Australian mental health nurses and transgender clients: Attitudes and knowledge

Abstract

As increasing numbers of transgender people access mental health services, so with this comes the requirement that mental health professionals are capable of providing inclusive and informed care. In Australia, mental health nurses play a key role in the mental health workforce, and are increasingly likely to engage with transgender people across a range of practice contexts. The research reported in this paper sought to explore the experience, knowledge and attitudes of a sample of Australian mental health nurses with regards to working with transgender people. A total of 96 mental health nurses completed a survey that included an attitudinal measure and a measure of clinical knowledge. Our findings indicated that a majority of the sample had worked with a transgender client before, but only a minority had undertaken training in working with transgender clients. Training was related to more positive attitudes; and both training and experience were related to greater clinical knowledge. Female and/or older participants had greater clinical knowledge, whilst more religious participants had less positive attitudes. The paper concludes by commenting on the dearth of competency and practice documents specific to mental health nurses working with transgender people, and it outlines the Australian standards that would mandate their development.

Keywords

attitudes competencies knowledge mental health nurses transgender

Introduction

Mental health nurses can play an important role in service provision to transgender people (i.e. people whose gender differs from that normatively expected of their assigned sex). This role can include providing initial and ongoing support related to gender identity, having a role in the assessment and referral of gender-affirming medical procedures, as well as supporting families of transgender people (McCann, 2015). Yet despite the importance of these roles, research findings continue to suggest that many transgender people have generally negative experiences with mental health services (McNeil et al., 2012; Riggs et al., 2014; Shipherd et al., 2010), with some mental health professionals displaying a lack of knowledge and sensitivity. In regards to mental health nurses specifically, it is noted that little attention has been paid to transgender clients and issues (Shattell and Chinn, 2014); and what attention has been paid in the literature, summarised in the following, suggests that nurses and nursing students appear to be lacking in experience and training for working with transgender clients. Drawing on an Australian study of mental health nurses’ knowledge about, and attitudes towards working with, transgender clients, the present paper examines the predictors of these two variables. Specifically, our survey sought to examine the relationship between training specific to working with transgender clients – the clinical experience in this regard, and attitudes towards and knowledge about transgender people amongst a sample of mental health nurses. The paper concludes with recommendations about increasing the skills of the mental health nurse workforce, so as to better meet the needs of transgender people.

Literature review

As noted, little attention has been paid to transgender clients and issues in the academic literature on nursing. Evidence for this claim appears in the work of Eliason et al. (2010), who conducted keyword searches for lesbian, gay, bisexual and transgender (LGBT) issues in the top 10 nursing journals, ranked by impact score, between 2005 and 2009. They found that five journals ‘had a complete silence about LGBT issues’ (Eliason et al., 2010), and only eight out of 4941 papers mentioned LGBT issues, including just one where transgender issues were mentioned. A broader review by Merryfeather and Bruce (2014) analysed the content of 77 papers relating to transgender and transsexual issues in nursing literature between 1985 and 2011. They found that transgender issues are often invisible or erased in nursing, evident in the lack of attention to gender diversity in nursing education and textbooks, the slow implementation of policies about transgender people and nursing, and the dearth of nursing research into transgender people’s lives. Similarly, Dorsen’s (2012) integrative review of 17 papers published between 1990 and 2010, which focused on nurses’ attitudes towards LGBT clients, found that no studies discussed transgender people. As such, despite the use of the LGBT acronym, research that claims to address the needs of all members of LGBT communities often ignores transgender people, instead only focusing on sexual orientation and homophobia.

A small number of studies have, however, examined attitudes and knowledge amongst nurses and nursing students’ attitudes, in regards to working with transgender clients. Importantly, to our knowledge only one previous study specifically examines the attitudes of mental health nurses towards transgender people. Kench’s (2015) qualitative research exploring LGBT issues with 19 mental health nurses in Australia includes a significant discussion of attitudes towards transgender people. Kench found that her participants generally spoke about their experiences with transgender people differently from the ways in which they spoke about their experiences with lesbian, gay or bisexual people. Specifically, Kench’s participants stated that they knew little about transgender people, and thus service provision could be ‘awkward’ and ‘uncomfortable’, affecting their ability to provide culturally competent and inclusive care. This lack of knowledge was considered to arise from the fact that participants infrequently (at least knowingly) came into contact with transgender people, and rarely provided nursing services to this sector of the community.

