A growing number of health plans are now covering gender affirmation surgeries, including Medicaid which has expanded coverage for this service in 9 states. This presents a choice to health system leaders who need to decide whether they will provide this offering. Yet, more importantly, it points to an opportunity for health systems to prepare staff to offer culturally competent care to LGBT patients, regardless of the services they offer.

We spoke with Shannon Whittington, the Program Director of the Gender Affirmation Program, to learn more about how Visiting Nurse Service of New York (VNSNY) has partnered with Mount Sinai (and other NYC hospitals) to build out their service offerings for LGBT patients, particularly caring for transgender patients post gender affirmation surgery. Since launching this program in March 2016, they’ve served over 350 patients, and have been recognized by SAGECare with a Platinum level LGBT cultural competency credential. Their post-operative gender affirmation patients have a significantly lower rehospitalization rates (estimated 4.9%) than the CMS benchmark (15.6%).

Tell us the history of the Gender Affirmation Program at Visiting Nurse Service of New York and how you went about identifying the right caregivers for the program.

Mt. Sinai hospital approached us to provide home care services to their gender affirming patients after surgery. I attended several lectures at Mt. Sinai led by Dr. Marci Bowers, (renowned gender affirming surgeon and pioneer). I spent an entire summer doing clinical observation at CTMS (Center for Transgender Medicine and Surgery-with Zil Goldstein who was director of the program at the time) to observe and develop educational material for our nurses. In three years, we’ve expanded the program so much that we now have 350 patients, and 250 trained clinicians.

To get this program off the ground, you had to train your home health nurses to be able to deliver culturally competent care to a transgender patient population. This obviously requires clinical expertise, but the harder part is the cultural elements of caring for someone who is changing their gender. How did you equip these nurses to care for patients who are receiving gender affirmation surgery in a way that is as respectful of this population as possible?

Yes, very important. Language is huge and a lot of people are uncomfortable with how to communicate with transgender patients—and can be anxious around communicating effectively. Therefore, it is important to address this head on and ensure that clinicians are using appropriate language, have the clinical knowledge to care for someone who is getting gender affirmation surgery, but more importantly that they can be empathetic, compassionate, and sensitive. One of the major things the nurses are learning is how to let the patient know they are not judging them and how to make them feel comfortable. We help our caregivers develop that sensitivity and awareness through our training by helping them understand the importance of using language that they may not be familiar with. It is only in recent years that we have started to ask pronouns and preferred named, whereas just a few years ago, these questions never came up. I always explain that it is not about the patient leading with being transgender, but the patient is a patient who happens to be transgender. Once the training is over, I often hear, “gosh, I had no idea! Wow, I feel like I can do this. When can I have my first patient?”

A 2015 survey of the transgender population found that 1 in 3 transgender patients who saw a health care provider had a negative experience. We’ve been very proud of the fact that our patients have been very pleased with the clinicians. In fact, many are pleasantly surprised that the nurses have this specialized knowledge because their experience in the past has been just the opposite. Many patients request the same nurse again if they have additional procedures because these patients are not used to feeling comfortable and open with their healthcare professional so they tend to latch on to the nurses.

What has surprised you the most about the evolution of this program?

It wasn’t easy initially to find clinicians who wanted to participate in this program to lack of knowledge. Many nurses were reluctant to be trained, and some outright refused to do the training. But by the second year I had nurses coming to me asking when the next training was and even requesting to take care of these patients exclusively because they enjoy the population so much.

When a nurse hears about the struggle of these patients, it tugs at their heartstrings and they realize how important their role is. Many of the nurses realized that treating patients competently is the most important part. They want to be able to take care of any and all patients and learning how to be culturally sensitive to different groups is imperative especially in this community. What changed for the nurses was realizing that these patients face a great deal of stigma. And nurses truly have a giving heart. They could feel the impact that they were making on these patients' lives.

What have you learned and what advice do you have for other organizations that are not making the investment you are?

The big thing is that you don’t know what you don’t know. Many organizations may not consider the transgender community as a community in need and so the lack of knowledge around it can be surprising. I also understand that every organization is not going to build a program like ours. Regardless, it’s critical to be an inclusive employer and provider for the LGBT population.

There are three things I’d recommend:

1. Survey your employees to understand how they identify (so that you can offer support/services where needed). Through building this program, I have been considering what diversity and inclusion really means and in what ways we can do more. One way to do this is by surveying your employees on how they identify. Knowing this can help you better understand your staff’s needs and what your blind spots might be.
2. Update your patient intake forms to reflect that gender is beyond the male and female binary. On intake forms, we ask the pronoun and preferred name because this information allows our health professionals to be more inclusive and more impactful towards our patients even if it shows up differently in the EMR. There are still some gray areas with this including the fact that we still ask the patients for their legal names because if they have not yet changed their name legally, we will need that info for insurance purposes. We are also looking into an enhancement of our EMR that is more customizable to include SOGI data.
3. Make your support of underrepresented communities visible. We provide LGBT pins to all staff to show our patients that they can feel safe and comfortable with our clinicians because many of them also identify as LGBT as well.

My mission is to share this work with other organizations – even our competitors. Our impact is not just about our own patients, but also about the transgender community in general. My dream is that one day there will be no need for specialized training or for us to need to designate specialized groups. That a patient is a patient who just happens to be transgender or LGBT.