3.1 Factors Influencing the Health of Persons Assigned Female at Birth

Reproductive System

In 2022 in the United States, approximately 35 million babies born were assigned female, and three out of every four persons of reproductive age received reproductive health (RH) services from a health-care provider that include contraceptive care and physical examinations (Annie E. Casey Foundation, 2023; Frost et al., 2021). The complete physical, mental, and social well-being in all matters related to the reproductive system and its functions is considered a person’s reproductive health. It encompasses the ability to enjoy a satisfying and safe sex life, the capability to reproduce, and the freedom to make informed decisions regarding reproductive health. Reproductive health is influenced by factors such as age at first menstruation, age at menopause, nulliparity, multiple pregnancies, and breast-feeding. These reproductive factors can affect the risk of developing conditions like breast cancer, ovarian cancer, and osteoporosis. Nurses contribute significantly to patients’ reproductive health by providing education, counseling, preventive care, and support throughout various stages of their lifespan.

Healthy People 2030 for Persons AFAB

Healthy People 2030 provides goals for Americans to increase the health of the population. Goals for persons AFAB focus on prevention of complications throughout the lifespan. These goals include providing therapy for those experiencing intimate partner violence (IPV); prevention of chronic conditions through postmenopausal hormone therapy; use of vitamin D, calcium, and weight-bearing exercise to prevent fractures due to osteoporosis; folic acid use to prevent neural tube defects; screening for ovarian cancer; and medication use to reduce the risk of breast cancer (Healthy People 2030, n.d.-b). Nurses can help provide information to patients on how these interventions can improve their health and prevent chronic diseases.

Hormone Changes

Hormonal fluctuations throughout a person’s lifespan can contribute to various health risks. For example, the female reproductive hormones, including estrogen and progesterone, can impact mood changes throughout the menstrual cycle. These hormonal fluctuations affect neurotransmitters in the brain, contributing to shifts in mood and emotions. Individual factors such as genetics, self-care practices, and overall health can influence the impact of hormonal changes.

Estrogen has been associated with positive mood effects. It can increase the production of serotonin, a neurotransmitter that plays a role in regulating mood. Estrogen also interacts with endorphins, chemicals in the brain that help relieve pain and induce feelings of well-being. On the other hand, progesterone can have more complex effects on mood. Progesterone can have calming and sedating properties. Fluctuations in these hormones contribute to symptoms like irritability, mood swings, and anxiety.

During the childbearing years when hormone levels typically change cyclically, some people may experience monthly premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). These conditions involve a range of physical and emotional symptoms, including uterine cramping, nausea, mood swings, irritability, sadness, anxiety, and fatigue. The exact causes of PMS and PMDD are not fully understood, but hormonal fluctuations are thought to play a role.

Perimenopause is the time prior to cessation of menses when hormonal fluctuations are erratic and unpredictable. Perimenopause can last between 2 and 10 years prior to menopause and can be a very challenging time as estrogen levels fall. This hormonal transition can lead to symptoms such as hot flashes, vaginal dryness, and mood changes, and it includes increased risk of osteoporosis and heart disease. During this time, estrogen and progesterone production significantly decline.

A person who has not had a menstrual cycle for 12 months is then considered menopausal. According to the Mayo Clinic (2023), the average age of menopause in the United States is 51 years of age. Patients who have had total hysterectomies with oophorectomies can expect to enter menopause shortly after surgery. Postmenopause is the time following menopause.

Age

Different age groups face unique health risks. Adolescents may be at an increased risk for unintended pregnancies. In 2021, persons aged 15 to 19 accounted for 13.9 births per 1,000 in the United States, representing a 78 percent decline in teen birth rates since 1991; however, the United States still ranks highest in teen births among developed countries (Martin et al., 2023). Sexually transmitted infections (STIs) are also a significant concern among young people, particularly those aged 15 to 24. This age group is at a higher risk for acquiring STIs due to limited sexual experience, multiple sexual partners, inconsistent condom use, fear of seeking contraception or inability to obtain contraception, and lack of comprehensive sexual education (Centers for Disease Control and Prevention [CDC], 2023f). This age group also participates in more risky behaviors. The Centers for Disease Control and Prevention (CDC) (2021c) estimates that half of new sexually transmitted infections in the United States occurred in people between the ages of 15 and 24, representing 26 percent of the $16 billion of total health-care costs in 2018.