Other more broad research with nurses and nursing students has similarly found a lack of knowledge and experience. Beagan et al. (2013) conducted semi-structured interviews with primary care nurses (n = 12) and physicians (n = 9) in Canada, and found that, with the exception of two nurses who had extensive experience with transgender clients, nurses were aware of their own lack of knowledge for working with transgender clients.

While nurses sought to educate themselves, some of this learning was done on the job and from clients, which may be an unfair demand upon the clients. Similarly, a study in one area of the US by Levesque (2013) examined nursing professionals’ knowledge, attitudes and self-efficacy for working with transgender clients. Of the 26 nursing professionals who completed surveys, most worked in primary care or acute care. While there was a high level of overall acceptance of transgender clients, respondents reported low self-efficacy or confidence for providing care, and no respondents had been taught about transgender clients in their nursing education. Again in the US, Kline's (2014) survey of 80 nursing practitioners who worked mostly in primary care settings found that 80% agreed with the statement ‘I need additional training to provide competent health care to transgender patients’.

Research with nursing students indicates similar findings in regards to attitudes towards transgender people. Utilising both pre- and post-measures focused on attitudes about LGBT client care, Carabez et al. (2015) reported on findings from a survey of 122 students enrolled in a community nursing course, in an urban US university. The participants completed a survey about their comfort and knowledge in regards to working with LGBT clients, before undertaking a unit and assessment piece specifically focused on working with LGBT clients, and were surveyed again after completion of the unit and assignment. The measure of knowledge suggested that participants were statistically more likely to have developed increased knowledge about issues related to gender identity than they were in regards to issues related to sexual orientation. Similarly, Strong and Folse (2015) examined the impact of an educational intervention at a US university for enhancing undergraduate nursing students’ knowledge of, and attitudes towards, LGBT client care. Comparison of pre- and post-measures suggested that positive attitudes towards transgender people increased more significantly than they did in regards to attitudes towards lesbians and gay men.

Methods

Procedure

Following ethics approval from the authors’ institution, our study participants were recruited primarily through an advertisement placed in the Australian College of Mental Health Nurses (ACMHN) eNewsletter, which appeared in February 2015. Information about the survey had also previously been circulated via the first author’s existing personal networks, using Facebook and email. The survey was open from July 2014 to April 2015, and administered via the SurveyMonkey website. All respondents gave their informed consent to complete the survey, by reading an information screen and selecting ‘yes’ to consent to proceed.

Participants

Current Australian figures have suggested that there are 19,626 nurses who work primarily in mental health settings (Australian Institute of Health and Welfare (AIHW), 2013); however, only a relatively small proportion of this potential sample population completed the survey (n = 96). Current figures also suggest that approximately a third of all nurses working in mental health settings are male gender, as compared to only 10% of nurses in general being male. A similar gender ratio was represented in the sample, with 72% being female and 28% being male nurses. Finally, current figures suggest that the average age of nurses who work primarily in the mental health settings is 47 years. This was closely reflected in the average sample age of 48.31 (SD 11.22). None of the participants identified as transgender.

In terms of their practice settings, over three-quarters of the sample worked in either a medical context (42.7%) or community mental health (36.5%). The remainder of the sample worked in private practice (9.4%), child and family services (4.2%), education (4.2%) or correctional services (3.1%). The sample participants were highly educated, with over a third having a Master’s degree (40.6%); the remainder of the sample had either a diploma or certificate (18.7%), a Bachelor's degree (15.6%) or a doctorate (2.1%). Importantly, for the purposes of the survey, potential participants were invited to complete the survey if they identified with the category ‘mental health nurse’ as their profession. In Australia, mental health nursing is not a category of registration with the relevant licensing board, the Nursing and Midwifery Board of Australia. Instead, registered nurses may undertake a specialist qualification in the form of a graduate diploma, after which they are recognised as a credentialed mental health nurse by the ACMHN. The survey did not assess whether participants had undertaken such credentialing, and instead accepted self-designation as a mental health nurse as the primary criteria for participation. Participants came from across six of the eight Australian states or territories: almost a third of the participant sample lived in New South Wales (NSW) (32.3%); the remainder of the sample lived in South Australia (SA) (19.8%), Queensland (QLD) (18.8%), Victoria (VIC) (15.6%), Western Australia (WA) (3.1%) or the Australian Capital Territory (ACT) (6.3%).

