When Trans People Must Choose: Nursing Actions for Transgender Health Justice
Article information
Cleofas, J. V., & Abesamis, L. E. A. (2025). Attending to transgender health dilemmas: Practical and strategic nursing actions toward gender justice for health. Nursing Outlook, 73, 102593. https://doi.org/10.1016/j.outlook.2025.102593
What this paper is about
This paper asks a practical and justice-oriented nursing question: What can nurses do when transgender and gender-diverse people are forced to make unfair choices about their health?
The authors focus on transgender and gender-diverse (TGD) people, who continue to face barriers in healthcare. These barriers include lack of culturally competent providers, lack of anti-discrimination protections, unaffordable gender-affirming care, limited insurance or public health coverage, and healthcare systems that often treat trans health as invisible or secondary.
The paper argues that nurses are in a unique position. Nurses often meet people at points of vulnerability: in clinics, hospitals, communities, schools, public health programs, and health systems. Because of this, nurses can provide direct care, build trust, support navigation, reduce harm, educate others, advocate for policy, and help reshape institutions.
The key idea: transgender health dilemmas
The central concept is transgender health dilemmas. This refers to the difficult decision-making situations that TGD people face when their trans-specific health needs are placed in conflict with other health and social needs.
The paper describes two main dilemmas.
Dilemma A: weighing trans health needs against other needs
The first dilemma happens when TGD people must choose between gender-affirming care and other basic needs. For example, a person may want hormones, surgery, a trans-competent doctor, or gender-affirming counseling, but also needs to pay for food, rent, transportation, school, family needs, or treatment for another health condition.
In the Philippine context discussed in the paper, gender-affirming care is often privatized, expensive, and not systematically covered by public health insurance. This means TGD people may delay, forego, or deprioritize trans-specific care. Some may turn to community-run markets or informal pathways because these are cheaper and less discriminatory.
This is not simply an individual “choice.” It is a forced choice created by systems.
Dilemma B: disengagement from formal healthcare
The second dilemma happens when TGD people disengage from formal healthcare because previous encounters were discriminatory, unsafe, unaffordable, or humiliating.
If a clinic uses a person’s legal name instead of lived name, refuses to use correct pronouns, treats trans people as abnormal, offers no relevant services, or exposes them to disrespect, the person may stop seeking care there. This disengagement can lead to delayed diagnosis, unmanaged health issues, risky self-medication, or reliance on informal sources of care.
The paper does not blame TGD people for disengaging. Instead, it asks nurses and health systems to understand why disengagement becomes a survival strategy.
The framework: practical and strategic nursing actions
To respond to these dilemmas, the paper uses Moser’s Gender Analysis and Planning framework, especially the distinction between practical gender needs and strategic gender needs.
Practical needs are immediate and daily. They reduce suffering now. Strategic needs are long-term and transformative. They change the systems that create inequity.
The article’s Table 2 on page 4 presents the key matrix: it crosses the two transgender health dilemmas with practical and strategic gender needs, then identifies corresponding nursing actions.
Practical nursing actions for Dilemma A
For TGD people struggling to afford or prioritize gender-affirming care, nurses can provide resource navigation. This includes giving clear information about low-cost or free trans-affirming clinics, community organizations, financial aid, referral networks, and available services.
Nurses can also provide harm reduction education. For example, if a person is using non-prescribed hormones because formal care is inaccessible, nurses can offer evidence-informed education on risks, warning signs, safe practices, and when to seek medical help. This does not mean endorsing unsafe systems. It means reducing harm while working toward better systems.
A third practical action is therapeutic itinerary support. This means respecting the different pathways TGD people use to seek care—formal, informal, community-based, online, alternative, or specialist-based—and helping them make safer, more informed decisions.
Practical nursing actions for Dilemma B
For TGD people who distrust formal healthcare, nurses can begin with affirming contact. This includes using lived names, correct pronouns, respectful language, and non-stigmatizing communication.
Nurses can also act as patient navigators or coordinators. They can help patients book appointments, understand procedures, complete forms, access referrals, and move through health systems that may otherwise feel hostile or confusing.
Another practical action is community partnership. Nurses can work with trans-led organizations to bridge formal healthcare and community care. This is important because many TGD people may already trust community networks more than hospitals or clinics.
Strategic nursing actions for systemic change
Practical care is not enough. The paper argues that nurses must also work on long-term structural change.
Strategic actions for Dilemma A
For the systemic lack of affordable gender-affirming care, nurses can advocate for trans health coverage in public health programs and universal healthcare systems. Gender-affirming care should not be treated as luxury care. It is part of health, dignity, and well-being.
Nurses can also push for curriculum integration. Nursing students need education on transgender health, gender-affirming care, cultural safety, minority stress, harm reduction, and intersectionality. Without this, future nurses remain underprepared.