Middle-aged and older persons face increased risk of developing chronic conditions such as diabetes, hypertension, arthritis, Alzheimer’s disease, osteoporosis, and genitourinary syndrome of menopause (Peacock & Ketvertis, 2022). In addition, the risk of some cancers, specifically breast, ovarian, uterine, and cervical cancers, increases with age, particularly after menopause.

After menopause, an increased risk of cardiovascular disease is noted. The decline in estrogen levels is thought to play a role in this increased risk (Peacock & Ketvertis, 2022). Maintaining healthy self-care practices, including regular exercise and a balanced diet, and managing other risk factors such as high blood pressure, high cholesterol, and diabetes is crucial for cardiovascular health. Decreased estrogen levels during menopause lead to bone loss and an increased risk of osteoporosis (Peacock & Ketvertis, 2022). This condition makes bones more prone to fractures. Adequate calcium and vitamin D intake and regular weight-bearing exercise can help reduce the risk of osteoporosis, and measures to prevent falls can reduce the risk for fractures.

Menopausal hormone therapy, small doses of estrogen, progesterone, and testosterone, is controversial. The North American Menopause Society released a position statement in 2022 noting that hormone replacement therapy for persons under the age of 60 or less than 10 years from menopause onset is beneficial for prevention of osteoporosis and treatment for vasomotor and genitourinary symptoms of menopause; however, they noted a less favorable benefit-risk ratio after the age of 60 or greater than 10 years after menopause onset. The position statement notes an increased risk of heart disease, dementia, thromboembolism, and stroke in this population. However, other studies have shown that low doses of estradiol and micronized progesterone, different from the estrogen and progesterone used in birth control preparations and routine hormone replacement therapy in the United States, actually decreased mortality and stroke with no increase in thromboembolic events, cancer, or stroke (Akter & Shirin, 2018; Genazzani et al., 2021). All research surrounding hormone replacement favors the individualization of treatment.

Nurses are essential in providing education on self-care practices and education on prescribed treatments. Nurses should encourage persons to discuss their sexual and reproductive health. Sexual and reproductive health includes practicing safe sex, using contraception effectively, receiving regular sexual health checkups, seeking comprehensive sexual education, and addressing concerns with health-care providers.

Mental Health

Approximately one in five Americans experienced a mental health condition in 2020, and persons AFAB experienced specific mental health conditions, such as depression, anxiety disorders, eating disorders, and postpartum depression (Substance Abuse and Mental Health Services Administration, 2022). Mental health risks can vary across different stages of life due to various factors, including hormonal changes, societal expectations, reproductive experiences, and life transitions.

Mental health risks related to hormonal changes can occur. During the reproductive years, persons can experience perinatal depression and anxiety. Hormonal fluctuations, sleep deprivation, and adjustment to their new role can contribute to these mental health challenges during menarche, pregnancy, the postpartum period, perimenopause, menopause, and the postmenopause period. These hormonal changes and physical symptoms contribute to the vulnerability of these chapters of life. Mood swings, irritability, anxiety, and depression are common during these transitional periods. Persons in midlife may face feelings of loss, identity changes, and increased stress related to empty-nest syndrome when their children leave home. Additionally, midlife can be a time of career transitions, relationship changes, or caring for aging parents, possibly causing symptoms of depression or anxiety. In older persons, mental health concerns can occur as a result of chronic health conditions, loss of loved ones, social isolation, and changes in physical functioning.

Mental health risks can vary among people, and not all persons AFAB will experience these challenges. Social support, access to healthy nutrition, access to health care, coping skills, and resilience can influence mental health outcomes. Nurses are crucial for addressing mental health concerns at any stage of life. Early intervention, self-care practices, and destigmatizing conversations about mental health can promote mental well-being across the lifespan.

