PROFESSIONAL ISSUES
How stigma affects healthcare
access for transgender sex workers
Kirsten Roche and Corey Keith
T
here has been recognition that stigmatisation is a major
contributor to physical and emotional illness among
transgender sex workers (TSWs) (Mulia, 2002; Slamah
et al, 2010; Grant et al, 2011; Houston, 2011; Zunner
and Grace, 2012). Likewise, it is well-known among health
professionals that nurses are in a unique and powerful position
as leaders and as frontline healthcare workers to improve the
quality of life and health outcomes for many clients, including
TSWs. Despite this, the unique needs and experiences of the
TSW population are largely overlooked in nursing education
curricula and in the continuing education of nursing graduates.
It is not surprising, therefore, that according to some researchers,
TSWs often report that nurses discriminate against them,
largely because of a lack of understanding and knowledge
of TSWs’ needs and experiences (Mulia, 2002; Slamah et al,
2010; Thornhill and Klein, 2010; Zunner and Grace, 2012).
The purpose of this article is to draw on published literature
to highlight what nurses need to know and understand about
TSWs to provide respectful, sensitive care to this population.
The article will begin by providing an overview of
transgender sex work, including why the proportion of
transgender people who have experience working in the
sex industry is so high compared with that of the general
population, and how the stigmatisation of TSWs among nurses
can compromise their health and wellbeing. The article will
then discuss the research findings: how TSWs feel healthcare
workers stigmatise them; the various reasons that have been
proposed why stigmatisation of TSWs is so prevalent; and how
the stigmatisation of TSWs by nurses negatively affects their
access to, and willingness to engage in, the healthcare system.
In conclusion, the article will identify the implications of this
literature for nursing practice and education.
Definitions of terms
Transgender people
Transgender people are:
‘Those whose psychological self (“gender iden-
tity”) differs from the social expectations for the
physical sex they were born with’ (Gender Equity
Resource Center, 2014).
The individual may or may not have undergone sexual
reassignment surgery (formerly called ‘a sex change’) or
choose to live daily as a member of the sex s/he identifies
© 2014 MA Healthcare Ltd
with. The term ‘transgender’ can encompass a wide variety
of lifestyles and ideas of self, and whether one identifies with
the term depends on personal circumstances and individual
ideas about gender identity.
British Journal of Nursing, 2014, Vol 23, No 21 
Abstract
Stigmatisation of transgender sex workers (TSWs) has been recognised
as contributing to illness and poorer health outcomes for this
population. It could be argued that part of this stigma comes from
nurses. With their frequent face-to-face interactions with their clients,
nurses come from a unique place of power to influence the health
outcomes and the feelings and thoughts that transgender sex workers
have about the healthcare system in general, and whether or not
they feel safe accessing it. Because there is very limited literature that
explores stigmatisation of TSWs on the part of nurses, the needs of
TSWs are scarcely being addressed. This article addresses why a higher
proportion of transgender people participate in sex work compared
with people in the general population; how stigmatisation by nurses
affects access to healthcare resources for TSWs; why nurses experience
stigmatising thoughts and beliefs; and how nurses can create a positive
impact on TSW clients. The authors have found that, although there
are a number of complex reasons for bias and stigma, it is extremely
important for the health of these clients that nurses put empathy,
sensitivity and compassion at the forefront of their practice.
Key words: Transgender ■ Stigma ■ Sex work ■ Sex workers
■ Health care ■ Stigmatisation
Sex worker
A sex worker is a person who receives money or goods in
exchange for sexual services (Overs, 2012).
Stigma
Stigma can be defined as:
‘The process of marginalising a group or class
of people by others in a more powerful position
by labelling them as different and understand-
ing them in terms of stereotypes. This results
in the loss of social status and discrimination,
and affects many areas of life for those who are
stigmatised’ (Hartney, 2010: 1).
Kirsten Roche, Fourth Year Nursing Student, Thompson Rivers
University; Corey Keith, Postgraduate Candidate in Education,
Thompson Rivers University, British Columbia, Canada
Accepted for publication: October 2014
1147
 The Canadian Mental Health Commission (2014)
describes it as ‘a complex social process that marginalises
and disenfranchises people,’ while ‘prejudicial attitudes and
discriminatory behaviours fuel inaccurate notions’ about
them (Langille, 2014).
He or she?
Although TSWs may be of different genders and sexes, for
the purposes of readability, TSWs will be referred to by the
feminine subject pronoun ‘she’. At the time of writing, the
authors were unable to find any literature that addressed
female-to-male TSWs.
Sex work and transgender individuals
It is estimated that 6% of the world’s sex workers are
transgender (European Network for HIV/STI Prevention
and Health Promotion Among Migrant Sex Workers, 2009).
In contrast, while it is extremely difficult to determine what
percentage of the world’s population is transgender (due
to variable ‘self-labelling’ practices among individuals and
to the fact that so many transgender people hide that part
of their identity out of fear of discrimination or violence),
it has been estimated that in the USA, only about 0.3% of
the population is transgender (Gates, 2011). A 2013 study
found that 16% of transgender people from Ontario, Canada,
reported having engaged in sex work or exchange sex at least
once (Bauer et al, 2013).
