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Sexual Health among Transgender Adolescents  Nursing 318Justina Crossan230103635November 14, 2017 Sexual Health among Transgender Adolescents   In today’s society, there are populations that health care professionals need to acknowledge that have not always been considered when giving care in the past; these groups include transgender and transsexual individuals (REFERENEce). This is not a condition that people develop; this is how individuals feel about themselves therefore this mostly arises in childhood and affects people into adolescence (REFERENCE). Because of the stigma that may be present within the health care setting these transgender and transsexual adolescents have been affected; they may even be stigmatized to the point of where they do not want to seek medical treatment to change their body to represent who they feel they actually are as a person. Medical professionals such as doctors have expressed in studies that they are not equipped with the technology and information to adequately care for these people (Vance, Deutsch, Rosenthal & Buckelew, 2016). Unfortunately, transgender medicine is not emphasized in medicine or post graduate education and training; therefore, some medical professionals report they do not feel comfortable caring for them (Vance etal., 2016). This is an issue since this population that is seeking medical advice is growing due to the change in society; as public awareness of gender diversity has increased over the last decade, more transgender youth are seeking health care services to support medical transition (Chen, Simons, Johnson, Lockart & Finlayson, 2017). There can be health risks associated with the hormone therapies and surgical intervention. A significant health risk is the preservation of fertility among those adolescents. The focus of this research study is to discuss the barriers this population has and how can health care professionals increase their knowledge to provide better care to transgender and transsexual adolescents. The first step to evaluating the barriers this specific population has to endure is to understand who the population is. The definition of a transgender person is where the state of one’s internal gender identity does not match one’s assigned sex at birth (Olson, Schrager, Belzer, Simons & Clark, 2015). The identity and behavior of transgender individuals are often socially and medically stigmatized, resulting in an underserved population at risk for negative health outcomes (Olson et al., 2015). The difference between transgender and transsexual is that transsexual people transition from one sex to another (Scutti, 2014). In this population, there can be a transition from a transgender individual, where they identify with the other gender than their assigned sex, to a transsexual individual who have changed their assigned sex to the gender they identify with. This can be either through hormone therapy or surgical intervention (Chen et al., 2017). A condition that is common among transgender adolescents is called gender dysphoria. Gender dysphoria refers to the discomfort or distress caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth and the associated gender role and/or primary and secondary sexual characteristics (Neira, 2017).As more transgender children and adolescents present for care, the need for standardized care is becoming more apparent (Lawlis, Donkin, Bates, Britto. & Conard, 2017). Transgender youth are confronted with numerous medical, mental health and social concerns. It is not uncommon for patients to have comorbid mental health conditions such as anxiety and depression which must be addressed in addition to their many medical needs. Transgender youth are at higher risk of depression, anxiety, and suicide attempts; sexually transmitted infections and obesity; and other health issues. Transgender youth encounter barriers to accessing health care, and health care providers also encounter barriers to delivering care, such as lack of clinical training in the care of transgender patients (Lawlis et al., 2017). Health care practitioners across all disciplines, including nursing, are not immune from a lack of awareness about transgender people and their health concerns; almost one-quarter of transgender patients report that their health care providers for non-transgender-related care know almost nothing about providing culturally competent transgender-related care, and 33% had a negative experience when seeking care because of their gender identity (Neira, 2017). It is a significant problem the health care system faces if these professionals do not feel competent in working with and taking care of transgender adolescents; these feelings of uneasiness and incompetency may be felt by the transgender youth and deter them even more from seeking any kind of medical guidance for any need that they might have, which could even be unrelated to the fact that they are transgender or transsexual. This may become a viscous cycle between needing help, having a health care professional not be able to adequately address their concerns, and then the transgender adolescents not seeking help at all. After understanding who is within the transgender pediatric population, health care professionals need to understand what these people need and how to care for them. There are many ways health care professionals can assist transgender individuals in feeling comfortable in their bodies and even transition sexes so that their physical sex aligns up with how they identify their gender. Hormone therapy is a treatment where transgender women receive hormones such as estrogen and anti-androgen whereas transgender men receive testosterone; there is also surgical intervention transgender adolescents can seek to change their bodies. Colebunders et al (2016) states that “bottom surgery” involves the modification of one’s current genitalia to look and function like those that are congruent with their