6. Trans Care is Primary Care: Erin Ziegler


Hi everybody and welcome back to ubiquitous evolution. Today we have an incredibly talented and passionate nurse practitioner and researcher, Erin Ziegler Erin thank you for joining us today. I'm wondering if you can start by telling us a little bit about yourself?


Thank you, Roberta I'm really excited to be here today. So, my name is Erin my pronouns are she and her and I am a primary care nurse practitioner. I am the clinical lead of the gender medicine program with Queen Square Family Health Team. That's a Family Health Team in Brampton which is an urban center outside of the GTA (Greater Toronto Area) and I am also an Assistant Professor with the Daphne Cockwell School of Nursing which is part of the Toronto Metropolitan University, formerly Ryerson University where I teach in the undergraduate, graduate, and the nurse practitioner program, and I am the Provincial Course Lead for the Advanced Health Assessment and Diagnosis course, which is part of the Ontario Primary Health Care Nurse Practitioner program. That's me.


You're very busy and I very much appreciate you spending the time with us today. So, I will start because I want to declare, who I am. She and her my pronouns, I'm a white, middle aged heterosexual, Canadian woman, and that gives me the kind of perspective and privilege that I think we haven't just even started tapping into. But in this case, I think it's an incredibly important issue, the care of trans, patients and primary health care, particularly because literature showing more and more that nurses and nurse practitioners may be reluctant to ask questions about, or even discuss the care of transgender people. And there's a fear of saying or doing something wrong, but that this means there's potential then for essential points about the care of trans people in primary healthcare to be missed. Or there to be misconceptions about so I'm so happy that you're here to discuss this with us today. And I guess we'll dive right in. So, I know that you've been conducting quite a bit of research related to the nursing care of trans people in primary health care, and can you start by talking to us a little bit about what some of the barriers are to nursing care for transgender people.


Yeah. So, my research has really looked. Initially I really wanted to delve right in and solve all of the problems but as you know, you really have to figure out the, the crux and the foundation of those problems first and so when I looked at what those are I really kind of themed them into barriers from a patient perspective, from a provider perspective and then also from an organizational perspective in terms of those barriers to accessing care. So, from a provider perspective, we as providers don't actually know a lot about trans care. We're not taught about it in our curriculum, whether it be... and I'm going to focus on nurses because we're nurses.

But it's not just nurses so I'm in general in healthcare, we do not do a good job teaching healthcare practitioners, about trans care or LGBTQI2S care at all.


So, there was a huge study in the States that looked at LGBTQ care curriculum inclusion and undergraduate nursing and only 2.12 hours in the curriculum were included in undergraduate curriculum. Not enough, and it was lumped into sexual health. So, like, let's talk about STIs and then let's throw in LGBTQ.


So, not really a great place. A little bit more is done in medicine, but not much more just less than five hours in the medical curriculum. But again, still lumped into STIs and not trans focused and we actually don't really know what, um, how much is specifically done in the NP curriculum. I did a study looking at it in the nurse practitioner curriculum, and there's not a lot of content. And so it varies depending on the instructor and how much they emphasize it. And so, there's huge barriers for practitioners to even feel comfortable, providing care knowing what that care is. That's, that's a huge barrier right now because providers don't even feel like they know what to do know what to say know how to even broach the subject.


Patients are themselves their own barrier to accessing care. We know that there is a history of victimization, discrimination and stigmatization accessing healthcare within the trans population, whether it be actual or perceived, so patients who have gone to access health care and been denied health care, or the way they present, because of their gender identity. The literature shows that up to 17% of trans identified individuals have been denied access to healthcare based on their gender identity. And because of that, and because of knowing that they may have to disclose their gender identity, trans people sometimes avoid going to carry to access care.


So, I'm, you know I hear stories of trans clients saying that they have acute episodic conditions that they do not go and get treated. They have higher rates of preventable conditions because they don't go get things treated, because they don't access the healthcare system. So that's a provider, a patient barrier, because they, they don't actually even want to access the system.


And then from an organizational system, the healthcare organization in itself has barriers, things like the binary system of the, of the healthcare system in general is very male/female from a sex point of view, our health records, our intake forms our EMR are you a male or are you a female? If you do not identify as a male or a female, what box do you check on the healthcare intake form? If your gender identity does not match your health card? If your name is your preferred name is different than the name that is on your health card, how do you check in for a medical appointment and worry about being outed in a waiting room? How do you go to the bathroom in a, in a clinic when you have to choose what bathroom you need to go into? All of these are systemic barriers that our health care system puts up in place. And so, right off the bat, these are barriers that trans individuals encounter on a daily basis accessing healthcare system, and healthcare services in Ontario.