Violence

Violence against women includes cisgender women (persons AFAB who identify as women) and transgender women (persons AMAB who identify as women) and refers to violence that results in physical, sexual, or psychologic harm or suffering. It is a violation of human rights and encompasses various forms. Violence or abuse within an intimate relationship, such as physical assault, sexual violence, emotional or psychologic abuse, controlling behaviors, and economic abuse, is considered intimate partner violence. Any nonconsensual sexual act or behavior, including rape, sexual assault, sexual harassment, and coerced or forced sexual acts is considered sexual violence. It can occur within intimate relationships and in other contexts such as workplaces, educational institutions, or public spaces. Recruiting, transporting, transferring, harboring, or receipt of persons through force, fraud, or coercion for exploitation is called human trafficking. Persons AFAB and young persons are disproportionately affected, with trafficking for sexual exploitation being a significant concern. Nurses are often the first health-care professionals to encounter persons who have experienced violence and should be vigilant in recognizing signs of abuse or violence, including physical injuries, emotional distress, or inconsistent explanations for injuries. It is important for nurses to screen every patient and never assume by a person’s appearance who is or is not experiencing violence. See Chapter 9 Violence Against Women for further discussion.

Access to Care

Sexual and reproductive health care is necessary, and access to these services is often limited by lack of health-care insurance and affordability. National and state policies may limit access to care and availability of health-care providers. The Affordable Care Act (ACA) improved access to sexual and reproductive health care by expanding Medicaid eligibility and offering private insurance to more people (Rapfogel et al, 2020). The ACA also required private health insurance to cover preventive services, such as screening for sexually transmitted infections and providing affordable contraception.

Limited access to contraception and family planning services can have social and economic consequences for individuals and families, as unplanned pregnancies may disrupt educational and career aspirations, strain financial resources, and contribute to poverty. Furthermore, access to reproductive health care often includes preventive measures such as STI testing, counseling, and treatment. Preventive measures can be as simple as offering education. When individuals lack access to these services, STIs can increase, leading to long-term health complications and a higher risk of transmission within communities.

Access to legal abortion services is controlled by national and state laws. These services can be restricted or inaccessible to some persons. Lack of access to reproductive health care can undermine individuals' ability to make informed decisions about their reproductive health and to exercise reproductive autonomy. Access to comprehensive sexual education counseling services allows persons to make choices that align with their circumstances and preferences.

Limited access disproportionately affects marginalized populations, including people with lower incomes, people of color, rural communities, and those with limited education or health-care resources. These disparities can exacerbate existing social and health inequalities and contribute to disparities in maternal and child health outcomes.

Efforts to ensure comprehensive and accessible reproductive health care can help mitigate these consequences, promote public health, and empower persons to make informed decisions about their reproductive and sexual health. Nurses often serve as the first point of contact when people seek care in various health-care settings. They are crucial in assessing needs and initiating appropriate care.

Access to Nutritious Foods

Inability to pay for nutritious food due to its increased cost is a recognized social determinant of health that can significantly impact individuals and communities. In 2021, the United States Department of Agriculture (USDA) reported that 13.5 million households were food insecure, and 5.1 million households had deficient food security. Limited access to healthy food options, such as fresh fruits, vegetables, whole grains, and lean proteins, can lead to poor nutrition; increase the risk of diet-related diseases such as obesity, diabetes, cardiovascular diseases, and certain types of cancer; and negatively impact overall growth, development, and immune function.

Limited access to healthy food is often associated with food insecurity, the lack of consistent access to enough nutritious food for an active and healthy life. Food insecurity can lead to hunger and malnutrition, compromising physical and mental well-being. It can also increase the risk of chronic diseases and exacerbate existing health conditions. Individuals in disadvantaged communities may face barriers, as these communities have food deserts where grocery stores are not available. Access to grocery stores can also be limited due to lack of transportation.

Inadequate nutrition can negatively impact cognitive development, particularly in children and adolescents. Malnutrition and deficiencies in essential nutrients can impair learning abilities, concentration, and academic performance and have long-term consequences for educational attainment and future opportunities.

