is a critical component of their health care management.
The findings in this study align with the results of several previous studies. For instance, numerous earlier studies demonstrated a lack of TGNC health competency within the nursing profession (Brown et al., 2020; Cahill et al., 2020; Carabez et al., 2016; Garbers et al., 2018; Manzer et al., 2018; Paradiso & Lally, 2018; Vermeir et al., 2018). Moreover, TGNC health education has yet to be widely implemented by educational institutions (Paradiso & Lally, 2018; Schweiger-Whalen et al., 2019). Although NPs understand that TGNC individuals require specialized care, they remain uncertain regarding their distinctive health implications (Carabez et al., 2016; Paradiso & Lally, 2018). Similar to the school-based NPs in this study, providers continue to lack knowledge of TGNC-specific health implications such as hormone therapy, sexual health screening, and surgical procedures (Vermeir et al., 2018). This ambiguity begs for more education unique to the physical health needs of TGNC individuals. In fact, the American Nurses Association (ANA) has called for the importance of integrating lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ) education into curriculums and for nurses to deliver culturally competent care (ANA Ethics Advisory Board, 2018). This cultural competency must begin with furthering the education of TGNC health. Furthermore, NPs in earlier studies recognized that a foundation of trust is required to effectively manage TGNC health care (Cahill et al., 2020; Manzer et al., 2018). The school-based NPs within this study identified that providing comfort and support is particularly critical within the adolescent developmental period, furthering the importance of the relationship between the patient and provider.
Previous studies have examined the impact of school health for TGNC adolescents. Garbers et al. (2018) found that school-based health clinics lacked gender-affirming environments and adequate staff training. However, after building awareness of TGNC health needs, school-based health providers experienced a sense of advocacy to improve their schools’ structure in a more positive, gender-affirming direction (Garbers et al., 2018). The National Association of School Nurses (NASN, 2016) currently advocates for LGBTQ students and calls for school health professionals to promote safe school environments for all of their students, regardless of their gender identity. This study resonates with these ideals, as school-based NPs noted that they are pivotal in providing safety and accessible health care for their students. Reisner et al. (2020) identified several barriers in schools that prevent these structural changes, such as time, resources, staff education, and administrative support. School-based NPs must overcome these barriers by working with administrative staff to advocate for their TGNC students. Willging et al. (2016) echo this, emphasizing for nurses to collaborate with schools to improve health care for this marginalized group.
School-based NP participants’ perceptions revealed important themes that may be crucial for addressing specific health promotion and safety needs for TGNC adolescents. Improvements are necessary in the areas of TGNC advocacy and education. In line with the NASN’s (2016) call to action, school-based NPs can advocate for safe environments within their schools through accommodation and the use of affirming gender language. For instance, school-based NPs can help reform school mission and vision statements to use inclusive language and streamline administrative forms to update names and gender identities (Fauer et al., 2020). School-based NPs can continue to support their students by promoting local, state, and federal mandates (e.g., Title IX) that protect the rights of TGNC students and ensure that there are resources available to them through the school if they need them. They can also promote legal groups that support TGNC individuals, including the GLBTQ Legal Advocates and Defenders (GLAD), the American Civil Liberties Union, and the Human Rights Watch LGBT Rights (Fauer et al., 2020). Education is another area that needs to be expanded for school-based NPs. As previously mentioned, a lack of TGNC competency is prevalent within health care. School-based NPs can improve this gap in knowledge by attending conferences and workshops specific to the health needs of TGNC individuals. Additionally, school-based NPs must necessitate integrating TGNC health into existing training content and nursing curriculums (Fauer et al., 2020). By refining their school climates and raising self-awareness, school-based NPs can help reduce health disparities for TGNC adolescents. Although this study is targeted to school-based NPs, it is also critical to acknowledge the role that registered nurses (RN) play in caring for this population. Notably, RNs are highly involved and prevalent within school clinics. Like NPs, RNs must also identify the need for resources and the health needs of this vulnerable population.
The COVID-19 pandemic will impact school-based NPs’ ability to care for and support TGNC adolescents. The school-based NPs in this study identified that their school clinics are safe havens for students to go to seek help away from the disapproving eyes of their parents. However, the pandemic changes this dynamic, as many clinics are closed due to remote learning. School-based NPs are now challenged to support their TGNC students in other ways, such as integrating video conferencing to discuss their students’ mental health or safety. Moreover, school-based NPs can improve privacy and openness with this sensitive topic during this time by allowing students to complete their routine health forms online independently from their parents.
This study used qualitative methods to explore perceptions of NP participants licensed to practice in New York State. Hence findings are not generalizable; however, findings may be transferred to readers in similar settings. A major limitation of this study was the small sample size, which resulted—in part—from recruitment challenges associated with changes in the school environment resulting from the switch to remote learning in many school districts across New York State in response to the COVID-19 pandemic. Furthermore, the sample included all Caucasian women with an average age of 54.7; thus, it is unknown if the results apply to more diverse samples of school-based NPs. Given the age of the participants, it is possible that there are cohortrelated differences in TGNC knowledge that would necessitate the need for targeted continuing education for those NPs who graduated before TGNC sensitive care was addressed in nursing education curriculum. More purposeful methods could have been used to obtain a sample of participants that captured a more rich, varied spectrum of NP perspectives. A triangulation of methods was also not utilized, thereby limiting credibility when analyzing data. Furthermore, due to the reflexive nature of this study, personal experiences of the authors may have been influenced by personal biases.
Future studies are needed that include school nurses and larger samples of school-based NPs from across the United States with diverse racial and ethnic backgrounds. A sample that includes a wider age range of participants also would provide insight into potential cohort differences among this population. Research is also needed to identify TGNC adolescents’ personal attestations about their health care management. A review of the current training methods for school-based NPs would also help clarify the current state of TGNC education.
Minority stressors related to their gender identity put TGNC adolescents at high risk for negative health outcomes such as depression, suicide, and substance abuse compared to their cisgender counterparts (Gilbert et al., 2018; Herek, 2016; Johns et al., 2019; Meyer, 2015; Staples et al., 2018). School health clinics allow TGNC adolescents greater accessibility to health care, potentially reducing these health disparities. School-based NPs can provide a safe environment while initiating the necessary gender-affirming health prevention practices that this population needs. However, school-based NPs must first educate themselves about TGNC terminology and physical health needs as well as advocate for gender-affirming school environments to optimize their care.
Jeannette Davis contributed to conception, design, acquisition, analysis, and interpretation; drafted the manuscript; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Amy Hequembourg contributed to conception, design, acquisition, analysis, and interpretation; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Pamela Paplham contributed to conception, design, acquisition, analysis, and interpretation; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Jeannette Davis, BSN, RN https://orcid.org/0000-0003-3295-9681
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Jeannette Davis, BSN, RN, is an FNP-DNP student at the University of Buffalo, Buffalo, NY.
Amy Hequembourg, PhD, is an associate professor and assistant dean for diversity and inclusion at the University of Buffalo, Buffalo, NY.
Pamela Paplham, DNP, FNP-BC, AOCNP, FAANP, is a clinical professor and assistant dean of the MS/DNP programs at the University of Buffalo, Buffalo, NY.
1 School of Nursing, The State University of New York at Buffalo, NY, USA
Corresponding Author:Jeannette Davis, BSN, RN, School of Nursing, The State University of New York at Buffalo, Buffalo, NY 14221, USA.Email: jadavis3@buffalo.edu