And I would imagine across North America, in various degrees, and certainly when you were speaking about the, the individual patient barriers. I couldn't help but think that the barriers you were describing were because of, the reaction that healthcare providers and perhaps other patients in the setting have for the most part, so, so much comes back to the role of the nurse practitioner in the care for trans people. So, in that case, then what are some of the activities that nurses or nurse practitioners, and really actually all healthcare providers can implement to help address these barriers?


Yeah, and I think, I think it's really important, it doesn't really matter whether we're talking about a trans individual someone who identifies as gay or bisexual or lesbian or queer, we really need to make our healthcare organizations safe. We need to make them inclusive we may need to make them free of assumptions and our own biases and judgment. You know, so, a prime example and it is, you know, we ask everyone who looks female...if we're sending them for a chest X ray if they're pregnant. We automatically are making an assumption that they could be pregnant. If they aren't having sex with someone who produces sperm, we've made an assumption that they are... you've potentially disrupted that nurse/client relationship right? You've, you've already put up a barrier and made an assumption about them. Same as when you're asking them if they're sexually active. They're sexually active. Yes. Do you use condoms? No. Well you know you could be pregnant. Well, you didn't even ask me if I'm at a risk of being pregnant.


All of these personal assumptions and personal biases and judgments that we make as nurses, whether they're implicit assumptions or, you know, right in our face, no valid assumptions that we're making, disrupt or nurse client relationships. So I think one of the first steps we have to do as nurses is really work on creating that safe and inclusive environment that you're able to provide a culturally safe environment where we are developing and maintaining a relationship that's based on respect and trust, and we are acknowledging ourselves as a learner when we don't potentially know about someone's identity. So if you don't understand what a gender identity and someone's trans identity means, asking about it or acknowledging what our own lack of understanding about it is okay, and learning about it. Learning about how we can make our clinic safe. So, how can we learn to ask the right questions? How can we learn to do a safe health assessment, intake assessment? How can we make our intake forms more inclusive where we have a space to ask about partners versus not just, you know, husbands or wives or boyfriends or girlfriends? Where can we ask about gender identity, not just are you a man or a woman? Can we put up a positive space sign so people know that they can feel comfortable you know, identifying their sexual orientation and their gender identity.


And so we need to, as nurses, go through a process of self -reflection and question our own assumptions and biases, to be able to understand how our own beliefs impact our engagement with our clients because we want to make sure that we are not bringing our own biases and judgments into our practice which would then impact how we're able to provide a positive and safe environment to be able to provide culturally, safe, and affirming healthcare to our clients. I think that's one of the biggest things that we can do to open up the space as nurses to be able to provide this care to any gender or sexual minority client.


You brought up some really amazing points. So, to start though, simply asking questions in a respectful way can go a really long way to creating safe care for trans patients, and you gave us a lot of really good ideas about how the organization can move the care toward a safer environment, such as the signage and inclusion in in the documents and that sort of thing. You spoke about reflection and self-reflection about biases and you know I think that's hard. It's hard for me because it's like I don't even know what I don't know and I think that you've tapped on another issue or this circles back to the problem that we have with the lack of visibility of trans care in our education. So, I'm going to put you on the spot a little bit. Are there resources that you could suggest to people or ideas for individual registered nurses or nurse practitioners to maybe delve into some of the self-reflection in a more guided way.


Yeah, so, self-reflection is hard and critically reflecting on your flaws, is really hard. One of the things that's a really good test to challenge yourself is the Harvard Implicit Bias Test. It's a test that you can actually take very rapidly, and it gives you a score on how biased you are about black people versus white people; gay her people versus straight people; rich people versus poor people. You think you don't have a bias about them, but then you take this test and it brings out these inner biases that you have and you can reflect on them. And you can learn and you can grow. You know, and I think as registered nurses and nurse practitioners, you know we should be doing reflections we're taught about them in school, we are forced to do them in our program and we think, you know, it's just part of our education and then our teachers and our profs make us do them. Then we graduate and we never want to ever do them again but, you know, technically, the College of Nurses makes us do them and we should be doing them as part of our portfolio.