In terms of the primary client population, the majority of our study sample (90.6%) worked primarily with adults. The remaining participants worked either primarily with children/adolescents (3.1%), or equally with both adults and children/adolescents (6.3%).

Survey instruments

Our survey utilised an adapted version of the Attitudes Towards Transgender Individuals Scale (ATTIS) (Walch et al., 2012), which uses a 5-point Likert scale on 20 items. Adaptations to the scale primarily involved substituting the word ‘people’ for ‘individuals,’ as the former was considered less pathologising in tone (e.g. ‘Transgender people should not be allowed to work with children’, rather than ‘Transgender individuals should not be allowed to work with children’). We changed two items entirely, as the wording was considered to be unclear. The item ‘all transgender bars should be closed down’ was changed to ‘transgender people should not be allowed in public spaces’. The item ‘transgendered individuals should not be allowed to cross-dress in public’ was changed to ‘transgender people should not be allowed to present as their preferred gender in public’.

When applied to the sample, no significant results were identified in regard to the ATTIS. It was hypothesised that this may have been a product of the fact that the ATTIS, despite the amendments made, is relatively blunt. In order to determine whether any aspects of the ATTIS were useful for the present study, a factor analysis was conducted with a Varimax (orthogonal) rotation. A three-factor solution was identified; however, only one of these factors explained a considerable proportion of the variance (48%). The eight items in this factor included ‘Transgenderism is a sin’, ‘Transgenderism is immoral’, and ‘Transgenderism endangers the institution of the family’. This factor displayed a high reliability: a = .93. Higher scores on the measure equate to more positive attitudes.

The second measure utilised was an adapted version of the Counselor Attitude Toward Transgender Scale (CATTS) (Rehbein, 2012), which uses a 10-point Likert scale on 20 items. Similar to the ATTIS, our adaptations to the CATTS primarily involved substituting the word ‘people’ for the word ‘individuals’. Two items were changed entirely, because their meaning was unclear: ‘Offices should display both heterosexual and LGBTQ books and pamphlets’ was changed to ‘All mental health services should provide materials that are inclusive of transgender people’, and ‘Transgender individuals must choose to live as male or female in order to lead healthy and productive lives’ was changed to ‘Transgender people should live as their natally assigned sex’.

Similar to the ATTIS, the CATTS produced no significant results when applied to the sample. It was hypothesised that this may be because the CATTS includes both items specifically about mental health practice with transgender people and items that are more general attitudinal questions about transgender people. A factor analysis using a Varimax (orthogonal) rotation confirmed this hypothesis. A 3-factor solution was identified, with one of these factors including the five questions in the CATTS that specifically focus on mental health practice (the other two factors include a mix of items that present no logically coherent factors). This one factor, which explained 45% of the variance, was utilised in the analysis presented here; and is referred to as ‘clinical knowledge for working with transgender clients’. Example items included ‘Transgender clients’ presenting issues always centre around or are linked to their gender expression’, ‘All mental health professionals should receive mandatory training in working with transgender people’ and ‘Using an incorrect pronoun when working with a transgender client is an acceptable mistake’. This factor displayed high reliability (a = .89). Higher scores on the measure indicate higher levels of accurate clinical knowledge about transgender clients.

In addition to these measures, participants were asked a series of demographic questions, including their gender, age, degree of religiosity (not at all, somewhat, quite, very), highest level of education, primary workplace setting and primary client population. Participants were also asked which Australian state or territory they lived in, whether or not they had undertaken training in working with transgender clients, and whether they had worked previously with transgender adult clients and/or transgender child/adolescent clients.

Analytic approach

Data were exported from SurveyMonkey into SPSS 21.0. Data were cleaned up in two specific ways. First, the negatively scored items on the two scales were reversed. Second, composite scores were generated for the scales outlined above. The minimum (min) and maximum (max) possible score for the two measures identified from the factor analysis were attitudes (min 8 and max 40) and clinical knowledge (min 5, max 50).

Results

Experience and training in working with transgender clients

In our sample overall, 72.9% of survey respondents had worked with an adult transgender client before, but only 11.5% had worked with a child or adolescent transgender client. In terms of differences amongst the sample in regards to working with transgender clients, those who worked in child and family services were statistically less likely to have worked with a transgender client than would be expected in an even distribution, whilst those who had worked in a medical context were statistically more likely to have worked with a transgender client, χ²= 22.59 (p < .001).

