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Abstract
Introduction Transgender and gender-diverse (TGD) people face a multitude of barriers to safe, accessible healthcare. One way to overcome access inequities is through the provision of gender-affirming care. Gender-affirming care is culturally safe and engaged care that values TGD identities and is focused on depathologising TGD people. Additionally, gender-affirming care encompasses awareness and support of TGD individuals as unique beings, including supporting gender-affirming medical goals for those who are interested. The discipline of nursing is well situated to advocate for gender-affirming care, however, receives little undergraduate education in the subject. Undergraduate schools of nursing (including faculty and curriculum) are in a crucial position to implement gender-affirming care, though how they have done this is not widely known. Our scoping review aims to understand how Canadian and US undergraduate schools of nursing teach and integrate gender-affirming education.
Methods and analysis Our scoping review will follow the six stages by Arksey and O’Malley and the advancements by Levac et al, reported on as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. The review will be completed in 2023, with the database searches carried out in spring 2023, followed by screening and analysis.
Ethics and dissemination Ethics approval is not required for this protocol. To aid in knowledge translation, a visual representation of the findings will be created. Results from the final scoping review will be published in a peer-reviewed journal, promoted on social media to schools of nursing, and presented at conferences and seminars.
Protocol registration number Open Science Framework (https://doi.org/10.17605/OSF.IO/Q68BD).
- Sexual and gender disorders
- EDUCATION & TRAINING (see Medical Education & Training)
- Protocols & guidelines
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- Sexual and gender disorders
- EDUCATION & TRAINING (see Medical Education & Training)
- Protocols & guidelines
STRENGTHS AND LIMITATIONS OF THIS STUDY
This review will be the first of its kind to map the state of gender-affirming care education in undergraduate nursing programmes in Canada and the USA.
This scoping review will identify journal articles from four biomedical databases covering health sciences education and healthcare services (Medline, Embase, CINAHL and SCOPUS). Additional searching will be done using Google Advanced to retrieve relevant grey literature.
Studies will be selected regardless of date or methodology.
A limitation of this review is that only literature published in English will be included.
Introduction
How we care for any group of people within society influences both their well-being and potential to contribute to our collective. Transgender and gender-diverse (TGD) people (people whose gender differs from their sex assigned at birth) continue to be labelled as mentally unwell and pathologised (to be in need of medical treatment or help) under the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-V).1 This pathologising amplifies stigma and discrimination,2 hindering access to equitable care3 and leading to considerable health disparities.3 4 TGD people are one of the diverse groups lumped under the evolving acronym of 2S/LGBTQiA+ (2Spirit people and lesbian, gay, bisexual, transgender, queer and questioning, intersex, asexual, agender and aromantic people, plus other diverse queer identities). As more TGD people share their authentic selves, awareness of their existence and healthcare needs increases. In Canada, over 100 800 people were identified as TGD during the first collection of the national census data in 2021, and this number likely under-represents the population of TGD people.5 6 An estimated 1 in 300 Canadians over the age of 15 years (including 1 in 150 people aged 15–34 years) identify as TGD,6 and our healthcare system needs to enhance care provision and access for this group. In the USA, over 1.6 million people over the age of 13 years identify as TGD, including 300 000 youth aged 13–17 years.7
An emerging practice of gender-affirming care is becoming more established.8 9 Gender-affirming care is culturally safe and engaged care that values TGD identities and is focused on depathologising TGD people.9 Additionally, gender-affirming care encompasses awareness and support of TGD individuals as unique beings. Within nursing practice, this includes the universal adaptation of gender-neutral language and mitigating assumptions, such as by normalising using an organ and bioanatomy inventory during assessments and asking patients their chosen name and pronouns.10 This includes understanding that some, but certainly not all, TGD people may seek gender-affirming medical care (ie, hormones, surgery, etc) to affirm their gender.9 While gender-affirming medical care (also called transitional care) is one aspect of care that falls within the spectrum of gender-affirming care, it is an example of how barriers are created within healthcare. To access gender-affirming medical care (and coverage), a medical diagnosis is required. The DSM-V diagnosis of ‘gender dysphoria’ (meaning distress or impairment because of one’s gender)1 has been used for the past decade, promoted