One of the things that I had developed with a grant from the CIHR was something called SOGI nursing, which is sexual orientation and gender identity nursing. It's www.SOGInursing.ca. It's an E-learning tool kit. It's a set of recorded lectures, virtual simulations and reflection tools, and the virtual simulations are all about cultural humility and nursing encounters with LGBTQI2S individuals. But the thing about them is they're not all good encounters with individuals. So, there, as an example with a trans individual, what happens when you misname an individual or you use the wrong pronouns, or you know give you give too much information, like you gossip about them when you're handing over and report. Those sorts of things. You can see the breakdown of the therapeutic relationship. It gives you reflective questions at the end to be able to reflect on you can actually use. The whole point of the development of these virtual simulations and this toolkit was actually developed as a professional development tool for nurses and nurse practitioners to use because there isn't any content in the curriculum. To be able to say "Look I really don't know about what I would do if I, you know, had a client that identified as trans" and if I mis-gender them, what would I do to fix the situation if I messed up. OR, how would I engage? So, this toolkit is really a way for nurses to sort of, you know, on their own time, work through these modules and use some personal reflection, use the reflection questions to sort of think about their answers. And that's sort of an asynchronous way of working through some things.


Another really fantastic resources is Rainbow Health Ontario. Rainbow Health Ontario provides multiple courses from making your practice inclusive and safe to caring for LGBTQ clients. All the way to providing hormone therapy for trans individuals, doing surgical assessments.

They do lots of workshops, both asynchronous and synchronous workshops. So, there are different professional development workshops that nurses and nurse practitioners can take to increase their knowledge and competence in caring for and providing care for the LGBTQ community. Because while we're trying to do it, and incorporate it more into the curriculum now, those of us that are already have in practice, kind of have a lot of catching up to do to get up to, feeling like we are, we do have the skills to provide that care. So, looking for those already available resources is really key to do some professional development.


That's amazing. And just so the listeners know, I will be posting links to the resources that were mentioned here. And if they're not available for free, there will be a link to a website that you can go and get more information. But just to clarify, then certainly the SOGI nursing website sounds like it is freely available?


It is free. Yeah.


And the Rainbow Health Ontario. Is it also available for free for anybody?


So, it is, um, they do sometimes they have their courses for free like during Pride Month. So, June is pride month so they do offer some of their courses for free, but their courses are offered at a very nominal fee compared to other courses like 30 - 40 dollars for a full day course.


Yeah, and then CMHA (Canadian Mental Health Association) also has an ECHO program on trans, health care, and that courses offered for free. So, there are lots of free resources and, yes, we can definitely develop a list of free resources.


Absolutely! Especially since I'm hoping that there will be listeners outside of Ontario and even across Canada, or even across North America for this and I think that anything that we can offer to individuals that they can have access to learn more is important.


So, from an individual perspective this is extremely helpful, and you've sort of given me the idea that perhaps there needs to be some lobbying so that organizations will make time, set dedicated time for their staff to go through modules like this and to learn more about the LGBTQ trans population so those are really, really helpful.


Yes.


Alright so we've, we've covered quite a bit in a short period of time. And I just wondered if there's any, if you were going to give us any advice or want to highlight any one particular thing is there's something that comes to mind?


I think the one thing that I get a lot. So, as a clinical leader of a transgender program. I get a lot that trans care is specialty care, and I'm a primary care nurse practitioner. And it is a program within primary care, but it is not specialty care. And I think I really, really want to highlight that trans care is primary care. It does not need to be done by a specialist. Trans individuals experienced an excessive amount of barriers trying to access gender affirming care, whether it be access to provider that's just safe for them to be able to get started on hormone therapy,

continue hormone therapy, or even be able to access preventative care. So, you know, a place to get a PAP. Or, you know, they also have chronic disease so you know, get care for their diabetes or their asthma or acute care management, And so I get a lot of times people saying to me that they should be referred to a specialist, like an endocrine endocrinologist, or to a gender medicine clinic. Well, always there's complex patients so you know if you have a very complex patients that has a lot of complex issues, then sure, they probably do need to be referred to a specialist. But, the majority of patients can be managed and should be managed in primary care. And all I'm a primary care practitioner I'm managing these patients in primary care. I just have, I have a specialty program because there's not enough primary care providers providing this care. So, I am trying to improve access to this care. So you know if you can provide a prescription for birth control, you can prescribe a prescription for hormone therapy, it's, it's the same medication. It's estrogen. It's testosterone.