identified gender (as cited in Ginsberg, 2016). Vaginoplasty most commonly involves penile and/or scrotal skin that is used to line the neovagina with a portion of the glans penis be- coming the neoclitoris and the testicles being removed. Men who undergo bottom surgery have two primary options for the construction of a penis. With metoidioplasty, the enlarged clitoris, from testosterone use, is detached from the labia minora and suspensory ligaments to create a 1- to 3-inch penis that is able to become erect, sometimes with the urethra extended for standing urination, and sometimes with a scrotoplasty made from the labia majora (Ginsberg, 2016). This highlights the importance of delaying finasteride in patients who may undergo this procedure to obtain the maximum length and girth of the clitoris. Alternatively, with phalloplasty, an average- sized penis is constructed from either adjacent (thigh, abdomen) or distant (forearm) tissue. In both metoidioplasty and phalloplasty, the natal vagina is maintained and hysterectomy is optional (Ginsberg, 2016). These are the medical ways health care professional can help transgender adolescents; however, there are adjustments in the health care system that can be made to approach these people with dignity and address them how they would like to be known. Neira (2017) had some suggestions for health care professionals after concluding her research on how to care for and communicate with transgender and transsexual adolescents: One, ask the patient how they would like to be called and what pronouns they used and then use them Many transgender patients do not have identity documents that align with their name. They should address them by the name they use. Also know that many younger individuals identify as genderqueer (meaning that they do not identify exclusively as male or female) and may use they as a singular pronoun or gender-neutral pronouns such as xe or ze. Second, ask every patient about their sexual orientation and gender identity information. These are pieces of demographic information that we need to normalize. We also need the information if we truly are going to provide holistic patient-centered care. Asking the question also indicates that we care enough to want an answer. Gender identity should be asked as a two-step process: What is your gender identity? What sex were you assigned at birth? Third, Use appropriate language. Transgender is an adjective, not a noun. There is also no -ed at the end of the word. Do not refer to a sex change; it is gender-affirming surgery or gender reassignment surgery. Also know that many transgender patients may not seek any type of gender-affirming surgery. Every transgender patient’s transition is unique, and what is medically necessary for one may not be appropriate for another. Fourth, ask only clinically relevant questions. Unless you are doing a genital-related study, belaboring what type of genitalia a patient may or may not have is irrelevant. Do not begin a question like this, “I don’t mean to be disrespectful ….” The next word is usually but and then comes something disrespectful and usually intrusive, asked out of curiosity, and not clinically relevant. Rather, ask, “I want to understand, can you explain or clarify for me, …?” (p. 89).These suggestions can be used by any health care professional working with transgender and transsexual youth such as nurses, doctors, pharmacists, and surgeons. Having respectful communication with people is important to preserve dignity and respect however it is even more important with this population because they can have mental health implications due to the fact their body does not represent who they are. Veale, Watson, Peter and Saewyc (2016) state that a study of U.S. college students found that transgender students had markedly increased risk of depression, self-harm, suicidal ideation, and suicide attempts compared with cisgender students, those whose gender identity aligned with their gender assigned at birth. These results point to a clear need to reduce the stigma, prejudice, and discrimination related to being transgender in these youth’s environments and to improve the supports for families, community groups who work with transgender youth, schools and universities, and health care providers. The high levels of mental health concerns reported by transgender participants in this study indicate a clear need for appropriate mental health care for this population (Veale et al., 2016). To achieve this, we suggest training for mental health care providers to go beyond providing care that is “transgender friendly” to providing care that is “transgender competent” and recognizes the unique issues faced by this group. Providing transgender competent care would include adequate training for mental healthcare providers to reduce biases or prejudices they may have toward transgender youth (Veale et al., 2016). This could include appropriate terminology and language to be used among transgender youth as well as the various challenges many transgender youth face. Finally, national mental health policies should include a focus on transgender youth as a population at extreme risk and develop strategies to promote positive mental health and reduce the mental health disparities for transgender youth (Veale et al., 2016).There are health risks with every medical treatment therefore there are risks that can affect these transgender and transsexual adolescents when they seek hormone therapy and surgical intervention. Not all of these risks are of the same magnitude; there are some smaller risks such as changes in sebum production with hormone therapy and acne however there are risks associated with these youths’ fertility. Women most commonly take estrogens and specifically estradiol, often in conjunction with an antiandrogen. Estrogens rapidly and persistently reduce sebum production (Giltay and Gooren, 2000; as cited in Ginsberg, 2016). Although no direct association with skin pathology