In terms of previous training in working with transgender clients, only one-fifth of the sample (19.8%) had undertaken such training. Similar to the experiences in working with transgender clients, those who had worked in child and family services were statistically less likely to have undertaken training in working with transgender clients than would be expected in an even distribution, whilst those who had worked in an educational context were statistically more likely to have undertaken training, χ²= 12.25 (p < .05).

Attitudes towards transgender people

The average score for attitudes was 32.11 (standard deviation (SD) = 4.69), meaning that in general, the study sample had positive attitudes towards transgender people.

We conducted a one-way, between-groups analysis of variance (ANOVA) to determine whether attitudes towards transgender people differed between practice contexts. A statistically significant difference emerged, F(6, 78) = 4.018 (p < .001). Our post hoc comparisons using the Bonferroni test indicated that the mean score for participants who had worked in child and family services was lower than the mean scores for all other practice contexts. Participants who had previously undertaken training in working with transgender clients reported more positive attitudes towards transgender people (mean (M) = 33.61; SD = 5.98) than did participants who had not (M = 28.30; SD = 2.32), with t = 2.904 (p < .05) and d = 1.17.

There was a strong positive correlation between attitudes towards transgender people and clinical knowledge about working with transgender people, r = .703 (p < .001). Participants with higher levels of clinical knowledge had more positive attitudes. There was a modest negative correlation between attitudes towards transgender people and religiosity, r = −.330 (p < .05). Those who were more religious had less positive attitudes.

Clinical knowledge related to working with transgender clients

The average score for clinical knowledge was 41.11 (SD = 9.02), meaning that in general, the study sample had a relatively high level of clinical knowledge.

A one-way between-groups ANOVA was conducted to determine whether clinical knowledge about working with transgender clients differed between practice contexts. A statistically significant difference emerged, F(6, 93) = 10.444 (p < .001). Post hoc comparisons using the Bonferroni test indicated that the mean score for participants who had worked in child and family services was lower than the mean scores for all other practice contexts.

Female participants reported higher levels of clinical knowledge about working with transgender clients (M = 44.15; SD = 8.35) than did male participants (M = 36.72; SD = 10.39), with t = 3.049 (p < .05), d = 0.78. Participants who had previously worked with transgender clients reported higher levels of clinical knowledge (M = 43.36; SD = 7.5) than did participants who had not (M = 37.84; SD = 7.40), t = 3.904 (p < .05), d = 0.74. Participants who had previously undertaken training in working with transgender clients reported higher levels of clinical knowledge (M = 42.84; SD = 5.71) than did participants who had not (M = 36.36; SD = 7.81), t = 3.2314 (p < .01), d = 0.94.

There was a strong positive correlation between age and clinical knowledge about working with transgender people, r = .455 (p < .001): older participants had higher levels of clinical knowledge.

Discussion

The findings reported here suggest that both training and clinical experience are related to more positive attitudes and greater clinical gender-related knowledge. In terms of other significant predictor variables, the practice context accounted for statistical differences, in terms of both attitudes and clinical knowledge; religion specifically accounted for differences in terms of attitudes; and both age and gender accounted for differences in terms of clinical knowledge. These findings largely mirror previous research on mental health professionals working with transgender people (Bowers et al., 2015; Claman, 2005; Rehbein, 2012). In order to elaborate on the implications of these findings, and having first acknowledged the limitations of the research, in the conclusion to this paper we outline something of the policy and professional contexts in which Australian mental health nurses currently operate, before then suggesting some potential changes required to further increase the skills of the mental health nurse workforce.

Limitations

Despite a concerted recruitment strategy that involved social media, email and correspondence with the relevant professional organisation, the research reported in this paper is based on a relatively small sample of survey respondents. Nonetheless, and without per se making claims to generalisability, the sample under discussion in this study is representative of general trends within mental health nursing in Australia, in terms of gender differences and age. The findings reported here are potentially also limited by the reliance upon a factor analysis to identity a subset of items from each of the measures. Whilst this is not per se an unusual analytical approach, and whilst the alpha values for each identified factor were high, it will be important that future research assesses the applicability of these measures with other cohorts of mental health nurses. Finally, whilst not a limitation, it is notable that the lowest levels of clinical knowledge and least positive attitudes were amongst those who had worked in child and family services. This was potentially because those who had worked in this sector were the least likely to have worked with transgender clients or undertaken training in working with transgender people. Further research, potentially of a qualitative nature, is required to unpack any potential differences between the experiences that differing cohorts of mental health nurses bring to their practice with transgender people.

