The Journal of School Nursing2023, Vol. 39(5) 377–384© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211025442journals.sagepub.com/home/jsn
School systems are often not set up to support transgender and gender diverse (TGD) students, which results in unsafe and unsupportive environments and other institutional barriers to helping TGD students thrive. An important factor to students’ feeling safe and supported in schools may be their relationship with school nurses. The purpose of this study was to describe school nurses’ experiences working with TGD students and their parents/guardians, their role in working with this community, and the challenges nurses face when trying to serve TGD students. Semistructured interviews were conducted with 23 school nurses across a Midwestern state. Thematic analysis was used to identify themes: gender-affirming education and interpersonal collaboration, bridging the gap between TGD youth and parents/guardians, gender-affirming care and confidentiality, and navigating parental acceptance and gender-affirmation. School nurses expressed a strong desire to support TGD students but lack the structure and training within schools.
Keywordsadolescence, gender, family, nursing education, qualitative research
Transgender and gender diverse (TGD) students face a range of needs across all contexts of the school setting that continue to be poorly addressed (Craig et al., 2018). Transgender people identify with a gender different than the sex they were assigned at birth (GLAAD, 2020). Gender diverse refers to the difference in a person’s identity, role, expression, and social norms (American Psychological Association, 2015). The 2019 National School Climate Survey found that over 40% of TGD students reported avoiding gender-segregated areas in schools, such as restroom (45.2%) and locker room facilities (43.7%), which contributes to a negative school climate and feeling unsafe in school environments (Kosciw et al., 2019). Toomey et al. (2010) found that school victimization associated with lesbian, gay, bisexual, and transgender status experienced as an adolescent, was strongly associated with depression and life satisfaction. Additionally, schools that have a Gay–Straight Alliance (GSA) or similar student groups were significantly associated with psychosocial well-being, educational attainment, and lower high school dropout rates among all students reporting participation in these groups (Toomey et al., 2011).
Family dynamics, support, and acceptance are important topics for those who work with TGD students. The Human Rights Campaign (2018) found that TGD youth experience higher levels of stress related to gender identity in their home environments. For example, transgender youth reported being taunted by their family members because of their gender identity two times more than cisgender lesbian, gay, bisexual, and queer or questioning youth (HRC, 2018). Given the gender minority stress that TGD youth may experience in their families and/or in the community, they are at a higher risk for poorer mental health, substance use, and other health concerns compared with their cisgender peers (Clark et al., 2014; Clark et al., 2018; Cotton, 2014; Eisenberg et al., 2017; Hendricks & Testa, 2012; Rider et al., 2018). Family acceptance in adolescence, however, is associated with young adult positive health outcomes, such as increases in self-esteem, social support, and general health, and is protective against negative health outcomes, such as depression, substance abuse, and suicidal ideation and attempts (Ryan et al., 2010; Sharek et al., 2018).
Importantly, having a caring adult in the community or home and feeling safe at school may be protective factors against experiencing emotional distress for TGD high school students (Gower et al., 2018). A recent study found that TGD youth report visiting school nurses more frequently than cisgender youth (Rider et al., 2018). Menkin and Flores (2019) suggested that a way that school nurses could help TGD students transition socially and reduce their risk for health disparities was by using students’ chosen pronouns and gender-affirming names.
School nurses are also in a pivotal position to assist with the connection between students and parents/guardians. The American Nurses Association and National Association of School Nurses (NASN) (2017) published School Nursing: Scope and Standards of Practice to guide school nurses as they work with students in educational settings. In the School Nursing: Scope and Standards of Practice, Standard 1 directs school nurses to assess “the impact of family dynamics on the students’ health and wellness†(ANA & NASN, 2017, 44).