And so, you know, I really, really want to, you know, break down that stereotype that trans cares is specialty care. It should be part of primary care. It is primary care. I think when, you know, primary care providers nurse practitioners, physicians, really start embracing it and just incorporating it into their practice I think that is going to really eliminate a lot of the barriers because patients are still having to wait on really long week less or traveling really great distances, just to get a prescription to access hormone therapy. You know, for a lot of trans patients hormone therapy is, is life-saving therapy for them. So, I think, you know, just getting some of these barriers broken down is critical and so, you know, if we can just eliminate that that stereotype that they have to go to a gender clinic, or they have to go to an endocrinologist, is not true. I think the more primary care providers that can take on,you know if they're, if they're client comes out to them as trans, it's okay to say I, I'm not...I don't know what to do because I didn't learn this in school...but then say, but I'm going to figure it out. And there are guidelines, you know there's the Sherborne Guidelines for Trans and Non-Binary Primary Care there's guidelines over BC (British Columbia) there's lots of guidelines and we can put these on the list, Roberta, as well. Um, you know, and it's no different than us following a guideline to manage someone's diabetes or COPD or their asthma. You know, we follow guidelines for other aspects of primary care and I think just normalizing it in primary care will also really help improve access for this vulnerable population.


And you say that and there are many conditions for which there are no guidelines, and you are left as a practitioner to search for the best evidence and make a clinical decision based on based with the client. So, so that doesn't make, it makes perfect sense to me what you just described. In fact, so important, given that there are very few gendered clinics and very little access to endocrinologist outside of major centers, particularly in Canada. So, this, you know, doesn't seem unreasonably difficult, what you've described the care of trans patients, and obviously extremely important to these people. So, yeah, just makes perfect sense. and I appreciate that you said that.


So this has been great. And I especially like the fact that there's so many helpful resources that have come out of our discussion that I will start tapping into because as I said I feel that, you know, certainly, there's a lot of work that I need to myself and I hope that others are willing to do the work too. It's not difficult and it will certainly make a big difference in the care of people in our practice. So, thank you very much!


Thank you for inviting me to talk to you, it was a pleasure.


Ziegler, E., Charnish, E. & DeCiantis, N. (2022). Out of the closet: Nurse practitioner faculty knowledge, comfort and willingness to incorporate LGBTQ2SA content into the curriculum. Canadian Journal of Nursing Research. Ahead of print. https://doi.org/10.1177/08445621211073289

Ziegler, E., Charnish, E., Carroll., B. & Layman-Pleet, L. (2021). A critical review of clinical practice guidelines for care of transgender and gender diverse children and youth for use by primary care practitioners. Transgender Health. Ahead of print. https://doi.org/10.1089/trgh.2020.0185

Ziegler, E., Luctkar-Flude, M., Carroll, B., Tyerman, J., Chumbley, L. & Shortall, C. (2021). Development of an online educational toolkit for sexual orientation and gender identity minority nursing care. Revista Latino-Americana de Enfermagem, 29(e3470), 1-9. https://doi.org/10.1590/1518-8345.4712.3470

Ziegler, E., Valaitis, R., Carter, N, Risdon, C. & Yost, J. (2020) Exploring the delivery and implementation of primary health care services for transgender individuals in Ontario: Case study protocol. Primary Health Care Research & Development, 21(e14), 1-7, https://doi.org/10.1017/S1463423620000109


Ziegler, E., Carroll, B. & Shortall, C. (2020) Design thinking in nursing education to improve care for lesbian, gay, bisexual, transgender, queer, intersex and Two-Spirit people. Creative Nursing, 26(2), 118-124. https://doi.org/10.1891/CRNR-D-20-00003


Ziegler, E., Valaitis, R., Risdon, C, Carter, N. & Yost, J. (2020) Models of care and team activities in the delivery of transgender primary care: An Ontario case study. Transgender Health, 5(2), 1–7, https://doi.org/10.1089/trgh.2019.0082.


Ziegler, E., Valaitis, R., Yost, J., Carter, N., & Risdon, C. (2019). “Primary care is primary care”: Use of Normalization Process Theory to explore the implementation and delivery of primary care services for transgender individuals in Ontario. PLoS ONE. 14 (4): e0215873. https://doi.org/10.1371/journal. pone.0215873


Clinical Practice guidelines

https://www.rainbowhealthontario.ca/wp-content/uploads/2021/06/Guidelines-FINAL-4TH-EDITION-c.pdf


http://www.phsa.ca/transcarebc/


https://transcare.ucsf.edu/guidelines


https://www.wpath.org/publications/soc


Professional Development


www.soginursing.ca


https://learn.rainbowhealthontario.ca/


https://camh.echoontario.ca/programs-tgdh/



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