Limited access to healthy food can also affect mental health through nutritional deficiencies and inadequate diets, which have been linked to depression, anxiety, and mood disorders (Selhub, 2022). Additionally, the stress and anxiety associated with the inability to provide nutritious meals for oneself or one's family can further contribute to mental health challenges.

By addressing the issue of limited access to healthy food and providing resources such as food assistance programs, community food banks, or local social services, nurses can contribute to improving the overall health and well-being of people facing food insecurity. Nurses can also collaborate with interdisciplinary teams, social workers, and community organizations to connect people with resources that address food insecurity. Nurses can provide individualized nutritional counseling, considering patients' dietary needs, cultural preferences, and budgetary constraints. Most importantly, nurses can help patients develop self-care management strategies that prioritize nutrition.

Opportunities for Physical Activity

Not everyone has equal access to exercise opportunities, despite the numerous health benefits it provides. Several factors contribute to this disparity, including socioeconomic status, neighborhood characteristics, systemic inequities, and personal circumstances. Persons with lower incomes may face financial constraints that limit their ability to access exercise facilities, fitness programs, or equipment. Gym memberships, fitness classes, or personal trainers can be costly, making them less accessible for those with limited financial resources.

Neighborhoods with limited access to safe parks, sidewalks, bike lanes, or recreational facilities can impede opportunities for exercise. Limited public transportation options or a lack of personal vehicles can hinder access to recreational areas outside of a person's neighborhood. Safety concerns related to crime, violence, or poorly lit areas may discourage people from exercising outdoors, particularly in specific neighborhoods or communities.

Cultural differences in perceptions of exercise, gender norms, and societal pressures can impact engagement in physical activity, particularly for specific populations. Addressing the disparities in access to exercise opportunities requires a multifaceted team approach.

Housing, Transportation, and Neighborhoods

Housing, transportation, and neighborhoods are significant social determinants of health that profoundly impact individuals and communities (Healthy People 2030, n.d.-a).

Access to safe, affordable, and stable housing is crucial for overall health and well-being. Inadequate housing conditions, such as overcrowding, poor sanitation, mold, or inadequate heating/cooling, can contribute to physical health issues and increase the risk of respiratory diseases, allergies, injuries, and mental health problems (Healthy People 2030, n.d.-a).

Frequent moves, eviction, or homelessness can disrupt continuity of care, create stress, and impact mental health. Stable housing is associated with better health outcomes, improved access to health-care services, and higher educational achievement.

Reliable and affordable transportation options are essential for accessing health-care services, employment opportunities, healthy food options, and recreational activities. Lack of transportation can limit people’s ability to reach necessary resources, leading to barriers to receiving timely and appropriate health care (Healthy People 2030, n.d.-a).

The physical design of neighborhoods, including access to parks, green spaces, sidewalks, and recreational facilities, can influence physical activity levels, social interactions, and mental well-being. Walkable neighborhoods with amenities that promote active living are associated with better health outcomes. Neighborhood characteristics, including social cohesion, crime rates, violence, and access to community resources, can influence social support networks, mental health, and overall well-being. Strong social connections and community engagement can enhance resilience and promote health.

Addressing housing, transportation, and neighborhood-related disparities requires comprehensive approaches involving collaboration among health-care systems, urban planners, policymakers, community organizations, and residents. Strategies may include affordable housing initiatives, improved public transportation systems, equitable urban planning, neighborhood revitalization efforts, and community engagement to create healthier and more equitable environments that promote positive health outcomes for all people (Healthy People 2030, n.d.-a).

Polluted Air and Water

Access to clean and safe drinking water is essential for good health. Polluted water sources can spread waterborne diseases such as cholera, typhoid, and hepatitis. Contaminants like bacteria, viruses, parasites, and chemicals in water can cause gastrointestinal illnesses, infections, and long-term health issues, particularly in communities without adequate water treatment and sanitation systems (Lee et al., 2023).

