Forensic Psychiatric Nursing and the Transgender Patient

At some point in our forensic psychiatric nursing career, we will be called upon to care for a transgender individual. We must be able to care for these vulnerable and highly stigmatized individuals in a culturally sensitive and medically competent manner. You may ask, what exactly does transgender mean anyway? The official DSM IV diagnosis is “Gender Identity Disorder”. Gender identity disorder can be described as a person who has strong, persistent cross gender identification. The person has a discomfort with their body and their secondary sex characteristics.  This discomfort causes significant distress in social, occupational, and other areas of life. It is now recognized that these individuals experience varying degrees of distress associated with their perception that their gender identity is inconsistent with their biological and social gender assignment. It has been only in recent years that the scientific study of this complex and stigmatizing phenomenon has brought together the fields of psychology, sociology, endocrinology, psychiatry, general medicine, and reconstructive surgery into a comprehensive field of sexual research (Diamond, 1999). Nurses may encounter individuals in different stages of gender consolidation, and therefore must be aware of the special interpersonal and medical needs of these individuals. What constitutes gender consolidation, and thereby the removal of mental discomfort, is very individualistic. Gender consolidation may be dressing and living as a woman. Whereas, for another individual, it would involve surgery to fully change to the desired body characteristics and genitalia. Examples of possible surgeries are: orchiectomy, penectomy, clitoroplasty, labiaplasty, neovagina, hysterectomy, salpingo-oophorectomy, vaginectomy, metoidioplasty, scrotoplasty, urethroplasty, testicular prostheses, breast surgery, and facial reconstructive surgery. Therefore, it is best to proceed with caution, assume nothing, ask the appropriate professional questions, and assess the individual’s comfort level prior to the actual physical assessment.

As a nurse, I have provided care for several individuals that have considered themselves transgender. When I have asked them what special needs that they may require and how they would like to be taken care of, every individual to a person has referred me to the “Harry S. Benjamin Standards of Care”. This is a very good reference that should be read prior to caring for transgendered individuals, and can be accessed at http://www.genderpsychology.org. The Harry S. Benjamin Standards of Care (HSBSC) were originally written in 1979 and have been revised as needed. The HSBSC reflect the current thinking of the professionals in the field. The purpose is to “articulate professional consensus about psychiatric, psychological, medical, and surgical management of gender identity disorders”. The goal is to help individuals with gender identity disorder to achieve “lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfillment” (Meyer, et al, 2001, p. 1). These standards describe the triadic therapy of hormones of the desired gender, the “Real Life Experience”, and surgery to change genitalia and sex characteristics. There is detailed information about eligibility requirements and readiness criteria for each step.  Knowledge of these standards is mandatory for the application of culturally-informed approaches to care, where the nurse seeks to understand and assist without judgment.  The obligation to “do good” and “do no harm” call for nurses to approach transgendered individuals with the utmost professionalism and interpersonal competency.

Transgender Healthcare Lawyer Attorney

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