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.
But procedures like this come with extra layers of communication for all involved. That’s where Wendy Renedo (pronounced ruh-NAY-doe) comes in. Trained as a nurse, she’s become one of Novant Health’s four transcultural health managers, positions created in 2017. Two are in Winston-Salem, and Renedo and one other are in Charlotte.
She and her colleagues work to ensure health care providers and team members are prepared to work with patients from any culture or background to deliver the best possible experience. The “trans” in the title is not referring to “transgender,” but rather a focus on understanding the cultural needs and beliefs of patients.
The importance of health care team members being “culturally competent” has gotten more attention in recent years in the effort to reduce 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 learning to consider the perspectives and experiences of patients coming from a culture that may be far different from their own. And the creation of these positions has put Novant Health ahead of the curve in health care in the U.S.
There for patients and team members
In recent years, Novant Health has recruited top plastic surgeons to begin performing gender-affirming surgery. That made the cultural competency education – especially the importance of using the correct pronouns – even more crucial.
Before a patient comes to the hospital for surgery, Renedo meets with the patient and the health care team who will care for the patient. Renedo will have team members role play with her using the appropriate pronouns for an upcoming patient. “I advocate for patients, but I always make sure team members know I'm there for them, too. If they have any questions or concerns, they can talk to me, and I'm 100% open to hearing them without judgment.”
“One of the things we’ve started doing with transgender patients is an organ inventory,” she said. “If the patient is a trans man, for example – meaning born a female and transitioned to a male – they may still have a uterus. That’s important to know.
“To ensure continuity of care, I now put all that information in the medical record,” she continued. “Now, the very first person the patient meets has all the pertinent information that they need to care for the patient and the person isn’t going to ask uncomfortable questions.”
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 helped Renedo navigate and better understand the ways that Novant Health could meet the needs of the LGBTQ population. “They let me ask questions with zero judgment.”
“Most of the time, it’s just that our staff has never encountered whatever the situation is they’re about to encounter,” Renedo said. “If there’s a team member having a concern related to any dimension of diversity – it could be generational or religious or just lack of exposure – I meet with the whole team, do an assessment and then build an education program.”
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, works with Renedo regularly. 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. Renedo 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’
Patients and staff alike are grateful for Renedo’s guidance. “She was just as excited as I was,” said Melissa, a 26-year-old from the Raleigh area who came to Novant Health Presbyterian Medical Center in April 2019 for the last stage of her transition – feminization facial surgery. “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. “I can remember in preschool getting to pick out toys from the toy box,” she 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,” she continued. “Growing up, a lot of my friends were girls. The few guy friends that I did have, I didn't really feel like I could relate to. 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. 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 those 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.
“About a year ago, 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.”
Health care for everybody and every body
“Inclusion is about creating an environment where everyone feels valued and can receive the care they need,” said Tanya S. Blackmon, an executive vice president and chief diversity, inclusion and equity officer at Novant Health. According to a major U.S. health initiative, health equity is the attainment of the highest level of health for all people, and this definition aligns with the Novant Health mission.
To better individualize personalized care, Novant Health now collects less visible characteristics of diversity, such as sexual orientation and gender identity, in addition to visible characteristics like a patient’s race/ethnicity or gender.
“For us, the beauty of looking at both the less visible and visible characteristics is that you see and understand the whole person. Not just what you see, but what you can’t see, as well,” Blackmon said. “Understanding those differences allows us to create environments where there’s trust, a sense of belonging, commitment to and a mutual respect for each other.”
An advocate for everybody
Renedo has become a fierce advocate for the transgender population. “I started by broaching the subject with our pre- and post-op teams,” she said. “My role is to educate and listen.” If a team member doesn’t feel comfortable, then he or she doesn’t participate in the surgery.
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.
Before COVID-19, Renedo was meeting every patient scheduled for gender-affirmation surgery when they arrived in the OR. “I made sure I was there before the patient got there,” she said. “I would often go in for part of the surgery and then would end up sitting with the family – and listening. These patients and their families have very complex stories, and sometimes very difficult stories.”
Annette, Melissa’s mom: “We always knew there was something different with Melissa, but we just didn't know what it was. 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? She used to be so shy; she didn't go to prom. She didn't do any of the milestone things you do. She’s experiencing all these things for the first time.”
Renedo and her colleagues also help bridge misunderstandings that may occur because of generational or racial differences. “We definitely see changes in people after we’ve worked with them,” she said. “There's nothing better than walking out of a consult and feeling that people opened up and shared themselves.”
“The No. 1 thing I can do in this role is to be vulnerable,” she said. “I often share my own story about having a special needs son and being a single mom. I put it all out there.”