by the World Professional Association for Transgender Health (WPATH) Standards of Care, Version 7.11 In a large Canadian study, only about half of TGD participants reported receiving gender-affirming care from their primary care provider, with 44% reporting an unmet healthcare need.3 This is not surprising given that TGD people face numerous health deficits,12 largely caused by negative healthcare experiences13 14 and lack of provider knowledge.4 However, in an effort to promote access to gender-affirming medical care and destigmatise TGD people, WPATH Standards of Care, Version 815 recommends shifting towards the International Classification of Diseases-11 new diagnosis of ‘gender incongruence’. This shift in language promotes TGD people to obtain medical care without a psychiatric diagnosis or experiences of distress pertaining to one’s gender. While the number of people receiving, or providers delivering, gender-affirming care is unknown, we know that gender-affirming care fosters positive health outcomes for TGD people.12 16
The discipline of nursing is well positioned to advocate for the implementation of gender-affirming care in undergraduate nursing education.8 A Canadian-wide survey of undergraduate nursing programmes found that of all 2S/LGBTQiA+ topics, gender-affirming care was the least included topic included in the curriculum.17 A US study of undergraduate nursing programmes suggests an average of 2.12 hours on ‘LGBT’ education but there is no mention of the amount of time devoted specifically to TGD health.18 This dearth of gender-affirming integration in curricula is partly due to faculty-reported barriers such as lack of time, knowledge and competence, and uncertainty for where to include the content in the curriculum.17–20 While there are increasingly more nursing-based resources for faculty to draw from, such as the tool for assessing ‘LGBTQI+’ health training,21 Rivera et al’s middle range gender-affirming nursing care model,22 or the sexual orientation and gender identity nursing eLearning toolkit,23 there have not been unified efforts to consolidate and disseminate resources, and many remain widely unknown.20 The provision of gender-affirming education to faculty (and faculty teaching students) improves attitudes toward TGD people and a greater sense of the importance of learning gender-affirming care.20 24 Finally, Kellett and Fitton highlight the need for nursing schools to model and implement inclusivity for students (including TGD students) through the institutional environment (such as using neutral language and having gender-inclusive washrooms), faculty leadership and advocacy.25
Scoping reviews are undertaken to identify the state of evidence located within the grey and peer-reviewed published literature, along with corresponding gaps.26 Our scoping review will map the evidence concerning gender-affirming care in nursing undergraduate programmes in Canada and the USA. We seek to identify what modalities nursing schools are using to facilitate gender-affirming care, including faculty development and curricular strategies. To the best of our knowledge, there is no existing review that evaluates gender-affirming care in these contexts in undergraduate nursing programmes.
Social location of authors
To position ourselves for this work, the principal investigator and lead author (JC) is a white settler, trans, non-binary, queer master of nursing student. Co-investigator and second author (ASHS) is a white settler, cis, queer woman and nursing professor. Co-investigator and third author (JL) is a white settler, ciswoman and health sciences librarian who has worked in community health for several decades. Co-investigator and fourth author (MK) is a white settler, ciswoman and assistant professor. Co-investigator and fifth author (JR) is a white settler, cis, queer woman and gender studies professor. All authors are committed to working in solidarity with the 2S/LGBTQiA+ communities and advancing gender-affirming care and TGD health equity. The authors are guests situated on Treaty 1, Treaty 6 and the Douglas Treaties. Living on the traditional territories of several First Nations and the Métis nation, we respect and affirm the inherent and human rights of all Indigenous Peoples.
Methods and analysis
This scoping review is being guided by the six stages identified by Arksey and O’Malley27 and expanded on by Levac et al.28 The final review will be reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews.29
Stage 1: identifying the research question(s)
The population, concepts and context framework30 was used to support the eligibility of the research question. The population of interest is undergraduate nursing students, faculty, curricula or programmes. The concept we hope to uncover within this population is evidence of gender-affirming content in schools of nursing. Lastly, our proposed context is to focus on undergraduate schools of nursing in Canada and the USA given the geographical location of the researchers and similarity of nursing codes of ethics and education requirements/curricula. Furthermore, this scoping review will inform a research project focused on undergraduate education in Canada, and given the scarcity of literature specific to Canadian nursing schools, we have opted to include literature from the USA.
