Date of Award

Summer 6-2023

Scholarly Projects

Projects: SPU Access Only

Degree Name

Doctor of Nursing Practice (DNP)



Faculty Chair

Dr. Chanam Shin

Faculty Reader

Dr. Chanam Shin

Executive Summary

Executive Summary

Background and Significance: Hormone replacement therapy (HRT) has been sought by transgender and nonbinary individuals to help alleviate the distress related to the incongruity of one's sex assigned at birth and gender identity (Jones et al., 2019). However, there are barriers to accessing care, specifically a lack of healthcare professionals providing gender-affirming care (Puckett et al., 2018). Guidelines for HRT have been in place but not consistently used because of healthcare professionals' varied training. The protocol can be followed to provide safe, effective, sensitive, and inclusive care to the transgender and nonbinary population (World Professional Association for Transgender Health [WPATH], 2012).

Problem and Purpose Statement: Gender-affirming treatment, specifically HRT, has been at the forefront of gender dysphoria treatment (Meyer et al., 2020). The goal of this treatment is to develop the physical characteristics of the affirmed gender. However, the lack of access to gender-affirming care and the availability of competent providers willing to provide hormone therapy are barriers for those seeking treatment (Puckett et al., 2018). The project site, a local hospital in Seattle, Washington, found that about 25% of all their LGBTQI+ patients are seeking HRT, but there is a lack of providers that prescribe HRT. This DNP project introduced a standardized HRT protocol in a local health system's primary care group as a guidance and education tool to increase the healthcare provider's competency in delivering gender-affirming care.

Methods: This DNP project evaluated a pilot educational program with the project hospital and its LGBTQI+ Initiative team and it was guided by the Extension for Community Healthcare Outcomes (ECHO) Model and the Theoretical Domains Framework. The three-hour educational session regarding transmasculine HRT was hosted virtually by the Medical Director of the LGBTQI+ Initiative, with the participants being primary care providers within the project hospital's network. A 25-item survey questionnaire covering cultural and clinical competence regarding transgender care was handed out before and after the intervention and the collected data were examined for the efficacy of the educational session.

Results/Outcomes: There was an improvement in cultural and clinical competence in delivering gender-affirming care. Regarding cultural competence, the pretest mean score was 19.40 (SD = 1.52), while the posttest mean score was 21 (SD = 1.41). There was also improvement in clinical competence. The pretest mean score was 68.2 (SD = 4.92), and the posttest mean score was 70.6 (SD = 2.30).

Sustainability: The ECHO program is designed to continue the learning and communication among the participants by having a quarterly meeting and presenting case studies. The current plan is to add a cohort yearly to recruit more providers comfortable prescribing HRT. In addition, the results of this pilot program will be incorporated into improving future HRT educational programs within the project site. The project site's LGBTQI+ Initiative Team has the support and funding from the organization and plans on continuing the ECHO Program indefinitely.

Implications: This DNP project can contribute to the growth of the LGBTQI+ Initiative at the project site. This can foster a culture change within the project site's organization which means more LGBTQI+ related training for healthcare providers to establish trusted relationships with the transgender and nonbinary community. Improvement in patient care can increase patient satisfaction and quality of care (WPATH, 2012). Furthermore, including multiple disciplines such as medical doctors, nurse practitioners, physician assistants, and pharmacists in the educational intervention can establish a provider referral network for transgender and nonbinary patients within the Puget Sound area. A regional network can create an environment of learning and different opportunities for clinical innovation across various community-based organizations and other healthcare providers.


Jones, B. A., Bouman, W. P., Haycraft, E., & Arcelus, J. (2019). Gender congruence and body satisfaction in nonbinary transgender people: A case control study. International Journal of Transgenderism, 20(2-3), 263-274.

Meyer, I. H., Brown, T. N. T., Herman, J. L., Reisner, S. L., & Bockting, W. O. (2017). Demographic characteristics and health status of transgender adults in select US regions: Behavioral risk factor survey system, 2014. The American Journal of Public Health, 107(4), 582-589.

Puckett, J. A., Cleary, P., Rossman, K., Newcomb, M.E., & Mustanski, B. (2018). Barriers to gender-affirming care for transgender and gender nonconforming individuals. Sexuality Research and Social Policy, 15(1), 48-59.

World Professional Association for Transgender Health. (2012). Standards of care for the health of transsexual, transgender, and gender-conforming people.