Another strategic action is institutional budgeting and programming. Hospitals, clinics, schools, and public health agencies can allocate funds for trans health services, staff training, gender-neutral facilities, referral systems, and community partnerships.
The paper also calls for critical and transformative research. Nurses can produce evidence on the effects of delayed care, unaffordable services, informal hormone use, discrimination, and institutional exclusion.
Strategic actions for Dilemma B
For discrimination and disengagement from formal healthcare, nurses can lead cultural competency and bias training. This should not be one-time token training. It must be ongoing, reflective, accountable, and tied to institutional change.
Nurses can also advocate for policy and system reform. This includes inclusive electronic health records, anti-discrimination policies, correct name and pronoun protocols, gender-neutral facilities, confidentiality protections, and clear reporting mechanisms for discrimination.
Finally, nurses can help create safe spaces in healthcare. This means making healthcare environments visibly and materially welcoming to TGD people: respectful staff, inclusive forms, clear signage, privacy, trained personnel, and partnerships with trans communities.
Bottom line
This paper argues that nurses should respond to transgender health dilemmas at two levels: care now and change systems over time. Immediate actions such as affirming contact, navigation, education, harm reduction, and community partnership matter. But they must be paired with strategic actions such as policy advocacy, curriculum reform, institutional budgeting, research, and anti-discrimination systems.
The key message is clear: transgender health justice is not only about being kind to trans patients. It is about changing the healthcare conditions that force trans people into impossible choices.
Policy/practice recommendations
- Train all nurses in gender-affirming care
Nursing curricula and continuing education should include trans health, lived names and pronouns, hormone care basics, stigma, confidentiality, and culturally safe communication. - Build resource navigation into nursing practice
Nurses should know where to refer TGD patients for low-cost, affirming, community-vetted, and safe services. - Use harm reduction when formal care is inaccessible
When patients rely on informal pathways, nurses should reduce risk without judgment while advocating for formal access. - Partner with trans-led organizations
Health systems should not design trans health programs without trans communities. Community partnerships build trust and relevance. - Include gender-affirming care in public financing
Policy advocates should push for coverage of gender-affirming care in universal health systems and public insurance schemes. - Fix institutional systems
Electronic records, intake forms, waiting rooms, bathrooms, privacy protocols, and complaint mechanisms should be redesigned to protect TGD patients. - Research trans health dilemmas in real settings
The proposed nursing action matrix should be tested in clinics, hospitals, community programs, nursing schools, and public health services.
Glossary of key terms
- Transgender and gender-diverse / TGD — People whose gender identity or expression differs from expectations based on sex assigned at birth.
- Gender-affirming care — Social, psychological, behavioral, legal, and medical support that affirms a person’s gender identity.
- Transgender health dilemmas — Forced decision-making situations where TGD people must choose between trans-specific health needs and other needs, or disengage from formal healthcare because of discrimination and cost.
- Dilemma A — Weighing trans-specific health needs against other basic health and social needs.
- Dilemma B — Disengagement from formal healthcare because of discriminatory, unaffordable, or unsafe systems.
- Therapeutic itinerary — The pathway a person follows when seeking care across formal, informal, alternative, community, and other systems.
- Messy survival — Everyday survival under conditions where material, emotional, political, and social struggles overlap.
- Practical gender needs — Immediate, daily, survival-oriented needs that reduce suffering without necessarily changing the system.
- Strategic gender needs — Long-term transformative needs that challenge the systems producing inequality.
- Moser’s Gender Analysis and Planning framework — A planning framework used to identify practical and strategic gender needs and guide gender-responsive action.
- Gender justice for health — Fair and accountable health arrangements that correct gender-based inequities so all people can attain the highest possible standard of health.
- Transgender health justice — Applying health equity and the right to health to TGD people by removing legal, social, economic, and healthcare barriers.
- Cisgenderism — A system that treats cisgender identities as normal and superior while marginalizing trans identities.
- Cisnormativity — The assumption that everyone is or should be cisgender.
- Intersectionality — A framework for understanding how systems such as gender, class, race, sexuality, disability, coloniality, and age shape experiences together.
- Epistemic injustice — Injustice that happens when marginalized people’s knowledge and testimony are dismissed or devalued.
- Resource navigation — Helping patients find services, referrals, financial aid, community resources, and care pathways.
- Harm reduction — Practical strategies that reduce risk and harm without moral judgment.
- Affirming contact — Respectful patient interaction that uses lived names, correct pronouns, and validating language.
- Patient navigation — Guiding patients through appointments, referrals, paperwork, procedures, and health system barriers.
- Cultural competency and bias training — Training that helps health workers recognize bias, understand diverse experiences, and provide respectful care.
- Safe spaces in healthcare — Clinical environments where TGD people can seek care without fear of discrimination, exposure, ridicule, or neglect.
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