Furthermore, school nurses are tasked with promoting a safe, healthy, supportive school environment and social climate, and engage with families and community partners to better support students and meet their physical and mental health needs (Neumann et al., 2017). In 2016, the NASN updated its position statement on the school nurse’s role in working with lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) students, with recommendations specific to working with TGD young people (Blackborow et al., 2016). A school nurse plays a critical role in supporting student health and well-being, and notes school nurses need to collaborate, provide culturally competent care, and provide support and resources for families (Blackborow et al., 2016). School nurses are also tasked with advocating for policies and practices that support a safe school environment for all students, including those who are TGD. For example, school nurses can encourage the use of forms that provide the option of identifying one’s gender that does not assume binary responses (girl or boy), inclusive gender-neutral changing spaces and bathrooms, and use the students’ chosen name and pronouns, while protecting confidentiality when contacting those that the student has not shared their gender identity with, including family members (Blackborow et al., 2016; Toomey et al., 2010).
Although guidelines and position statements have been published to help school nurses in their work with gender diverse students, few studies examined school nurses’ experiences working with TGD students. Thus, the purpose of this study was to describe school nurses’ experiences working with TGD students and their parents/guardians. Research questions focused on school nurses’ role in working with middle and high school–aged TGD students and their parents/guardians. The research questions were as follows:
(1) What are the experiences of school nurses working with TGD student and their parents/guardians?
(2) What roles do school nurses see themselves in to support TGD students and their parents/guardians?
(3) What challenges do school nurses identify in regard to serving TGD students in the school setting?
This qualitative study involved semistructured interviews with 23 school nurses working in middle schools and high schools across the state of Minnesota, United States of America. The interview questions were first developed by two of the researchers and reviewed and revised by a third member of the research team, who is a content expert. Following the first two interviews, additional questions were added to elicit a more open-ended dialogue between the interviewer and interviewee. To recruit this convenience sample, an email invitation was sent to a listserv of all Minnesota school nurses from a contact within the Department of Health. Participants received a $50 gift card, which was possible through funding from the Glen Taylor Nursing Institute for Family and Society. Participants that met the inclusion criteria were included on a first reply basis. Inclusion criteria were registered or licensed practical nurses working in a public middle or high school. Interviews and recruitment continued until saturation was met. The Institutional Review Board at St. Catherine University approved all study protocols with an Institutional Review Board Joint Review Authorization Agreement with Minnesota State University, Mankato. All participants provided written informed consent before proceeding with the interview process.
Before participating in the interview, all participants also completed a brief demographic form as part of the study. The demographic survey asked about nursing experience, school nursing experience, degree attainment, education or professional development in gender diversity, age, gender identity, religiosity/spirituality, and race/ethnicity. All interviews were conducted in person at a private meeting room in a public setting at the participant’s discretion. Two researchers on the team each conducted half of the interviews. Data collection took place during May and June 2019. Each interview was audio-recorded and professionally transcribed. The accuracy of the transcriptions was verified by the two research team members who conducted the interviews.
A thematic analysis was conducted to characterize participants’ responses. An inductive approach was used and so no a priori categorization or coding frame was made, and themes and subthemes are heavily linked to the data itself (Braun & Clarke, 2006; Thomas, 2006). Two members of the research team independently reviewed each transcript, organized responses by topic, and assigned a descriptive code to portions of text. The strategy of intercoder agreement and the use of audio recording interviews established reliability in this study (Cope, 2014). These descriptive codes were then organized into initial themes. The codes and initial themes were discussed with the research team. Final themes were selected once consensus was reached. Within themes, quotes were reviewed to identify any subthemes. The use of direct quotes in the reports of this study enhances the confirmability of this study (Cope, 2014).
Prior to proceeding to the interview, participants signed an informed consent and completed a demographic survey. Twenty-three school nurses participated in this study with a range in experience from 3 to 45 years (M = 22.5, SD = 13.4). The majority (83%) of school nurses were Registered Nurses and the remaining 17% were Licensed Practical Nurses. Fifty-two percent of the school nurses fell between the ages of 39–56 years and 96% self-identified as female. Seventy-eight percent of school nurses reported their religion as some form of Christianity when asked if they identify with a specific religion or spiritual group. Fifty-two percent had earned a master’s degree. Most school nurses (61%) responded that they had some education in gender diversity; however, only 40% reported it was employer encouraged and only 30% received reimbursement for attending the education. Most school nurses (74%) in this study also reported having personal experience with TGD individuals. When asked for an explanation of the personal experience, 12 of the 16 written responses referred to working with students in their professional life while the other four referred to relationships outside of the work environment. The majority of school nurses worked in a high school setting (48%), followed by combined K-12 schools (22%), combined middle and high schools (17%), and middle schools (13%). All participants identified as White. There was a mix of school nurses from schools in the urban area (61%) and those from rural areas (39%).