Conclusions

While there are a number of resources that focus on competencies for working with transgender clients amongst mental health professionals more broadly (e.g. American Psychological Association (APA), 2015; Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC), 2009; Australian Psychological Society (APS), 2013), there have to date been no such resources developed for mental health nurses or nurses in general. In lieu of this, the primary document referred to in the nursing literature is the Standards of Care, produced by the World Professional Association for Transgender Health (2011), although this is seldom used in the nursing field by nursing practitioners (Kline, 2014) or in nursing programmes (Walsh and Hendrickson, 2015). In addition to an absence of resources focused on competencies for working with transgender clients, there is also an absence of guidelines for mental health nurses working with transgender clients (Kench, 2014; Zunner and Grace, 2012), although some recent documents produced in the UK by the Royal College of Nursing and Public Health England (RCN&PHE) do include information about transgender clients (Evans, 2015; Royal College of Nursing and Public Health England (RCN&PHE), 2015). Furthermore, the RCN&PHE has endorsed the document Good Practice Guidelines for the Assessment and Treatment of Adults with Gender Dysphoria (Royal College of Psychiatrists (RCP), 2013), which includes several mentions of nurses; however, none of these documents specifically target mental health nurses.

Despite this lack of resources and guidelines related to competencies specific to working with transgender people, there are nonetheless sources from which a mandate for the development of such documentation can be derived. In the Australian context, where the research reported in this paper took place, Standard 3 of the National Practice Standard for the Mental Health Workforce (Department of Health, 2013) states that clinicians should understand the importance of ‘meeting diverse needs’, which includes understanding about gender diversity. Similarly, Standard 6 of the Standards of Practice for Australian Mental Health Nurses (ACMHN, 2010) states that mental health nurses should work towards reducing stigma and promoting social inclusion. Together, these documents indicate that coverage of issues specific to transgender people is both warranted and important.

Whilst it is beyond the scope of the present paper to outline in detail the contents of potential training materials and documents specific to mental health nurses working with transgender people, the following should serve as a guide to the types of issues typically addressed in similar documents. First and foremost, other mental health professional organisations have voiced opposition to discrimination against transgender people. This includes public and private discrimination based on actual or perceived gender identity or expression, including legal discrimination and its impact upon transgender people’s lives (Association of American Medical Colleges, 2014; ALGBTIC, 2009). Vocalising such opposition is thus a core agenda for mental health nurses, and in Australia would clearly meet the requirements of Standard 6, previously outlined.

In terms of specific skills for working with transgender clients, existing guidelines state the importance of using the preferred language of the client, such as in relation to pronouns and name (ALGBTIC, 2009; Association of American Medical Colleges, 2014; British Psychological Society, 2012; World Professional Association for Transgender Health, 2011). In addition, professionals are advised to be sensitive to ethical issues and challenges related to providing multiple psychological services, such as in both treatment and assessment (Australian Psychological Society, 2013).

Developing an adequate skill set requires developing an accompanying knowledge set. At its most basic, mental health nurses must be aware that being transgender is not indicative of a mental disorder (British Psychological Society, 2012), despite the diagnosis of ‘gender dysphoria’ appearing in the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-5). Professionals are advised to understand the current socio-political context (ALGBTIC, 2009) and how this informs their own attitudes about transgender issues, as well as how this context may more generally place clients at risk (British Psychological Society, 2012). It is also recommended that professionals be knowledgeable about the diversity of transgender people’s identities and experiences, and avoid assumptions about their clients’ decisions concerning medical interventions, including that they may or may not choose particular surgeries (Australian Psychological Society, 2013). Importantly, in order for changes such as these to occur, there needs to be a shift beyond that of the individual professional being responsible for acquiring additional knowledge, and towards one where the requirement for increasing skills is mandated by the registering body.

Nursing education provides a clear opportunity for training in regards to working with transgender clients. In Australia, the Australian Nursing and Midwifery Accreditation Council (ANMAC) is the accreditation authority responsible for accrediting education providers and programmes of study for the nursing and midwifery professions. The Nurse Practitioner Accreditation Standards (Australian Nursing and Midwifery Accreditation Council (ANMAC), 2015) were revised in 2015 after public consultations, yet whilst there are several mentions of ‘diversity’ in terms of culture, there is no mention of gender diversity or of working with transgender people. There would, however, be scope to include transgender issues under, for example, ‘Standard 2: Curriculum Framework’, ‘Standard 3: Program Development and Structure’ and/or ‘Standard 4: Program Content’. In relation to mental health nurses specifically, the ACMHN has an important role to play in ensuring the inclusion of knowledge and competency around transgender issues. Given that mental health nurses are already required to engage in continued professional development, mandating for this to include training in working with transgender clients would seem important.