Poor air quality due to pollution can result in respiratory problems such as asthma, bronchitis, and other chronic respiratory conditions. Inhalation of particulate matter, nitrogen dioxide, sulfur dioxide, and ozone can irritate the respiratory system, trigger inflammation, and worsen existing respiratory conditions (Healthy People 2030, n.d.-a). Long-term exposure to air pollution is also associated with an increased risk of lung cancer and cardiovascular diseases. Particulate matter and other pollutants can enter the bloodstream, leading to systemic inflammation, oxidative stress, and damage to blood vessels.

Exposure to polluted air and water can have detrimental effects on child development. Children are particularly affected by the impacts of pollution, which can affect their cognitive development, respiratory health, and overall growth (Shah et al., 2020). Pollutants can also cross the placenta, potentially causing infant prenatal complications and developmental issues.

Certain pollutants in water and air, such as heavy metals, volatile organic compounds, and carcinogenic substances, are associated with an increased risk of cancer (Lee et al., 2023). Long-term exposure to these contaminants can lead to the development of various cancers, including lung, bladder, liver, and kidney cancer.

Polluted water and air often disproportionately affect marginalized communities and low-income populations (Ferguson et al., 2020). These communities may face higher pollution exposure due to proximity to industrial areas, lack of environmental regulations, and limited access to clean water sources. This exacerbates existing health disparities and contributes to inequalities in health outcomes.

Racism and Discrimination

Racism, discrimination, and violence significantly impact health-care outcomes, contributing to health disparities and inequities among different racial and ethnic groups. Racism can affect physical well-being, leading to higher incidence of diabetes, poor sleep, obesity, hypertension, and heart disease and resulting in a lower life expectancy (CDC, 2023b; Nong et al., 2020). Racism and discrimination also affect mental health. Research shows that Black and Hispanic populations receive less mental health care than other ethnicities due to problems with lack of culturally sensitive care, stigma, and lack of health insurance (Feldman et al., 2022). In 2021, approximately 31 percent of Hispanic adults and 15 percent of Black adults under 65 years of age were without health insurance, while only 9 percent of White adults were uninsured (Feldman et al., 2022). Also, most mental health care providers are White and may not understand the effect structural racism has on them and their communities (Feldmanet al., 2022).

In a 2022 study, 70 percent of Hispanic and Black respondents felt they had received care that was unequal due to their race (Feldman et al., 2022). Discrimination can impact the quality of care received by racial and ethnic minorities. This study noted that 33 percent of Black patients surveyed felt they received a lower quality of care (Feldman et al., 2022). These disparities can result in higher rates of complications, extended hospital stays, and increased mortality among people from underrepresented groups (Tong & Artiga, 2021). See Chapter 2 Culturally Competent Nursing Care for a discussion of this topic.

People discriminated against in the health-care system have decreased trust, health-seeking behaviors, and communication with health-care providers (Nong et al., 2020). Discrimination can deter people from seeking health care, resulting in delayed diagnoses and poorer health outcomes. Research shows that the five most common types of discrimination in the health-care system are race and ethnicity, weight, education and income, age, and sex (Nong et al., 2020).

Addressing racism and discrimination in health care requires a comprehensive approach that includes integrating equity in gender, cultures, and human rights into public policies, and supporting measures that decrease discrimination and allow for comprehensive, quality health care (World Health Organization [WHO], n.d.-a). Efforts to eliminate racism and discrimination are essential for improving health-care outcomes and achieving health equity for everyone.

Crime

Violent crime is a significant social determinant of health, as it plays a crucial role in shaping individual and community well-being. Violence is caused by many factors. Violence, considered an adverse childhood experience, leads to depression, posttraumatic stress disorder, cardiovascular disease, anxiety, substance misuse, aggression, risky behavior, and premature death (Rivara et al., 2019). Suicide, homicide, and unintentional injury are the top three causes of death in Americans 15 to 34 years of age (Freire-Vargas, 2018). Communities experiencing high levels of crime hold families hostage, making them live in fear, and interrupting their feelings of security (Understanding community violence, n.d.). Violence in the community prevents people from using parks, walking, riding bikes, and using recreational areas (CDC, 2022a). This contributes to chronic diseases and poorer health outcomes.

