Enhancing Healthcare Accessibility for Trans & Gender Diverse Populations

1. The Right Provider at the Right Time: Maximizing RNs’ Scope of Practice to Increase Access for Marginalized Populations Sheena Howard, RN, BScN, Primary Care Nurse Dr. V. Lokanathan, MDCM, CCFP, Family Physician

2. Conflict of Interest • None to declare • Passion • Dedication • Advocate

3. Social Media • #primarycarenurse • #primarycarenurses • #PatientsFirst • @SheenaLGHoward • @VanitaLok • @RNAO • @RPNAO • @RainbowHealthOn

4. Patient Population Focus • Trans and Gender Diverse (TGD) • Historical and current social marginalization • Historical and current disparities regarding their ability to access equitable health care services • Poor health outcomes based on marginalization and health inequity • Ideal patient population to outline how to increase access to primary care services by maximizing RN scope

5. Presentation Outline • Terms • Situation for TGD people regarding access to health care • Background regarding health disparities for TGD people • Assessment of TGD population’s needs • Response of Team • Outcomes of Increased RN Scope for Patient Population • Conclusion • Q and A

6. Terms Gender Dysphoria Transgender Gender Diverse Cisgender Non-Binary MTF FTM Gender Affirming Surgery

7. Gender Dysphoria Distress associated with gender identity not matching assigned gender

8. Trans/Transgender Gender identity doesn’t match gender assigned at birth

9. Gender Diverse A person whose gender identity does not align with binary gender categories such as “man/ woman”, “boy/girl”

10. Cisgender Gender identity matches gender assigned at birth

11. Non-Binary Umbrella term for anyone who does not identify with static, binary gender identities Includes persons who may identify as having an intermediary gender (e g genderqueer), as being multiple genders, as having a constantly shifting gender, or as not having a gender altogether

12. MTF An old term to describe trans women It has fallen out of favour as it implies that trans women are something categorically different or apart from being “women”

13. FTM An old term to describe trans men It has fallen out of favour as it implies that trans men are something categorically different or apart from being “men”;

14. Gender Affirming Surgery Previously known as sex reassignment surgery Can refer to any number of surgeries that a trans person may undertake in order to better align their sex with their gender identity

15. Situation for TGD people in Central Ontario regarding access to health care • Limited access to primary care providers who were willing to assess and treat gender dysphoria or provide referrals for assessment, treatment or surgery • Two urban Gender Clinics were the only option for TDG people wishing to transition with medical support, each with wait times of up to two years. One clinic was only accessible with a Toronto address. • Approaches to assessment - Pathologization vs. Gatekeeping vs. Informed Consent • Health care providers belief that assessment and treatment “out of their scope” • Historical mistreatment of TGD people by health care professionals

16. Background Regarding health disparities for TDG people • Increased risks of suicidal ideation, self harm and suicide • Increased mental health co-morbidities • Increased risk of Sexually Transmitted Infections • Increased risk of sexual and physical violence • Despite level of education, worse socio-economic status • Risk of adverse effects due to self medication • Biggest risk to health is related to violence and self harm from social stigma and discrimination, not to medication side effects

17. Assessment of TGD Populations Needs in Central Ontario • Unofficial wait time at CAMH Gender Identity Clinic in Toronto was four years and this is the only referral centre for patients outside “the 416 area code” • TranspulseResearch, Being Safe and Being Me Survey, EGALE National Survery on Homophobia, Bi-Phobia and Transphobia in Canadian Schools • Greatest risk of self harm in the interval between self realization (coming out) and access to competent medical care • Access to assessment and hormone treatment was lacking in Central Ontario’s small cities and rural areas • Began with one patient, referrals kept coming, some from very curious places! • MD’s ability to deliver accessible care was becoming untenable without support

18. Every Class in Every SchoolFirst National Survey on Homophobia, Biphobia & Transphobia in Canadian Schools Guess which are the two school spaces experienced as most unsafe by LGBTQ students?

19. Being Safe, Being MeThe Trans Youth Health Survey Reported Rates of Harm Reported Rates of Help

20. Transpulse Research Reports… • 71% transOntarians report ever having considered suicide • 50% considered suicide because of being trans • 43% attempted suicide • 60% reported depression at some time in their life Cis Trans*

21. Response from Team • Increased requests for assessment and hormonal treatment was starting to become overwhelming • RN already working to full scope in other areas of primary care practice, and was working with strong interprofessional collaboration and support • Willingness + social justice • Reviewed Sherbourne Guidelines and realized that many Guidelines fit perfectly with the Phase Two Role Description of the Primary Care Nurse outlined in the RNAO Document - “Primary Solutions for Primary Care” • Rainbow Health Ontario Trans Cultural Competence and Clinical Training for RN and On-the-job mentorship with MD • GP/RN team asked to support Trillium Grant for community driven group support group – Gender Journeys

