There’s a “cultural competence deficit” among healthcare workers, as well as med school and nursing students, that not only impacts the quality of care received by transgender people, but that keeps them from seeking HIV preventative services, said Steven Cardenas, who teaches at NOVA Southeastern University and Galen College of Nursing, and works as a nurse practitioner at Midland Medical in Oakland Park, Florida. Cardenas has come up with a small but essential solution—an educational session that, while not comprehensive transgender healthcare training, at least helps show healthcare practitioners and students where their trans blind spots are.
“Some healthcare workers know nothing about trans health, more so at the more established clinics with older generations of providers,” Cardenas said. “For example, when a patient asks for PrEP, they’re more likely to be referred to an infectious disease doctor. Even now, many doctors are still wary of prescribing PrEP.” And some are downright clueless about how to care for trans patients, he suggested.
There are data to back up his claims. A 2018 CDC report concluded that transgender patients face persistent and pervasive stigma and discrimination. Some even endure physical and verbal abuse while seeking medical care, and in some cases are denied healthcare services altogether, the report found.
“The biggest challenge for trans patients is fear of rejection by providers,” Cardenas said. “This fear prevents trans people from seeking health care.”
Such fears can lead to dire consequences for trans people who might benefit from HIV prevention services. There is an estimated HIV prevalence of 9.2% among all transgender people in the United States, and even higher among transgender women. An estimated one in five women who identify as transgender are living with HIV—even higher among African American transgender females in the U.S. Cardenas says that trans patients who mistrust doctors, and the medical establishment in general, are less likely to ask their primary care doctors for PrEP and PEP.
The intervention: one quality improvement project
Inadequate training worsens the challenge in caring for transgender people. Both the U.S. and Canada include only five hours of LGBTQ+ education within their medical and nursing training programs, and at least 18 nursing schools have no LGBTQ+ education. Cardenas set out to raise awareness for providers in primary care settings through what he calls a “quality improvement project,” rather than an education module. The goal is to help healthcare professionals understand how stigma and discrimination can influence the willingness of transgender patients to engage in HIV screening.
“Continuing education modules, which are usually credits that healthcare workers need, are usually not engaging,” Cardenas said. “Learning in a classroom setting is better,” he said. But if not in a classroom, the educational session should be interactive, “with quizzes, to make them want to read.”
His clinical question was narrow: can one educational session enhance healthcare professionals’ understanding of how stigma and discrimination against transgender people in healthcare settings influence their willingness to offer HIV screening? The answer, he found, was yes.
The interactive educational session took about 30 minutes. Workers at his outpatient clinic, Midland Medical, completed it over their lunch break. There were questions in between every 3 or 4 slides to keep participants engaged, he said, “different from the ones in the survey, but helpful in making sure that everyone was paying attention.”
Before and after the education session, participants were asked several questions such as: True or False: Sexual orientation and gender identity are the same thing. What percentage of transgender people do you think reported negative experiences in a healthcare setting?
The idea was to see whether a single presentation could not only educate healthcare workers on sexual orientation, trans stigma and the significance of HIV screenings, but also show them where their knowledge fell short. The pre-survey mean score was 43.77% and the post mean score was 74.82%, a greater than 31% mean increase in awareness of trans issues and statistics. “The findings indicate a significant improvement in participants’ understanding of trans stigma and discrimination in healthcare settings and how it impacts their willingness to engage in HIV screening,” Cardenas said.
What’s also noteworthy about the results was how much healthcare workers didn’t know about trans patients in what Cardenas described as a clinic that’s generally more welcoming to trans folk than most healthcare settings. Midland offers LGBTQ+ STI screening and treatment, as well as HIV care and primary care and is one of the few private care providers for trans people in the Broward County area. Staff members who completed the session included phlebotomists, patient care coordinators, pharmacists, pharmacy technicians, nurse practitioners, medical doctors and members of the linkage team. “All potential participants either provided care to transgender patients or routinely engaged with the transgender community in their daily roles,” Cardenas said.
Out of 23 participants in the pre-survey, Cardenas said, most had three to five years in the medical field and most had previously received some LGBTQ+ education in the past. For most participants, that LGBTQ+ training came on the job, Cardenas said.
This project comes amid a backdrop of state laws banning gender-affirming care—one of the most extreme is in Florida—causing demoralization and panic for trans youth and adults, and sometimes the fear of prosecution for their providers.
Cardenas says that he’d like to see the training session incorporated into continuing education for healthcare workers across the country, but he admits that there should be a greater effort to incorporate significant LGBTQ+ education in medical and nursing schools across the country.
“I would rather focus on the newer generation, which is generally more open about trans issues, even if they don’t know everything,” he said.
Larry Buhl is a multimedia journalist based in Los Angeles. He has covered HIV/AIDS and other infectious diseases for more than two decades. In addition to POSITIVELY AWARE, he is a regular contributor to TheBody.com, Everyday Health and capitalandmain.com. His work has appeared in USA Today, Salon, Undark, KQED, the New York Times and others.