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As a family nurse practitioner (FNP) student, it is important to provide unbiased and culturally-competent healthcare services regardless of age, race, religion, socio-economic status, or gender orientation. Transgender is an umbrella term for individuals who identify with a gender different than what was assigned at birth (World Health Organization, 2018). As with any other subpopulation, transgender women come from all walks of life and are mothers, fathers, sisters, and brothers in their families. Despite their prevalence and presence all throughout history, they are classified as a marginalized population that struggle to receive inequitable healthcare due to their gender orientation (Bradford, Reisner, Honnold, & Xavier, 2013). The focus of this paper is to evaluate the marginalization of transgender women. It will include the current prevalence, socioeconomic aspects, social justice and its relationship to health disparities, ethical issues, plans for action to address the health issue, and conclude with a summary of key points.

Background
An individual’s gender identity is based on their personal judgement of whether they identify as male, female, or neither sex. Some transgender people identify themselves with their transitioned gender: female to male, male to female, or members of a third sex (World Health Organization, 2018). Legal identification documents that contradict a person’s birth gender may subject transgender individuals to punitive laws and discriminatory policies. According to the World Health Organization (2018), marginalized populations such as transgender women are often stigmatized and criminalized for their contradictory gender identity from their birth gender; affecting their ability to access health care services, social protection, and equal opportunity for employment. Transgender women are considered one of the five subpopulations that are disproportionately affected by HIV because their increased risk exposure (Divan, Cortez, Smelyanskaya, & Keatley, 2016). The other subpopulations that World Health Organization identifies are: intravenous drug abusers, men who have sex with men, sex workers, and prisoners. In some countries, transgender women are 49-80 times more likely to have HIV compared to non-transgender adults of reproductive age, an estimated 19% prevalence worldwide (World Health Organization, 2018). In addition to the HIV epidemic amongst transgender population, mental health issues including depression, anxiety, mood disorders, and suicidal ideations were the most commonly identified health issues in researched publications.

Another essential component for gaining wider recognition for transgender health issues is required revision of the International statistical classification of diseases and related health problems (ICD), the standard diagnostic reference for epidemiology, health management, and clinical practice. The current version, ICD-10, “gender identity disorders” were categorized under “mental and behavioral disorders”. The next edition, ICD-11, which is due to be published in 2018 will classify transgender health issues in a new category of “gender incongruence” (Robles, et al., 2016).

On June 29, 2015, Nevada became the 10th state that banned transgender discrimination in healthcare and insurance. Nevada State’s insurance commissioner determined that the state and administrative code would “prohibit the denial, exclusion or limitation of benefits relating to coverage of medically necessary health care services on the basis of sex as it relates to gender identity or expression” (National Center for Transgender Equality, 2015). This inclusion for transition-related healthcare has since made it more accessible for transgender individuals to move forward with gender assignment surgeries which were formerly not covered by health insurance carriers.

Socioeconomics
The ways in which marginalization impacts a transgender person’s life are interconnected to socioeconomics derivatives. Stigma and transphobia in the community hearten a society of isolation, poverty, violence, lack of socioeconomic support systems, and compromised health outcomes since each circumstance cohabits and exacerbates the other (Divan, Cortez, Smelyanskaya, & Keatley, 2016). This is pertains especially to those individuals who express their gender identity from youth, they are often rejected or outcast by their own nuclear families. This behavioral trend typically results in the lack of opportunities for education and further disregard to their need for mental and physical health needs. The hostile environment that envelopes the young transgender community fail to understand their needs and threaten their safety by being discordant to provide sensitivity to health and social requirements. Such discrimination and exclusion criteria fuel a sense of vulnerability, resulting in fewer opportunities to advance education, increased odds of unemployment, higher risk for homelessness and poverty (Lenning & Buist, 2013).

Transgender workers are the most marginalized in the workplace, often excluded from gainful employment and undergo severe discrimination during all phases of the employment process (including recruitment, training, benefits, and advancement opportunities) (Divan, Cortez, Smelyanskaya, & Keatley, 2016). These workplace adversaries incubate pessimism and internalized transphobia in transgender people and ultimately discourage attempts to applying to many professional careers. Extreme limitations in employment often lead transgender people to uphold positions that have limited opportunities for career growth and development such as beauticians, entertainers or sex workers. The high prevalence of unemployment and low-income, high-risk unstable jobs promote the cycle of homelessness and poverty. In 2016, a socioeconomic study reported the estimated annual incomes of two groups: A – socioeconomic and racial privileged (n=239; transgender, with associate’s degrees and were non-Latino, White), B – educational privileged (n=191; transgender, with bachelor’s degrees and people of color). Group A reported annual household incomes of $60,000 or more and Group B reported total household incomes of $10,000 or less per year (Budge, Thai, Tebbe, & Howard, 2016).

Social Justice
The transgender society continue to endure adversarial challenges despite the increased social awareness of gender orientation and gender identity portrayed in media, news, politics, and even early education in recent years. The ever growing prevalence of the lesbian, gay, bisexual, transgender, queer (LGBTQ) community’s presence in society continue to surpass the rate of open-mindedness and acceptance amongst coexisting citizens and is demonstrated by unequal societal structures (Budge, Thai, Tebbe, & Howard, 2016). The antagonistic perceptions they endure from the public are linked to ambiguity in gender – the binary classification of identification and differentiation in western society (Neufeld, 2014). The severity of marginalization deepens when transgender individuals reside in smaller remote communities where resources are limited and the prominent impact of colonization isolate transgender individuals. The collective consequence of family, social, and institutional transphobia contributes to the increased risk of mental health issues, frequency of substance abuse, and prevalence of sexually transmitted infections within the transgender population (Lenning & Buist, 2013). Social justice for transgender patients in healthcare should translate to the equally entitled fair distribution of healthcare resources with unbiased regard to their gender identity, preferred name in the electronic medical record (EMR). Furthermore, billing for medical procedures should be exceedingly scrutinized to ensure that the billing name and pronoun match the patient’s insurance identity (Hann, Ivester, & Denton, 2017).

Ethical Issues
The principal ethical issue that concerns the transgender community is the inequality of healthcare access. Transgender individuals that contribute to the society should be provided equal access to healthcare as a non-transgender individual who mirrors the same type of existence in society. Transgender care should have equal focus in medical education, research and funding. Extending to healthcare access for transgender inmates in prison, Amendment VIII of the United States Constitution should be enforced. “Excessive bail should not be required, nor excessive fines imposed, no cruel and unusual punishments inflicted” (United States Constitution, Amendment VIII).

Plan for Practice
Considering that Nevada is one of ten states that passed a law which bans discrimination of transgender persons in healthcare and insurance, it is imperative to have a plan for practice that echoes the same intent. Forecasting the future as an FNP in the clinic setting, the three actions for practice that I plan to implement are: 1) Encouraging of cultural competency training amongst staff in regards to LGBTQ population. This includes incorporating written nondiscrimination statements specifically to protect transgender rights (Hayhurst, 2016). This can be measured implementing an annual competency written test, to assess retained knowledge and also provide opportunity to refresh their practice. Another method of outcome measurement can be the report card from a transgender (secret-shopper) patient’s care experience. 2) Establishing transgender-friendly environment from arrival. Offering small clues such as a rainbow sticker or flag at the check-in counter or adding LGBTQ community literature