Communities of color experience more crime than White communities (CDC, 2022a). Crime has economic implications that can impact health outcomes. It can disrupt local economies, limit job opportunities, strain education systems, and increase poverty rates in affected communities (CDC, 2022a). Economic hardship, in turn, affects access to health care, housing, education, and other determinants of health, perpetuating health disparities. Research suggests that violence can be preventable, noting that education at an early age on conflict resolution and life skills along with supportive relationships can stop the cycle of violence in communities (Freire-Vargas, 2018).

Language and Literacy Skills

Language is considered a social determinant of health because it influences people’s access to health care, health information, and health-care outcomes. Limited English proficiency or lack of proficiency in the dominant language spoken in a particular health-care setting can hinder effective communication with health-care providers, making it challenging to express symptoms, understand medical instructions, or provide informed consent. Language barriers can also limit people’s ability to navigate health-care systems, schedule appointments, and understand health insurance options. Health education materials, websites, and public health campaigns are often produced in a specific region or country's dominant language leading to lack of understanding of vital health information. Culturally and linguistically competent care involves providing interpreter services, ensuring translated materials, and training health-care providers to navigate diverse linguistic and cultural contexts.

Literacy significantly impacts health-care outcomes. Personal health literacy refers to an individual's ability to understand, seek, and use health information to make decisions about their health and health care (Health Resources & Services Administration, 2022). Organizational health literacy refers to organizations’ ability to equitably understand, seek and use health information and services to allow for making informed decision and actions; it is the responsibility of the organization to improve health literacy (Health Resources & Services Administration, 2022). Health literacy increases preventive care use, improves management of chronic diseases, and increases patient satisfaction (Health Resources & Services Administration, 2022). People with low health literacy are more likely to have difficulty navigating the health-care system, understanding medical terminology, and adhering to treatment plans, which can result in poorer health outcomes.

Nurses can help by using supplemental education tools that are visual or translated into the patient’s native language. Nurses can also encourage questions or teach-backs, making sure the patient understands and can repeat the instruction back to them (Health Resources & Services Administration, 2022). Utilizing medical interpreters is a legal requirement that provides great benefit to the patient and nurse when discussing important health-care education (Health Resources & Services Administration, 2022).

Education, Job Opportunities, and Income

Education significantly impacts health-care outcomes and is said to be “the most important modifiable social determinant of health” (The Lancet Public Health, 2020, para 6). Education plays a crucial role in life expectancy, health behaviors, morbidity, employment, and income (The Lancet Public Health, 2020). Education has been credited for reducing poverty and socioeconomic and political inequities. Those with higher levels of education tend to have better reading comprehension, critical thinking abilities, and information-seeking behaviors. Education enables people to understand health information, make informed decisions about their health, and effectively navigate the health-care system.

Education is linked to increased health-care utilization. People with higher education levels are more likely to seek preventive care, have regular checkups, and access timely medical interventions (The Lancet Public Health, 2020). They are also more likely to understand the importance of early detection, screenings, and vaccinations, leading to earlier diagnoses and better management of health conditions.

Employment is not always equitable. Employment can influence people’s access to health-care services; exposure to toxic substances and adverse working conditions; and housing, social status, and economic security (Steege et al., 2023). Stable employment and adequate income can enable persons to afford health insurance coverage. They also provide financial resources to access necessary medical treatments, medications, and preventive care services (Steege et al., 2023). In contrast, persons without job opportunities or with low income may face challenges in obtaining health insurance coverage, leading to delayed or limited access to care (Steege et al., 2023).

Job opportunities and higher income levels can enable access to safe housing, nutritious food, and a supportive social environment, all of which contribute to better overall health and well-being. Certain jobs impact occupational health and safety conditions. Work environments that prioritize safety and provide adequate resources for injury prevention and occupational health can reduce the risk of work-related illnesses and injuries. Access to job opportunities that offer fair working conditions, including reasonable hours, paid leave, and work-life balance, also contribute to overall well-being (Steege et al., 2023).