Patient Care

Leadership Initiatives in Patient-Centered Transgender Care

Advanced practice nurses develop solutions that can improve health care access and services for transgender persons in the VA.

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Patient-centered care is of fundamental importance when caring for the transgender population due to the well-established history of social stigma and systemic discrimination. Therefore, nursing education is mandated to equip graduates with culturally competent patient-centered care skills.1 In 2009, the Institute of Medicine (IOM) in partnership with the Robert Wood Johnson Foundation (RWJF) launched The Future of Nursing initiative, which outlined the major role nursing should play in transforming the health care system to meet the health care needs of diverse U.S. populations.

The initiative produced a blueprint of action-focused institutional recommendations at the local, state, and national levels that would facilitate the reforms necessary to transform the U.S. health care system. One of the recommendations of the IOM report was to increase opportunities for nurses to manage and lead collaborative efforts with physicians and other health care team members in the areas of systems redesign and research, to improve practice environments and health systems.2

The VHA is the largest integrated health care system in the U.S., serving more than 8.76 million veterans at more than 1,700 facilities. The VHA has an organizational structure that uses centralized control in Washington, DC, and branches out to 18 regional networks that are divided into local facilities in 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Philippines. This type of structure is known for promoting efficient standardization of processes and procedures across an organization.3

The VHA Blueprint for Excellence envisions the promotion of a positive culture of service and the advancement of health care innovations necessary to create an environment that all veterans deserve.4 To that end, the VHA can be a promising health care institution through which patient-centered initiatives can be standardized, promulgated nationally, and replicated as a model for the country and international health systems. However, it is important to note that the bureaucratic organizational structure of the VHA's national integrated system of care is based on a systemwide standardization effort.5 Therefore, more time may be required to implement organizational changes.

Transgender populations face significant social stigmatization, discrimination, and marginalization that contribute to negative patient outcomes. Consequently, this population experiences high rates of suicide, HIV/AIDS, substance use disorder, poverty, and homelessness.6 Due to the growing evidence of health disparities and negative health outcomes affecting transgender populations, the federal government has identified transgender patient care and outcomes as a major health concern and priority in the Healthy People Initiative 2020.2,7,8

In 2012, the VHA issued a directive mandating services for transgender veterans.9 Nevertheless, health care staff significantly lack the knowledge, skills, and cultural competencies that are vital in transgender care.

This article reviews the prevalence and demographics of the transgender population, social challenges, global health concerns, and public health policies. The article also examines how the doctor of nursing practice (DNP)-prepared nurse leader can provide transformational nursing leadership to facilitate culturally competent, patient-centered initiatives to improve access and services for transgender individuals in the VHA and provide a model for change in transgender population health.


Gender is a behavioral, cultural, or psychological trait assigned by society that is associated with male or female sex. Sex denotes the biologic differences between males and females. Transgender is an umbrella term used to describe people whose gender identity or gender expression is different from that of their sex assigned at birth. Transsexualism is a subset of transgender persons who have taken steps to self-identify or transition to look like their preferred gender.


Estimates of the prevalence of transgenderism are roughly drawn from less rigorous methods, such as the combination of parents who report transgenderism in children, the number of adults reportedly seeking clinical care (such as cross-sex or gender-affirming hormone therapy), and the number of surgical interventions reported in different countries.10 A meta-analysis of 21 studies concluded that the ratio of transsexuals (individuals who are altering or have already altered their birth sex) was predominantly 1:14,705 adult males and 1:38,461 adult females.11 Since all transgender persons do not identify as transsexual, these figures do not provide a precise estimation of the number of transgender persons worldwide.


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