In conclusion, it is important that any attempts at increasing the skills of the mental health nurse workforce to better meet the needs of transgender clients should include consultation with transgender people themselves, so as to be sure to identify what currently works well in practice, in addition to what needs improving. Whilst an increasing body of research has been conducted on mental health professionals in general, in terms of working with transgender clients and the experiences of clients themselves, the experiences of mental health nurses and the clients they work with has, to date, received little attention. Continued research that allows for the development of both evidence-based education and practice in the field is thus very much warranted.

Key points for policy, practice and/or research

Mental health nurses with more training are more knowledgeable about transgender issues.

There are potential differences across cohorts of mental health nurses that warrant closer attention, in regards to the impact of these differences upon competent service provision.

Training is neither currently mandated nor widely available to mental health nurses, in regards to transgender issues.

Guidelines and resources should be developed that mandate increasing the skill levels of the mental health nurse workforce, in terms of engaging with transgender clients.

Continued research is needed that considers the voices of both mental health nurses and their transgender clients.

Footnotes

Acknowledgements

We begin by acknowledging the sovereignty of the Kaurna people, the First Nations people upon whose land we live in Adelaide, SA, Australia. Thanks must go to Donna Hodgson for her helpful feedback about the credentialing of mental health nurses in Australia, and to the two reviewers whose positive and encouraging comments helped strengthen this paper.

Declaration of conflicting interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Ethics

The research reported in this paper was approved by the Flinders University Social and Behavioural Research Ethics Committee.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research reported in this paper was funded by a small grant from the Flinders University Faculty of Social and Behavioural Sciences.

Damien W Riggs is an Associate Professor in Social Work at Flinders University, and an Australian Research Council Future Fellow. He is the author of over 150 publications in the areas of gender, family and mental health, and he also works in private practice as a psychotherapist, specialising in working with young transgender people.

Clare Bartholomaeus is an adjunct Research Associate in the School of Social and Policy Studies at Flinders University. Her research interests include gender, diversity and childhood/youth. She is currently working on a number of projects about transgender issues in the areas of education and mental health.

References

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing.

American Psychological Association (2015) Guidelines for psychological practice with transgender and gender nonconforming people. Available at: www.apa.org/practice/guidelines/transgender.pdf (accessed 10 August 2015).

Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC) (2009) Competencies for Counseling with Transgender Clients, Alexandria, VA: ALGBTIC.

Association of American Medical Colleges (AAMC) (2014) Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who are LGBT, Gender Nonconforming, or Born with DSD: A Resource for Medical Educators, Washington, DC, USA: AAMC.

Australian College of Mental Health Nurses (ACMHN) (2010) Standards of Practice for Australian Mental Health Nurses, Canberra, Australia: ACMHN.

Australian Institute of Health and Welfare (AIHW) (2013) Mental health nursing workforce. Available at: mhsa.aihw.gov.au/resources/workforce/mental-health-nursing-workforce/ (accessed 17 August 2015).

Australian Nursing and Midwifery Accreditation Council (ANMAC) (2015) Nurse Practitioner Accreditation Standards 2015, Canberra, Australia: ANMAC.

Australian Psychological Society (2013) Guidelines on working with sex and/or gender diverse clients. Available at: www.psychology.org.au/Assets/Files/EG-Sex-gender-diverse-clients.pdf (accessed 18 August 2015).

Beagan

Chiasson

Fiske

(2013) Working with transgender clients: Learning from physicians and nurses to improve occupational therapy practice. Canadian Journal of Occupational Therapy 80(2): 82–91.

10.

Bowers

Lewandowski

Savage

(2015) School psychologists’ attitudes toward transgender students. Journal of LGBT Youth 12(1): 1–18.

11.

British Psychological Society (2012) Guidelines and Literature Review for Psychologists Working Therapeutically with Sexual and Gender Minority Clients, Leicester, UK: British Psychological Society.

12.