22. Sherbourne Guidelines and Protocols for Hormone Therapy and Primary Health Care for Trans Clients Five Steps for Assessment Period Psychosocial Readiness Trans Care Assessment Period Checklists Hormone Monitoring Summaries for Collaborative MD and Nursing Team

23. RNAO Primary Solutions for Primary Care Maximizing and Expanding the Role of the Primary Care Nurse in Ontario Primary Care Nurse Task Force Report

24. RNAO Primary Care Nurse Task Force Report Case Study 35 yr old MTF from a rural community. Married to a cisgender woman and has one child. Full time job in a traditionally male dominated environment. Has known since childhood that she was a female, and struggled with gender dysphoria related to her stereotypical physical male traits, and dysphoria was complicated by anxiety and depression. She was not being treated with medications for her anxiety or depression. Family history of high blood pressure and mental health issues. Her wife was tentatively supportive, but not interested in being married to a woman. She was accessing counseling for support in home community with a trans-friendly social worker, however, family physician declared assessment and treatment as “out of his scope”. She self referred for assessment and treatment of possible gender dysphoria. Phase Two Role Description Review

25. Phase Two Role DescriptionsRegistered Nurse – Domains of Practice • Assessment * • Program Management • Care Co-ordination* (New Domain) • Documentation • Quality Improvement • Treatment * • Patient Self-Management * • Management/Administration • Planning • Education • Advocacy * • Collaboration* • Knowledge • Professional Commitment

26. Provide comprehensive physical and psychosocial patient assessment • Health Screening • Interpreting Assessments – “huddles” • Ordering diagnostic tests * • Identifies and communicates a diagnosis to initiate prompt treatment for health conditions within the RN competencies, knowledge and skill * • CASE STUDY – the assessment period was over 3 visits, as patient identified ambivalence to transitioning Assessment Private office Dedicated time EMR Messaging Templates Diagnostic Tests

27. Gender Journeys Advisory Committee • Gender Journeys evaluation Program Management Rainbow Health Ontario Advocacy Centre for Addiction and Mental Health

28. Provides primary care patients with a seamless experience through the health system through timely access and working closely with all health professionals • Assists patients with navigating the health system and accessing the right care, at the right time, by the right health professional • Interprets findings and evidence to develop a comprehensive care plan in collaboration with interprofessional team with a focus on preventing unnecessary hospitalization • CASE STUDY Care Co-ordination Private office Morning and Afternoon Huddles EMR Messaging CAMH Referrals by RN Referrals to Mental Health Clinicians by RN Consult Letters to GPs and NP from RN

29. Maintains thorough and comprehensive documentation in alignment with standards and the needs of the interprofessional team • Embraces electronic documentation • Evidence-based champion, using evidence-based knowledge and best practices to guide clinical and work environment practices (streamlining assessment process) • Participates and leads QI initiatives by collecting, interpreting and reporting health data to support continuous QI • CASE STUDY Documentation andQuality Improvement (QI) EMR Utilization EMR Messaging EMR Templates and Forms Sherbourne Guidelines and Protocols imbedded in EMR Data to support Trillium Grant

30. Remains accessible via telephone and in person to provide health counseling • Manages immunization programs including assessing records, identifying outstanding vaccinations required, and administering vaccines when appropriate • Provides medication management expertise, including the initiation and renewal of prescribed medication * • Provides clinical services with a higher degree of complexity *testosterone and delegation of function • CASE STUDY Treatment Public Health Immunizations Telephone EMR Messaging Disease Prevention CNO Delegation of Function Guidelines

31. Leads upstream health promotion activities, rooted in social determinants of health, that also emphasize accessibility , early detection/intervention, lifestyle counseling, and disease prevention • Supports patients at identifying and utilizing community resources • Develops, monitors and refines individualized care plans in collaboration with interprofessional team • Involves the patient in the forefront of all care decisions • Works as a systems navigator to ensure appropriate referrals and connections are made • CASE STUDY Patient Self-Management Informed Consent Smoking cessation counseling STI prevention and Diagnostic tests Gender Journeys CAMH referrals

32. Acts as resources to the clinical practice team by providing knowledge and expertise within the RN Role • Support staff development • Leads the review, implementation, and planning of projects that support effective patient care • Provides a nursing perspective on planning activities within organizations • Conducts patient and community needs assessments • Evaluates programs and practices, and revises as necessary • CASE STUDY Management/Administrationand Planning FHT TransHealth Initiative RHO Advocacy for SRS Referral Process Changes Cultural Competency Gender Journeys Advisory Committee Positive Space Training in FHO Environmental Scanning to Benchmark Best-Practices

33. Assess education needs amongst patients and within community • Engages in one-on-one patient education regarding: health promotion, disease management and prevention, mental health, lifestyle, medication management, community supports and social considerations • Supports staff education • CASE STUDY Education RHO Peterborough Aids Resource Network Rainbow Youth Gender Journeys Positive Space Training