The themes that emerged from the data related to school nurses’ interactions with TGD students and parents/guardians included gender-affirming education and interpersonal collaboration, bridging the gap between TGD youth and parents/guardians, gender-affirming care and confidentiality, and navigating parental acceptance and gender affirmation.
The role that school nurses play in supporting students and families is the expressed desire to educate and be available to students and their families. One nurse described supporting both students and parents by saying, “make sure that students have information they need to help themselves, and parents have information to support their children.†School nurses noted that it was important for them to know about health disparities for which transgender individuals are at risk and provide support with building healthy behaviors. For example, one nurse described that it is “important to know and to share that this population is at an elevated risk for negative health outcomes in general, because they’re going through this potential big transformation in their life.†Another stated that nurses are “in a prime position to influence the formation of health-seeking and wellness-focused behaviors… [to help TGD students] avoid poor decisions and loop in supports that we have.†This nurse highlights the position of the school nurse as one of support through education and relationship building with TGD youth. Some nurses described supporting students and their parents/guardians where they were in the process of acceptance with gender transition. One nurse stated,
understanding that those reactions [from parents towards TGD youth] might run the gamut, and that’s going to be what it’s going to be. We’re not going to change that, necessarily, but we can provide information to help support whatever needs to be supported.
One nurse described an incident of self-talk when having a difficult conversation with a parent regarding information being provided, saying, “I thought to myself, those are not my shoes that they are walking in; they are walking in their shoes. I need to entirely respect them.†Some nurses explained that giving factual information is a form of support. One school nurse believed that if they presented facts that this would help to change people’s minds about acceptance and understanding gender diversity. A few of the school nurses commented on how they view the whole person, including the whole family, and seeing students and parents as separate units but also as parts of a larger unit. One nurse said, “it’s support for both the student and family, not that they’re not one unit, but they’re also separate units.â€
Many of these aspects of school nursing described by the participants overlap with the idea of school nurses as a listener resource. School nurses in this study many times described themselves as there to listen, to provide resources even if they did not have them readily available, and to act as an advocate. School nurses repeatedly stated phrases such as “I guess just to be open and listen to them,†and “I’m usually a listener.†School nurses wanted to be perceived by the students and the community as a resource. School nurses wanted to be available to students and their families even if they did not have the resources that were needed. One nurse stated, “it would be nice to have counselors that know more about this and how to support families.â€
Bridging the Gap Between TGD Youth and Parents/Guardians. School nurses saw one of their roles as bridging the gap between TGD youth and parents/guardians. Thirteen of the 23 school nurses in this study offered some type of description of helping students and families come together or be accepting of the student’s gender identity. School nurses described this role as helping “both parties think and process,†encouraging parents to “just say ‘it’s okay’ to them [student],†and “it’s okay for kids to feel angry or sad or whatever they’re feeling…, and it’s okay for parents to feel that way, too… you try to get back to that place of: ‘We’re still family.’†School nurses discussed how their offices can be a neutral ground for students and parents to communicate. One school nurse discussed this role when a parent was not supportive of the student when saying:
It’s very hard because when you come up to a parent who is very non-supporting of their child, bringing that up to them is very off putting, so trying to make a relationship with them without saying, ‘you’re really hurting your child,’ even though you are really hurting your child.