Carabez

Pellegrini

Mankovitz

(2015) Nursing students' perceptions of their knowledge of lesbian, gay, bisexual and transgender issues: Effectiveness of a multi-purpose assignment in a public health nursing class. Journal of Nursing Education 54(1): 50–53.

13.

Claman EE (2005) Construction and Validation of a ‘Counselor Knowledge of and Attitudes Towards Transgender Issues’ scale. Master’s Thesis, Ohio State University, USA.

14.

Department of Health (2013) National Practice Standards for the Mental Health Workforce. Victoria: Department of Health.

15.

Dorsen

(2012) An integrative review of nurse attitudes towards lesbian, gay, bisexual and transgender patients. Canadian Journal of Nursing Research 44(3): 18–43.

16.

Eliason

Dibble

DeJoseph

(2010) Nursing’s silence on lesbian, gay, bisexual and transgender issues: The need for emancipatory efforts. Advances in Nursing Science 33(3): 206–218.

17.

Evans

(2015) Proud: Lesbian, Gay, Bisexual or Trans Clients or Patients: Guidance for Nurses and Health Care Support Workers on Next of Kin Issues, London, UK: Royal College of Nursing.

18.

Kench T (2014) L.G.B.T. and mental-health nursing care: A qualitative research project. Polare, 93. http://www.gendercentre.org.au/resources/polare-archive/archived-articles/lgbt-and-mental-health-nursing-care.htm (accessed 4 October 2015).

19.

Kench T (2015) Towards sustainable equity in mental health services for LGBT people: A rhizomatic contribution from nurses constituted at n – 1. PhD Thesis, University of Canberra, Australia.

20.

Kline LI (2014) Health care provision to transgender individuals: Understanding clinician attitudes and knowledge acquisition. Master’s Thesis, University of Vermont, USA.

21.

Levesque

(2013) Nurse practitioners' knowledge, attitudes and self-efficacy for working with transgender patients. Clinical Nursing Studies 1(4): 93–100.

22.

McCann

(2015) People who are transgender: Mental health concerns. Journal of Psychiatric and Mental Health Nursing 22(1): 76–81.

23.

McNeil

Bailey

Ellis

(2012) Trans Mental Health Study 2012, Edinburgh, Scotland: The Scottish Transgender Alliance.

24.

Merryfeather

Bruce

(2014) The invisibility of gender diversity: Understanding transgender and transsexuality in nursing literature. Nursing Forum 49(2): 110–123.

25.

Rehbein RN (2012) Transition in conceptualizing the transgender experience: A measure of counselor attitudes. Master’s Thesis, Eastern Illinois University, US.

26.

Riggs DW, Coleman K and Due C (2014) Healthcare experiences of gender diverse Australians: A mixed-methods, self-report survey. BMC Public Health 14: 230–234.

27.

Royal College of Nursing and Public Health England (2015) Preventing Suicide among Trans Young People: A Toolkit for Nurses, London, UK: Royal College of Nursing and Public Health England.

28.

Royal College of Psychiatrists (2013) Good Practice Guidelines for the Assessment and Treatment of Adults with Gender Dysphoria, London, UK: Royal College of Psychiatrists.

29.

Shattell

Chinn

(2014) Nursing silent on LGBTQ health: Rebel nurses provide hope. Archives of Psychiatric Nursing 28(1): 76–77.

30.

Shipherd

Green

Abramovitz

(2010) Transgender clients: Identifying and minimizing barriers to mental health treatment. Journal of Gay and Lesbian Mental Health 14(2): 94–108.

31.

Strong

Folse

(2015) Assessing undergraduate nursing students’ knowledge, attitudes and cultural competence in caring for lesbian, gay, bisexual and transgender patients. Journal of Nursing Education 54(1): 45–49.

32.

Walch

Ngamake

Francisco

(2012) The Attitudes Toward Transgendered Individuals Scale: Psychometric properties. Archives of Sexual Behavior 41(5): 1283–1291.

33.

Walsh

Hendrickson

(2015) Focusing on the ‘T’ in LGBT: An online survey of related content in Texas nursing programs. Journal of Nursing Education 54(6): 347–351.

34.

World Professional Association for Transgender Health (2011) Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, http://www.wpath.org/uploaded_files/140/files/Standards%20of%20Care,%20V7%20Full%20Book.pdf (accessed 4 October 2015).

35.

Zunner

Grace

(2012) The ethical nursing care of transgender patients. American Journal of Nursing 112(12): 61–64.