There are a number of reasons why sex work attracts
such a high proportion of transgender people. The most
commonly reported reason is the lack of job opportunities
for people who identify as, or especially live as, a member
of their non-biological sex. Many transgender (also referred
to as ‘trans’ for short) people leave school early as a result of
bullying, limiting both job and post-secondary education
prospects (Slamah et al, 2010;Tucker, 2011). A survey of 6450
transgender people released in 2011 by the National Center
for Transgender Equality and the National Gay and Lesbian
Task Force in the USA found that ‘90% of respondents had
reported harassment or discrimination on the job’, and ‘47%
said they had been fired, not hired or denied a promotion
because of being transgender’ (Grant et al, 2011: 3).
Self-esteem and self-concept also play a major role in
the decision to enter into sex work (Tucker, 2011). In all
countries, from India and Russia to Kenya and Canada,
there are TSWs. However, there are few positive role models
or roles in society for this population—at times, the only
obvious trans people that can be seen are indeed sex workers.
Not only that, but people who use their services are often
ashamed to be found engaging in sexual relationships with
TSWs, so may outwardly reject the advancement of rights
for these populations. This objectification, sexualisation
and depersonalisation of transgender people has a very
negative effect on the self-worth of the group as a whole,
and individuals may see sex work as their only viable option
(Slamah et al, 2010).
Finally, some transgender people come to North America
from places such as Latin America and Southeast Asia in
search of work, or to escape the violence against them
in their home countries. Some arrive with a low level of
1148
formal education or with language barriers, and are forced
to resort to sex work (Slamah et al, 2010). This group is
triply stigmatised—being trans, sex workers and immigrants
or from ethnic minorities—and has the added risk of being
uninformed about Canadian law and unaware of available
health care, language, educational and legal resources available
to them (Slamah et al, 2010).
Consequences for the health of TSWs
of nurse stigmatisation
Stigma, discrimination and prejudice from nurses affects
access to health care in a multitude of ways, and can have
significant effects on health outcomes for TSW patients.
One of the primary concerns relating to the health of
TSWs who have experienced discrimination in a healthcare
setting is that they tend to delay seeking medical care
in the future. Blanchard and Lurie (2004) found that
31% of patients who felt ‘disrespected’ by care providers
delayed seeking medical care. The National Transgender
Discrimination Survey in the USA found similar results,
with 28% of transgender survey respondents reporting
that they had postponed medical care due to fear of
discrimination (Grant et al, 2011: 4). A Canadian study
found that 21% of trans Ontarians reported avoiding
the emergency department when emergency care was
required due to fear of discrimination on grounds of their
transgender status (Bauer et al, 2013).
Delaying medical care until the need is urgent can mean
waiting until a seemingly insignificant medical issue becomes
serious and often more difficult to treat, or even life-
threatening. Localised infections may enter the bloodstream,
important treatment measures for chronic conditions may be
ignored, and sexually transmitted infections (STIs) or HIV
testing may be postponed due to fear. This may increase the
risk that the patient passes the virus or infection on to her
sex-trade clients. One TSW explained:
‘I used to get tested every 3 months prior to
working in the sex industry, as I believed it
was always a good idea to stay safe and inform
partner(s) if anything did happen. However, as a
trans individual, I was hesitant to go to the clin-
ics as you never know the criticisms you might
get from staff or doctors. For one, you never
know who you are going to get—one week you
could get a real positive person and another you
could be getting someone that is real sex nega-
tive or transphobic. Once I started sex work I
put it off or avoided getting checked because I
just don’t want to deal with the judgement from
the staff. If I got this much grief and negative
attitude just for being trans and getting an STI
check, I could only imagine what would be the
judgements if I told them I am a sex worker.
Today, I still have not told my family doctor for
© 2014 MA Healthcare Ltd
the same reason’ (‘Amy’, Central Interior Region
of British Columbia, Canada: personal commu-
nication, 2013)
Stigmatisation by nurses can influence how much
British Journal of Nursing, 2014, Vol 23, No 21

information a patient is willing to share about their health
and their life. Chapmen et al (2011) noted that when a
person feels disrespected by healthcare workers, she can
easily lose the sense of trust she has towards those workers,
or not develop one at all. Once that has happened, she will
be less likely to share information that is important in order
to provide the best possible care. Employment, lifestyle and
relationships affect one’s health greatly, and the less that the
patient discloses about those areas of her life, the less likely
the nurse is to know what kind of resources, information
or support the patient needs. This could also potentially
contribute to misdiagnosis. One TSW said in an interview
about her healthcare experiences:
‘If you’re already transgender, often you’re going
to hide the sex work part of things. Why would
you want to add more stigma? Many don’t
want to be in the line of work and are ashamed
already—they’re self-stigmatising … they don’t
want to add stigma from others as well. You’re on
your guard when sharing information’ (‘Amy’,
Central Interior Region of British Columbia,
Canada: personal communication, 2013)
Because care delays, mismanaged pain and inadequate
information about patients can worsen health outcomes,
nurses have a responsibility to prevent these things from
happening (Zunner and Grace, 2012). Nurses are in an
excellent position, with their relational skills and frequency
of direct patient care, to provide support and help for this
group of patients.
