37.1 Overview of Transgender and Nonbinary Health

Terms Related to Gender Identity

Gender identity describes a person’s deeply held beliefs about which, if any, gender they identify with—man, woman, gender fluid, or nonbinary. A person’s gender identity is not always the same as the sex assigned at birth and is not always related to an individual’s sexual organs or sex characteristics. Instead, it refers to how an individual sees themselves and presents themselves to others as male and/or female.

The following terms are used to discuss gender-related topics. Individual clients will have their own terms to describe themselves, and the nurse must clarify those with each client. A client may find some terms to be offensive, and their use would compromise trust in the nurse–client relationship (Annie E. Casey Foundation, 2023; Barredo, 2020; Centers for Disease Control and Prevention, 2023; International Society for Sexual Medicine, n.d.; National Center for Transgender Equality, 2016; Rafferty et al., 2018; T’Sjoen et al., 2019).

• Gender dysphoria a deep sense of unease, anxiety, or discomfort that may occur in people whose gender does not align with their sex assigned at birth.
• Gender expression refers to ways in which a person outwardly expresses their gender identity. Gender expression includes behavior, clothing, body characteristics, and/or voice. Gender expression may or may not conform to what is considered socially acceptable male and female behaviors and characteristics.
• Gender fluid refers to a person who does not identify with a single fixed gender or has an unfixed gender identity.
• Nonbinary is used to describe individuals whose gender identity does not fit into the man–woman dichotomy and who do not identify with one gender over another. The term may be used to include individuals who are gender fluid and/or transgender.
• Transgender is a broad term used by individuals whose sex assigned at birth does not match their gender identity. Some transgender individuals are assigned male at birth but identify as a woman; others are assigned female at birth but identify as a man. Some transgender individuals do not identify strongly as a man or a woman, or they may identify as a combination of both genders. Some transgender individuals choose to have medical treatment to physically transition into the gender with which they identify; others choose not to undergo treatment. The male-to-female (MTF) and female-to-male (FTM) abbreviations are used in this chapter to refer to the procedure of transitioning.
• The term transsexual is an older term that may be interchangeable with the term transgender; however, transsexual has different meanings depending on the individual’s preference, the cultural context, societal norms, and the historical meaning of the word. In addition, transsexual can be used by some to identify individuals who have undergone medical treatment and surgery to make their bodies physically match the gender with which they identify.
• Cisgender describes individuals whose sex assigned at birth and gender identity are congruent. A cisgender person assigned male at birth identifies as a man, and a cisgender person assigned female at birth identifies as a woman.

Clinical Manifestations of Gender Dysphoria

Gender dysphoria is a medical diagnosis that describes the condition of an individual who is experiencing social and mental distress because of gender identity issues. The feelings may range from unease to severe distress and can impair the individual’s ability to function in society. Going to school, work, and other social events can be associated with fear and anxiety about harassment or mistreatment (Klein, 2023; Matsuda, 2022; National Center for Transgender Equality, 2016; Selby, 2022). The individual feels that their sex assigned at birth is incongruent with their gender identity. These individuals are often adolescents or young adults who have faced a great deal of socially negative experiences because they do not identify with the sex that was assigned to them at birth. Zaliznyak et al. (2020) collected data from more than 200 transgender individuals and found that gender dysphoria tends to start very early in life. Among their study participants, the earliest memories of gender dysphoria generally began around 4 1/2 years of age, with the majority of participants experiencing gender dysphoria memories by age 7.

Gender dysphoria does not occur in every transgender individual, nor is every person who experiences gender dysphoria transgender (National Center for Transgender Equality, 2016). For those who do experience gender dysphoria, typical manifestations include depression, anger, anxiety, body aversion, posttraumatic stress disorder, hopelessness, violence, self-harm, and suicide. Some individuals with gender dysphoria may dress differently, change their name to match their perceived gender, and make other outward changes that are congruent with their gender identity (Klein, 2023; Matsuda, 2022; National Center for Transgender Equality, 2016; Selby, 2022).

Supporting Intersex People

Intersex is a general term used to describe people whose sex traits, reproductive anatomy, hormones, or chromosomes are different from the usual two ways human bodies develop. Some intersex traits are recognized at birth, while others are not recognizable until puberty or later in life. Intersex people and transgender people are not the same (and they are not interchangeable terms); many transgender people have no intersex traits, and many intersex people do not consider themselves transgender. Furthermore, most recent literature refers to the atypical conditions themselves as "differences of sex development," (DSD); nurses may find relevant guidance and evidence with that terminology, even though many intersex people do not use it to refer to themselves and some reject the terminology (Sandberg, 2022; Davis, 2013).

Most in the nursing, medical, and intersex community reject unnecessary surgeries intended to make a baby conform to a specific gender assignment (Behrens, 2020). If a physical trait or medical condition prohibits a baby from urinating or performing another bodily function (which is very rare), surgery may be needed. In other cases, intersex people may require hormonal therapies similar to those described below. Treatment of intersex clients, especially adolescents and adults, can be complex: Diagnoses, decisions, and therapies may have implications regarding the client's gender identity, gender role behavior, and sexual functioning, as well as physical and psychological outcomes (Sandberg, 2022; Warne, 2005).

Hormonal Therapy Guidelines for Transgender and Nonbinary Clients

Drug therapy of any kind is affected by several factors, including gender at birth, transgender status, weight, and overall health. Renal and liver cytochrome expression, renal or liver disease, age, and gastric pH also affect pharmacokinetics and pharmacodynamics. Webb et al. (2020) explored the literature regarding drug dosing for transgender individuals. In some cases, the dosing was comparable; for example, a transgender male’s pharmacokinetics and pharmacodynamics were like those of a cisgender male, and drug dosing could be the same. However, appropriate dosing also depended on the length of time an individual had been on hormonal therapy. Thus, the nurse must ensure that any transgender client has been properly assessed for these factors and communicate this information to the health care provider, pharmacist, and other health care professionals as needed.