This scoping review aims to understand how undergraduate nursing programmes integrate gender-affirming care. Naturally, it follows that our overarching research question is: How have undergraduate nursing programmes integrated gender-affirming care? Secondary questions this review seeks to answer include:
How are undergraduate nursing faculty prepared to teach gender-affirming care?
What teaching strategies/approaches are employed to teach gender-affirming care to students?
What are undergraduate nursing students’ experiences learning about gender-affirming care?
What strategies/approaches are employed to support the implementation of gender-affirming care in the undergraduate nursing curriculum?
What are the gaps?
Additional questions may be added as they emerge.
Stage 2: identifying relevant studies
The search strategy methodology has been iteratively developed in consultation with the research team, consisting of an expert health sciences librarian with experience in scoping reviews (JL) and three expert stakeholders (one who is an expert in undergraduate nursing curriculum (MK), one who is an expert in women and gender studies (JR) and one who is an expert nurse educator with experience in scoping reviews (ASHS)). Keywords were developed in collaboration with all members of the research team alongside keyword and subject heading selection from purposively selected TGD literature31 (please see online supplemental appendix A for our preliminary search strategy). It should be noted that many of the terms included in our search strategy are out of date including disrespectful terms. For this reason, we plan to define and contextualise keywords and subject headings in the final review to minimise harm and to guide future literature reviews supporting the health of TGD people.
Supplemental material
Beginning in spring 2023, JC will run searches in Medline (Ovid), Embase (Ovid), Cumulative Index to Nursing and Allied Health Literature (EbscoHost) and SCOPUS (Elsevier). Grey literature will be searched in Google Advanced, screening the first 10 pages of search results. No publication date limits will be set.
Inclusion and exclusion criteria
Our initial inclusion criteria for selecting articles require that the population be undergraduate nursing students, faculty, curriculum, and/or schools of nursing in Canada and the USA. The concept of interest is the presence of gender-affirming or inclusive education, TGD health education, or variations of gender diversity and nursing education. We will also include studies if they highlight 2S/LGBTQiA+ education, so long as the education is concomitant with TGD education. We are interested in mapping all journal articles and reviews that have been published, regardless of the date. Sources will be limited to retrieval of full text in English, as this is the language of the authors. Exclusion criteria consist of articles that focus on graduate nursing students, faculty, curriculum or programmes, nursing professionals or continuing education; the absence of gender-affirming education; any schools of nursing outside of Canada and the USA; commentaries, abstracts or conference proceedings; and any article whose full text is unattainable and/or not in English. Grey literature such as theses and dissertations will be searched and screened by the same criteria as peer-reviewed articles.
Notes on terminology, keywords and subject headings
In designing the search strategy, we are cognisant of how knowledge is inherently tied to power.32 In early discussions about the utility of subject headings used in each database’s index, along with keywords drawn from contemporary academic writing and discourse, it was noted that the database indexes themselves underscored their limitations in the terminology necessary to accurately retrieve publications about TGD people’s health. In some cases, index terms were quite new, such as the Medical Subject Heading (MeSH) term, transgender persons (added in 2016 and in use since 2013) or the EMTREE term, transgender (added in 2014). In other cases, searchers are directed to move backwards in time to use outdated and inaccurate terms, such as transsexualism (MeSH) or transsexuality (EMTREE). It should be noted that this is in spite of the fact that transgender is not a new term, used in textbooks as early as 1965, commonly used in academic literature in the 1970s and 1980s, and well ensconced in academia by the early 2000s.33 34 The concept of self-identification of oneself as being what one might refer to as TGD today has been documented in the historical record since ancient Greek and Roman societies.33 The concepts of diagnoses and pathologisation of TGD people are not new, but it must be stated that this can be a barrier to accessing the health sciences literature. The medicalisation of 2S/LGBTQiA+ people, including TGD people, is rooted in 19th century psychiatry and these pathological classifications persist today affecting the equitable delivery of healthcare services.33 Inaccurate, imprecise, outdated, and offensive terminology and categorisation all contribute to persistent, systemic transphobia and the wholesale erasure of TGD experience and perspective in healthcare.4 This is not just a historical problem but one that affects the lives of individuals today.34 For our purposes, we had to create a list of terms to enter into the databases for retrieving the most comprehensive literature for this review. This list is comprised of approximately 50 keywords or key phrases, including variant spellings, along with the addition of prescribed subject headings as directed by the thesauri found within each database. In so doing, we felt obliged to include some of the outdated or imprecise terms that we would not use in writing about TGD people today (see online supplemental appendix A for details of the search strategy).
