When transgender patients arrive at a Novant Health hospital for gender affirmation surgery, it’s one of the most exciting days of their lives: Their body will finally conform to their gender. For many, it’s the moment they’ve dreamed of for years.

Procedures like this come with extra layers of communication for all involved. That’s where Novant Health’s transcultural health managers come in to help. The managers work to ensure all team members are prepared to work with patients from any culture or background to deliver the best possible experience. The prefix "trans" means across or beyond, and the title represents the commitment to understanding the cultural needs and beliefs of patients, and making sure these are communicated across all levels of care.

The importance of health care team members being “culturally competent” is a component of reducing health care disparities that can shorten the lives of people who face discrimination and disadvantages in everyday life. Learn more at the Transcultural Nursing Society.

In everyday terms, this means health care providers must learn to consider the perspectives and experiences of patients coming from a culture that may be far different from their own. Transcultural health managers have helped put Novant Health ahead of the curve in achieving this within health care in the U.S.

Cultural competency

In recent years, Novant Health recruited top plastic surgeons to perform gender-affirming surgeries. That made the cultural competency education – including the importance of using the correct pronouns – even more crucial.

Before a patient comes to the hospital for surgery, a transcultural manager meets with the patient and the health care team to make sure everyone uses the correct pronouns. If team members have questions or concerns, the manager is there to talk through all issues. If a team member doesn’t feel comfortable, then he or she doesn’t participate in the surgery.

One important step is making an "organ inventory” for the patient. For example, if the patient is a trans man – meaning born a female and transitioned to a male – they may still have a uterus. That’s important to include in the patient's medical records used by their doctor.

Welcoming all

Transcultural health managers educate team members on issues they may never have encountered. They do that, in part, through developing customized education and strategies that may relate to gender, race/ethnicity, age and other dimensions of diversity. It could involve something as commonplace as an accent that’s hard to understand or as complex as gender-affirmation surgery.

Novant Health’s LGBTQ Community Advisory Committee has helped educate the managers on a variety of questions and issues. And making all patients feel welcome is critically important when it comes to serving populations who have either faced discrimination or felt unwelcome, said Dana Thomson, co-chair of a Novant Health internal LGBTQ resource group.

“Care can be delayed when patients feel they are not welcomed, understood or heard,” Thomson said. “That’s the case for many members of the LGBTQ community.” And if they’re also a member of a minority that’s faced racism, the issue is further compounded.

Bottom line: Delays in care can mean medical problems are not discovered until conditions are further along and more difficult and expensive to treat, she said.

‘Honor and a thrill’

Katie Hackenbracht, pre-op clinical coordinator at Novant Health Center City Outpatient Surgery, often works with the transcultural managers. Her team performs breast surgeries on patients who are transitioning from male-to-female or female-to-male patients.

When the procedure was new to Novant Health, there was apprehension among some team members, Hackenbracht said. A manager gave the team the insight into the patient’s perspective and the new vocabulary they needed to ensure the patient felt welcome and well-cared for by the team.

Recently, Hackenbracht had a patient “who woke up in the recovery room (after breast surgery) and literally cried tears of joy.” She called it “an honor and a thrill” to be present for surgery that transforms someone’s life.

‘Respect and dignity’

Wendy Renedo

Wendy Renedo, a former transcultural manager who has moved on to a new position at Novant Health, is a fierce advocate for the transgender population. “My role (was) to educate and listen," she said. The education happens with every team member a patient might encounter. That starts with the person a patient sees when he or she arrives – often a volunteer at the front desk.

In April 2019, Renedo met Melissa, a 26-year-old from the Raleigh area who came to Novant Health Presbyterian Medical Center for the last stage of her transition – feminization facial surgery.

“She was just as excited as I was,” Melissa said. “She did a lot to reassure me that I would be treated with the same respect and dignity as anyone else.”

Melissa’s mom, Annette, said, “Wendy told me she’d be in the OR during surgery. And then she came to the waiting room to tell me Dr. Joel Beck had taken such good care of Melissa and that he even washed her hair so gently. I was amazed by the care everyone showed us. We felt really well treated.”

Melissa had gender affirmation surgery at a Raleigh hospital in 2016 – something she’d wanted since early childhood.

“We always knew there was something different with Melissa, but we just didn't know what it was," Annette said. "And to see how she's grown and become herself, it makes you wonder: Had we known earlier, could we have helped her before high school?"

Feeling different as a child and adolescent meant Melissa didn't experience many milestones, like high school prom. She had few guy friends and those she did have, she felt she could not relate to.

“I can remember in preschool getting to pick out toys from the toy box,” Melissa said. “I would pick a little Barbie doll and hide it because I was so scared someone would see and bully me. My sister and I would play Barbies together, and she would close the door so our dad wouldn’t see. ... For the longest time, I didn't think it was possible to be myself because the media used to only show trans people being ridiculed. I had only seen trans representation on Jerry Springer and shows like that – very negative portrayals.”

And so, she kept her story to herself.

“I’ve just been, I guess you could say, living stealth for a long time,” she said. “Back when I was going through my transition, I’d give updates on Facebook. I gave a speech for one of my psychology classes about being trans. But now I don’t post about it. I actually came out to one of my friends as trans a couple of months ago. That was the first time I had mentioned it in years.”

Revealing that she’s trans can change the dynamic. “If I tell friends I’m trans, they might not talk to me about stuff like periods and getting pregnant," she said. "And I don’t want to be excluded from those conversations. I can’t have children, but that doesn't mean I don't want to talk about that.”

If you don’t ask, you won’t know

It’s these nuances Renedo is aware of – and she makes Novant Health team members aware, too. Empathy is a job requirement. Renedo and her colleagues have to metaphorically walk a mile in someone else’s shoes.

“We realized our patients had no way to let us know – if they wanted to – their sexual orientation or gender identity on medical records,” she said. “And by not knowing, there were some health gaps in a patient population that’s already prone to experiencing disparities in their care. So, we began a project to make those fields available.”

It took a massive effort to create a cultural shift this size. “I created a computer-based learning module – ‘Know Me: Providing Inclusive Healthcare’ – to all 30,000 teammates that helps them understand why this is important,” Renedo explained.

Not all providers were aware, at first, that they even needed cultural competency education.

“I’ve had providers say to me, ‘I don’t have any patients in the (LGBTQ) population,’” Renedo said. “Once we revised our medical forms to include gender identity and sexual orientation, doctors would discover that this 70-year-old woman they'd been treating for 20 years is not married to a man – but to a woman.”