Gender-Affirming Care and Confidentiality. The next major theme that emerged from the data was gender-affirming care and confidentiality. The school nurses in this study shared that they respect the privacy of their students and do not disclose information regarding gender identity without the student’s permission. Advocating for students to lead the way in how they want to approach situations and discussions is one way that school nurses provided students with autonomy and privacy. For example, one school nurse noted, “I think we have a responsibility to give them choices and allow them to be part of the decision-making, whatever it is ….â€
Some of the school nurses reported that the school’s charting system allowed for the inclusion of chosen names and pronouns, while others did not. One nurse in a school without that option said, “we’ve also done some kind of soft rules behind the scenes, like changing someone’s gender, even if it’s not a legal change, just for ease of interaction with that student at school.†School nurses often use the student’s chosen name and pronouns when interacting with the student but also noted that they needed to check with the student before calling a parent because “to out somebody is not our job.†Similarly, one school nurse noted that they do not initiate contact with a known student outside of the office because “they may not want to be called out [such as], ‘What are you doing with the nurse? [What is going on] that the nurse is talking to you?’†by their peers and classmates. Lastly, one school nurse noted being “careful with what…what I’m documenting†when encountering students as well because while the student is under 18 years old, the parents can get access to the school nurse’s notes on the student. This nurse went on to say, “I keep coming back to my student and what’s going to be best for them. Oftentimes, the parent might know or have an inkling, but they might not. I don’t think that’s my place to tell them. But also, as a parent myself, it’s my kid and I want to know. Parents often want to know what’s happening, so there is that line.†Nurses described having to balance what is best for the student and protecting the students’ privacy while at the same time expressing empathy from a parent’s perspective of wanting to know what is going on with their child.
Navigating Parental Acceptance and Gender-Affirmation. The theme, navigating parental acceptance and gender affirmation, addresses issues with acceptance and having to switch pronouns depending on the person with whom the school nurse was talking. Most school nurses in this study reported some level of interactions with parents or guardians of TGD students in their schools. About one-third of nurses reported no interactions with parents or guardians of this student population. School nurses in this study mostly gauged how much the parents or guardians were accepting the students’ gender identity through conversations with the students and not in direct interactions with the parents or guardians. In some rare cases, parents or guardians met with the school nurse quite often. One of the most challenging situations that school nurses reported experiencing was having to call a parent or guardian because of an illness that required the student to leave school. In these situations, the challenge was knowing whether parents or guardians knew about the student’s chosen name and pronouns. One school nurse said, “I have to call home and say … (His [chosen] name is Jonathan, but his [legal] name is Sally,) and I’ve got to call mom and say, ‘Jonathan is down here.’ They’re like, ‘I have a daughter, not a son.’†This described a situation where the parents might not have known the student went by a different name at school or the parents may not have been accepting of their child’s gender identity if the student was out to the parents.
Similarly, other situations that school nurses described included parents refusing to accept the student’s name and pronouns, or situations in which one parent was accepting while the other was not. School nurses described these situations as difficult to navigate given they were trying to respect both the parents and the students. A few school nurses shared that they explain to the student that they would use the chosen name but for legal documents or interactions with parents, the nurse would use the student’s legal name. For example, using a pseudonym, a school nurse explained:
So, I’ll say to the student, “In your IEP, I need to type that your name is Emma Jones.†However, I then will go on to say, “Emma is requesting that she be referred to as August,†and I’ll put quotations or something, or identify it as a request, but not the legal name. And that has felt okay for me, feels like it’s okay. And usually the parents are okay with that, so I think you’re reflecting both.
Another nurse stated, “Sometimes, we’ll ask [the student], ‘Hey, we’re calling dad. What name should we use? What pronouns should we use?’†Nurses also stated that they will have the student step out of the room if they speak to a parent that has an issue with the student’s gender identity, chosen name, and/or pronouns as a way of protecting the student.
Other nurses noted transformations they have seen in parents during the time the student is in the school. For instance, one nurse described a parent that was sure the child’s gender identity was “just a phase.†Later in the relationship, the parent had appeared to become more understanding and supportive of the child’s gender identity, and the parent spoke with ease in calling the school nurse to say “[Student’s name] wasn’t feeling well, and …like, ‘Yep, I think…he has his period.’†The student’s parent used the student’s chosen name and pronouns, even when talking about a bodily process that is often gendered, which signified some changes in comfort and gender literacy.