34. AdvocacyandCollaboration RHO Advocacy for SRS Referral Process Changes

35. Advocates for the patient as a care co-ordinator *even within your team! • Advances the principles of primary health care within communities • Advocates for health communities through social justice and equality • Advocates for an environment that supports the patients’ and maximizes their participation and control in meeting their health goals • Participates in community groups to address identified needs • Collaborates, as an active member of the interprofessional team, with a number of health professionals to support quality patient care • Consults with a more experienced team member of the interprofessional team if an issue arises outside of RNs scope or if unclear • Fosters strong linkages with public health • CASE STUDY Advocacy and Collaboration LGBTQ TaskForce FHT TransHealth Initiative Gender Journey LHIN Funding Informed Consent

36. Holds expert knowledge and proficiency within the RN role regarding current evidence-based practices, leveraging best-practice guidelines, effective delivery of primary health care and nursing, social determinants of health, cultural competence • Mentors students • Maintains a commitment to life long learning, self reflection and professional development • Disseminates knowledge to peers and community through publications and presentations KnowledgeandProfessional Commitment Sherbourne Guidelines and Protocols RHO Conference Maximizing RN Scope Social Media RN Student Preceptor Provincial, National & International Conference and Workshop Presentations LGBTQ RNAO Best Practice Guidelines

37. Outcomes of Increased RN Scope of Practice for Patient Population • Increased patient capacity and volume to provide timely access to assessment and treatment of gender dysphoria • Improved patient outcomes, increased self efficacy • Decreased unnecessary hospital visits • Decrease in suicidal ideation for an at risk population • Increased availability of surgical referrals • Increased community support links for patient population • Increased community capacity • Increased cultural competency • Increase role satisfaction • Increased spread of knowledge and competency • Increased point-of-care leadership

38. Patients’ Voices • “Having Sheena as my RN has changed my life in so many positive ways. She has guided and cared for me through the most important journey of my life, and continues to offer me the highest quality of professional medical care I have ever experienced. The fact that I have had the opportunity to visit Sheena and have her oversee this journey has in many ways saved my life-both emotionally and physically. I am extremely fortunate to be the patient of an RN - and a fantastic one at that! Having prescriptions written by Sheena's consulting physician has never, in any way, been a hindrance to me and my medication and treatment needs have always been met more than promptly through this process of care. I feel privileged to have access to Sheena's care as an RN and would strongly advocate for more individuals to have access to such valuable medical professionals. " M. - 27 yr old. Transman from a small city in Central Ontario

39. Patients’ Voices • “Having access to an RN has majorly impacted my access to care because it fast-forwarded my accessibility to HRT and my impending surgical referrals. I am so very grateful to my nurse, and for the confidence and happiness she bestowed on me. It doesn’t really bother me that Sheena can’t write my prescriptions, and I wish that more nurses could prescribe medication. I trust Sheena to support me to make decisions for myself about the best route to go and what the available prescriptions are. “ • P. - 21 yr old Transman from a large city in Eastern Ontario

40. Provider’s Voices • “Increased access is not just about more timely availability of care. Embracing the idea of “the right provider at the right time” also means knowing there are some things nurses do better than I do. For my trans patients it means that sometimes I am able to “see” them more fully and be a better doctor to them when I see them through a nurse’s eyes. “ Dr. V. Lokanathan, MDCM, CCFP • “Having Sheena in a full scope RN capacity in the community is about putting patients first. That’s what nurses do every day in our communities. The full potential of nursing capacity is an untapped resource if we want to improve the quality of patient care. We need to recognize that the current nursing scope does not reflect the true capacity of nurses as knowledge professionals. The question of nursing scope is to capture the essential work that is already taking place to support patients at the point of care and expand upon their knowledge capital to build healthier communities.” Lisa Ducharme, MScN, RN(EC)

41. CASE STUDY • “Having access to an RN for my transition has been an amazing experience. I will say that I did not have this kind of health care before, and not having Sheena in my life would mean that I wouldn’t be alive today. My RN has been one of the most caring and helpful people in my whole transition. She has provided me access to assessments and treatments without having to wait for 4+ years for CAMH. It has also been more than the medical aspect. When I go to see her I feel like part of the family. It is a very safe and comfortable environment. I am able to talk with her about anything. This is something I’ve never had with a DR. She has even advocated for help for me to have my surgical assessment expedited. I am eternally grateful for the wonderful life changing health care experience Sheena has provided me. Without this kind of access to care, I don’t know what would’ve happened to me.” R. a 35 yr old Transwoman from a rural community in Central Ontario

42. CASE STUDY Update All pictures used with express written and verbal consent of parties pictured

43. Conclusion Contact: showard@xplornet.com Thank you to RNAO for supplying the hardcopies of Primary Solutions for Primary Care Maximizing RN Scope is possible in a traditional health care setting, and we can be the agents of change to support marginalized populations to have timely access to primary care.

44. Are you still engaged? Questions?