has been reported, women who are already prone to xerosis may experience increased pruritus and eczematous changes. Estrogens also lead to a reduction in quantity and density of body hair, which is often a desired effect. However, there is typically not a complete elimination of facial hair. Notably, facial laser hair removal has been reported as the most common transition-related procedure, including surgeries, that is performed on transgender women (Ginsberg et al., 2016; as cited in Ginsberg, 2016). Men who take hormonal supplementation use one of many formulations of testosterone (Spack, 2013; as cited in Ginsberg, 2016). Contrary to treatment with estrogens, there is often a significant increase in sebum production (Giltay and Gooren, 2000; as cited in Ginsberg, 2016). In addition, severe acne has been observed in this population, especially upon initiation of the therapy (Turrion-Merino et al., 2015; Wierckx et al., 2014; as cited in Ginsberg, 2016). Although topical agents and oral antibiotic medications remain first-line treatments for testosterone-induced acne, many transgender men ultimately require isotretinoin. There is growing recognition that fertility and fertility preservation are important considerations among transgender adults when seeking hormonal/surgical interventions (Chen et al., 2017). While gender-affirming hormones such as estrogen for birth-assigned males; testosterone for birth-assigned females are indicated to alleviate gender dysphoria, side effects include impairments in gonadal histology that may cause infertility or biological sterility (Chen et al., 2017). Estrogen use by transgender women results in impaired spermatogenesis and an absence of Leydig cells in the testis. Testosterone use by transgender men causes ovarian stromal hyperplasia and follicular atresia. Gonadal effects of hormones are thought to be at least partially reversible, and pregnancy has been reported in transgender men who have previously used testosterone. However, thresholds for amount and duration of exogenous hormone exposure causing permanent negative effects on fertility have not been established (Chen et al., 2017). Some youth presenting to gender clinics may feel a sense of urgency to move forward with medical transition, and initiating hormones may be prioritized over other considerations, including fertility and fertility preservation (Chen et al., 2017). These could lead to health implications later in life and they may not realize this; there are some studies that state that transgender adolescents should seeks a counselling before initiating any therapies so that the adolescents are fully informed and have time to make the decisions that are best for them. In conclusion, there needs to be more discussion and acknowledgement of the transgender and transsexual adolescent population in the health care setting and how health care professionals can adequately address their needs. There is a need for more education on this population in professional programs such as medical school or nursing programs so that when these people go into the work for they feel competent in interacting with these people. AS well proper communication and how to have a discussion around assigned sex and gender identity so that this discussion can be at the start of a relationship and there is no room for offending someone for who they are. In addition to treating the physical aspects and changes of these transgender youth, their mental health also needs to be addressed to provide holistic care. In raising awareness of the issues within the community and health care system, maybe the stigma of this population can be decreased and therefore that may even address mental health issues, just by allowing these adolescents to be who they are without judgement. That is what every person desires in life; just to be completely who they are without feeling ashamed and having to hide themselves. If the health care system can be one of the first to acknowledge this desire, a difference may be made in the approach to how these individuals are treated and respected. ReferencesChen, D., Simons, L., Johnson, E. K., Lockart, B. A., & Finlayson, C. (2017). Fertility preservation for transgender adolescents. Journal of Adolescent Heath, 61(2017), 120 123. doi: org/10.1016/j.jadohealth.2017.01.022Ginsberg, B. A. (2016). Dermatologic care of transgender patient. International Journal of Women’s Dermatology, 3(2017), 65-67. doi: org/10.1016/j.jwd.2016.11.007 Lawlis, S. M., Donkin, H. R., Bates, J. R., Britto, M. T. & Conard, L. A. E. (2017). Health concerns of transgender and gender nonconfirming youth and their parents upon presentation to a transgender clinic. Journal of Adolescent Health, 61(2017), 642-648. doi: org/10.1016/j.jadohealth.2017.05.025Neira (2017). Caring for the transgender patient. Journal of Radiology Nursing, 36(2017), 88-89. doi: org/10.1016/j.jradnu.2017.03.02202Olson J., Scharger, S. M., Belzer, M., Simons, L. K., & Clark, L. F. (2015). Baseline physiologic and psychological characteristics of transgender youth seeking care for gender dysphoria. Journal of Adolescent Health, 57(2015), 374-380. doi: org/10.1016/j.jadohealth.2015.04.027Scutti, S. (2014). What is the difference between transsexual and transgender? Facebook’s new version of “it’s complicated”. Medical Daily. Retrieved from www.medicaldaily.com/what-difference-between-transsexual-and-transgender- facebooks-new-version-its-complicated-271389Vance S. R., Deutsch, M. B., Rosenthal, S. M., & Buckelew, S. M. (2016). Enhancing pediatric trainees’ and students’ knowledge in providing care to transgender youth. Journal of Adolescent Health, 60(2017), 425-430. doi: org/10.1016/j.jadohealth.2016.11.020Veale, J. F., Watson, R. J., Peter, T., & Saewyc E. M. (2016) Mental health disparities among Canadian transgender youth. Journal of Adolescent Health, 60(2017), 44-49. doi: org/10.1016/j.jadohealth.2016.09.014

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