There is very little research in the literature that describes school nurses’ experiences working with TGD students and their parents/guardians; this study aimed to fill this gap. The school nurses in this study described ways in which they tried to educate and support students and parents/guardians and bring students and parents/guardians together while still maintaining the privacy of the student and recognizing parents/guardians’ level of acceptance. Nurses found navigating between respecting the students’ gender identity and the parents/guardians’ level of acceptance, particularly challenging when there was parental conflict or parents were unknowing of the students’ gender identity.
Nurses recognized the increased risks for TGD students, especially when parents/guardians were not accepting. One nurse said they tried not to say “‘you’re really hurting your child,’ even though you are really hurting your child.†Ryan et al. (2010) studied the impact of family acceptance on young adults. Young adults that reported family acceptance at high levels also had higher scores in the areas of selfesteem, social support, and general health (Ryan et al., 2010). Conversely, Ryan et al. (2010) found that young adults with lower levels of family acceptance had higher scores for depression and substance abuse. This study also found that young adults with low family acceptance were twice as likely to report suicidal ideation as compared with young adults with higher levels of family acceptance (Ryan et al., 2010). While nurses in the current study did not relate specific health concerns, they suggested that a lack of parent/guardian acceptance of the student’s gender identity could be causing harm.
In attempts to bridge the gap, school nurses described ways in which they feel they can bring students and parents/guardians together. Nurses described meeting the parents/guardians where they were in accepting their child’s gender identity while also maintaining respect for the student by using chosen names and pronouns. The use of chosen names and pronouns are strategies that are supported by Menkin and Flores (2019). School nurses described the charting system and how they were careful when documenting especially when parents/guardians may not know the student’s gender identity. Minnesota Statutes (Minnesota Legislature, 2020) allow for minor consent in certain circumstances; however, these do not include privacy for gender identity. The Family Education Records Privacy Act allows parents access to students’ health records kept by the school nurse. The state law regarding minor consent would benefit froma revision that includes gender identity, to ensure that student disclosure of gender identity is protected from parental access if the student so wishes. The U.S. Department of Education (2016) published examples of school and school district policies to aid schools in creating a safer space for TGD students, including examples of protecting gender identity.
School nurses expressed the desire to be a resource for students and parents/guardians but often reflected that they lacked the knowledge and resources for guiding and referring students and parents/guardians. This highlights the need for education in TGD care. All types of nursing care require continuing education to stay up-to-date. School nurses should be provided adequate, ongoing professional development opportunities in caring for TGD students.
The current study was completed prior to the coronavirus 2019 pandemic that closed schools for extended periods of time. According to Szilagyi and Olezeski (2021), 13.2% of adolescent-aged students received mental health services at school. The authors noted that 35% of these students used the school services exclusively for other mental health services (Szilagyi & Olezeski, 2021). In light of the pandemic closing schools, this could cause negative outcomes for students that rely on school settings for mental health services; similarly, those students that have low acceptance from family regarding gender identity could suffer exacerbated negative outcomes previously identified as higher rates of depression, substance abuse, and suicidal thoughts and behaviors (Ryan et al., 2010).
This study provides insight into the experiences school nurses have while working with TGD students and their parents/guardians. School nurses in this study described a strong desire to help TGD students and their parents/guardians come together through education, gender-affirming interaction, and care, while navigating parental acceptance and confidentiality issues. This study can serve as a basis for developing and introducing interventions for educating school nurses in best practices and skills in communicating and supporting TGD students and their families.
There were limitations to this study. Given our small convenience sample, purposive recruiting strategies, and volunteer participation, our sample may not necessarily represent all school nurse providers. While most of the nurses described their roles as an ally or advocate, there were a small number of nurses that wanted to remain neutral in their role as a school nurse and not identify in any particular way, such as hanging a pride flag or ally indicator in their office. All the participants identified as White and most identified with some Christian religion. The homogeneity of the participants closely matches the demographics of the state’s nursing population as the Minnesota Department of Health and Board of Nursing (2017) survey reported 91% of Minnesota nurses were White. This, however, does not provide a perspective from a diverse background nor does it represent the 36.2% of Minnesota students that identify as a student of color (Minnesota Department of Education, 2018). According to the 2019 Minnesota Student Survey, 3% of ninth graders and 3% of 11th graders identified as transgender, genderqueer, or genderfluid (Minnesota Student Survey Interagency Team, 2019). Transgender youth of color have reported that having a transgender community that was also diverse in race and ethnicity supported their “whole self†and were affirming (Sherman et al., 2020). Additionally, when transgender youth of color had peers that had similar identities, they had a role model and source of validation (Sherman et al., 2020). As the demographics of the population become more diverse, so should the health care providers. This is necessary to provide more culturally sensitive care and meet the needs of our clients (Institute of Medicine, 2011) in all settings including schools. The participants were all from the same Midwestern state, which also limits the voice of diversity; however, there was a near equal participation among rural and urban school nurses. As such, results may be specific to these particular demographic groups.