Stage 3: study selection
Throughout the search, JC will export and save all files to a Google Drive folder, subsequently importing them to Zotero. Given feasibility constraints, the title screening and initial deduplication will be done solely by JC in Zotero, followed by abstract and then full-text screening by two independent reviewers (JC and ASHS) in Covidence. A meeting will be held after each reviewer pilot tests roughly 25 abstracts or full texts, respectively,35 with decisions and discrepancies documented. The reviewers will meet after each screening phase to discuss and resolve discrepancies. Any unsolved discrepancies will be brought to the stakeholder experts for deliberation. All articles included in this review will be saved in a Google Drive folder as well as in a separate group library in Zotero (see online supplemental appendix B for the version of PRISMA, V.2 flow diagram).36
Stage 4: charting the data
Data extraction will be conducted by two reviewers (JC and a graduate student), with a third reviewer (ASHS) available to resolve discrepancies. We have limited our data extraction to correspond with our research questions, including authors, year of the study, location of the work (which school(s) of nursing), key theories/conceptual frameworks used, the type of methodology, the intervention type, the population, evaluation methods and recommendations. As this review is iterative, changes to the data extraction template are fluid and will be reported on in the scoping review35 (see online supplemental appendix C for the sample data extraction table). The risk of bias in studies will not be assessed as it is not required for a scoping review.37
Stage 5: collating, summarising and reporting the results
Results will be reported in a tabular form in the final review, highlighting the population (students, faculty, curricula, programmes), statement(s) of positionality by the authors, types of interventions, location, ways gender-affirming care was present and recommendations from each article. The analysis will be descriptive, including prevalence of various descriptors of eligible studies, and the results of the mapping will be reported via narrative synthesis. As scoping reviews are not intended to provide recommendations but rather to map the state of current evidence,37 implications will focus on the amount and variety of gender-affirming care in nursing education and associated gaps in evidence. We will also situate the strengths and limitations of the review and its contribution to nursing education and future research in this area.35
Stage 6: consultation
The evolution of consultation in scoping reviews has led to this step as mandatory—stakeholders hold invaluable knowledge and experience and ought to be consulted,28 35 as such, our review has engaged stakeholders from its conception. The stakeholders (ASHS, MK, JR) have been instrumental in shaping the research question and aims of the study, and identifying relevant studies. The stakeholders will be continually consulted throughout the review process. Stakeholders are being kept informed throughout the progression of the review and consulted for any major screening discrepancies or otherwise. In the final review, the consultation will extend to include feedback from peer reviewers while continuing with seeking feedback from the expert stakeholders.
Study status
The searches and screening of this review are intended to start in spring 2023, incorporating feedback from peer reviewers (from publishing this protocol) and stakeholders; thus, the study will remain ongoing until the review is accepted for publication.
Patient and public involvement
There is no plan to involve patients or the public at any stage in this scoping review.
Ethics and dissemination
Ethics approval is not required for a scoping review of the literature. Our dissemination strategy includes a peer-reviewed publication to share the scoping review study, along with presentations at conferences, for schools of nursing, and promote study outcomes via social media. To aid in knowledge translation, a visual representation of the state of gender-affirming care in undergraduate nursing education will be created.37 Moreover, we aim to explore ways to inform the development of threshold concepts related to gender and sexuality that can guide curricula in both traditional and concept-based learning in nursing.
Ethics statements
Patient consent for publication
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @CrawfordNursing
Contributors JC and ASHS conceptualised and designed the study, incorporating feedback from JL, MK and JR. JC developed the research questions, with revisions based on feedback from all authors. JC and JL co-developed the search strategy, with feedback from ASHS, MK and JR. JL drafted the notes on terminology, keywords and subject headings section, with input and revisions from JC. All authors contributed and approved the manuscript prior to submission. ASHS is supervising this work.
Funding This work was supported by the University of Manitoba Graduate Fellowship award (award number: n/a), received for JC’s thesis work.
Disclaimer The funding body has no role in the study.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.