This study also has several noteworthy strengths. There is a paucity of literature that specifically addresses school nurses’ experiences working with TGD students and their parents or guardians. The public-school nurses were eager to share their experiences working with TGD students and their families, and they shared a range of experiences and points of view, which is important for better understanding their strengths and needs. Additionally, the nurses interviewed covered a diverse geographical and economic area (both rural and urban areas in the state) and worked in both middle schools and high schools.
The results of this study have the potential to guide future changes in practice and recommendations for research.
Practice Recommendations. As noted in the NASN (Blackborow et al., 2016) position statement on LGBTQ students, school nurses are competent in many areas that could benefit LGBTQ students. School nurses provide support and resources to students and parents/guardians (Blackborow et al., 2016). School nurses in this study described situations where they reported supporting students and parents, but also expressed a lack of knowledge to share. It is recommended that school nurses be required to attend educational seminars to enhance their knowledge about gender diversity. One study found that barriers to professional development among nurses included time constraints and financial burden (Waltz et al., 2020). In an effort to remove barriers to education, schools and school districts should provide dedicated time and cost reimbursement for school nurses to attend conferences or other educational opportunities to better support their TGD students.
It is also recommended that school nurses be actively involved in developing a safe learning environment that is inclusive. School nurses should be involved in policy development regarding antibullying policy and the development of Gender–Sexuality Alliance (also known as GSA) student groups (Blackborow et al., 2016). The presence alone of GSA student groups was correlated with psychosocial wellbeing and educational attainment into the future of young adults (Toomey et al., 2011). Additionally, school nurses can be the champions of change in their schools. As Ricca et al. (2018) explained, a champion is a person within a community that has an interest in a cause and can be the starting point for change. This can then lead to analyzing policies for inclusive language, identifying strengths and challenges with developing a more inclusive school environment, and seeking out experts in the community to provide training (Ricca et al., 2018).
Research Recommendations. Future research should focus on developing training for school nurses to be involved and work with interdisciplinary professionals within the school to support TGD students. Research should also be family focused and help school nurses create strong bonds with parents and families to reduce the health disparities that TGD students are at higher risk for experiencing. This might include studies that ask TGD students and their parents/guardians how they are or would like to be supported by school nurses. Utilizing the scopes and standards of care and position statements already developed by the NASN can help to guide school nurses in their own practice, such as using chosen names and pronouns (Blackborow et al., 2016). The research will lead to evidence for effective interventions or practices and environments where TGD students can learn and grow.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the GHR Innovative Scholarship Grant and the Glen Taylor Nursing Institute for Family and Society.
Tammy Neiman, PhD, RN-BC https://orcid.org/0000-0001-9297-5937
G. Nic Rider, PhD, LP https://orcid.org/0000-0002-6730-5613
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1 School of Nursing, College of Allied Health and Nursing, Minnesota State University, Mankato, MN, USA
2 Henrietta Schmoll School of Health, St. Catherine University, Saint Paul, MN, USA
3 Sanford Health, Sioux Falls, SD, USA
4 Institute for Sexual and Gender Health, National Center for Gender Spectrum Health, University of Minnesota Medical School, Minneapolis, MN, USA
Corresponding Author:Tammy Neiman, PhD, RN-BC, School of Nursing, Minnesota State University Mankato, 360 Wissink Hall, Mankato, MN 5600, USA.Email: tammy.neiman@mnsu.edu