The reasons for stigma of TSWs among nurses
There are numerous factors that contribute to nurses’
stigmatisation of TSWs. The stigma may be due to the
individual’s transgender status, the type of work she is
involved in, the lifestyle she lives, or other factors.
According to Zunner and Grace (2012: 62), reasons for
discrimination may include ‘discomfort, prior experience,
unexplored prejudice, immaturity, poor self-esteem and so
on’. Other reasons may include parental or family attitudes,
religious and cultural beliefs, and fear. Chapman et al (2011)
found that nursing students were less or more supportive of
lesbian, gay, bisexual and transgender people depending on
the student’s race, sex, religious beliefs, attendance at religious
services, and having a friend who is openly gay, lesbian,
bisexual or transgender, with Caucasian women who do not
consider themselves religious being the most supportive.
Prior experience
A common reason for discrimination against this population
is discomfort, resulting from lack of understanding, or prior
interaction with transgender people or sex workers. If a
nurse has never knowingly interacted with a transgender
person, the experience can leave the nurse at a loss. Meeting
someone who does not follow the traditional gender roles
© 2014 MA Healthcare Ltd
for that society—for example, a biological man who wears
clothing that is typically reserved solely for women, or acting
in a manner typically expected only of women—can cause
feelings of discomfort for some people. In this case, exposure
British Journal of Nursing, 2014, Vol 23, No 21 
PROFESSIONAL ISSUES
to a new situation (i.e. dealing with someone who has had
life experiences that one has not considered before) can result
in the nurse feeling unclear on what to say—for example,
by which gendered words to address the patient (sir or
madam?) and how to act. Lack of knowledge is another
challenge for nurses: not knowing what resources are
available to these individuals in each community, or what
their specific needs may be, can easily lead to frustration and
avoidance (Foster and Richmond, 2003).
Unexplored prejudice
Some nurses may perceive themselves as open-minded and
supportive of all people’s differences, but then are presented
with a situation that challenges their openness to non-
traditional views of gender. Perhaps on a purely cognitive
level, they believe that everyone is entitled to live as they
wish, but when put in the situation of working with a TSW,
they experience a surprising emotional reaction and find
themselves unable to support the patient adequately or quell
their own judgements.
In this situation, it is very important for nurses to reflect
on why they are uncomfortable or what in their lives has
contributed to the development of these feelings. Exploring
this through self-reflection can help nurses to understand their
own reactions, and what can be done about them. It can be
helpful for the nurse to engage in discussions with someone
they trust and feel comfortable with, in order to gain a deeper
insight into the reasons for their negative feelings. Doing even
a small amount of research on the challenges TSW face in
society can also help nurses to become more empathetic to
the struggles and humanity of their TSW patients.
Fear
Fear of being ‘hurt’ by the patient is one reason why nurses
stigmatise marginalised or disenfranchised populations
(Maze, 2005). The prevalence of HIV for TSWs is higher
than it is for other sex workers, and significantly higher than
it is in the general population (Operario et al, 2008). There
are many reasons for this. Inconsistent use of condoms is
one, due in part to a saturated sex market (where, if the
TSW insists on wearing a condom, the client may simply
go to another sex worker who does not). Another reason
is the sharing of needles used for injection drugs, silicone
injections (Slamah et al, 2010), or hormones that may be
either prescribed by a physician or bought on the black
market (Thornhill and Klein, 2010). Although needle
exchanges are funded by provincial governments and are
common in Canadian cities, rural communities sometimes
do not have them at all or have exchanges that are only
open on certain days of the week and at certain times,
thereby limiting access. Lack of knowledge of Canadian
law with regard to drug use also prevents people from
accessing needle-exchange services. Although purchase and
possession of clean needles is legal in Canada, possession of
drug ‘paraphernalia’ is illegal, and the fact that the law does
not include needles in its definition of paraphernalia is not
known by many drug users (Klein, 2007).
One final reason for increased HIV rates among TSWs
is that the risk of HIV transmission while receiving
1149
 anal intercourse from an infected person is approximately
18 times higher than receiving vaginal intercourse from the
same (Dotinga, 2012).
Due to the increased risk of developing a blood-borne
virus as a result of sex work, nurses may fear transmission
when working with these patients, even without knowing the
individual’s HIV or hepatitis status.
Perceived difficulty of providing care
Some nursing and healthcare staff have stigmatised sex
workers (especially if they are also drug users) by labelling
them ‘difficult patients’. This is due in part to their sometimes
complex medical or psychosocial challenges and ‘special
needs’, their perceived levels of motivation, and their general
attitudes (Mulia, 2002).TSWs may be perceived by healthcare
workers as having more complex needs than the general
population, both physically and psychosocially. Perceptions
about how motivated the patient is to take care of her own
health, to access community resources, to leave sex work
and to adhere to medical advice or treatment, can lead to
frustration and judgement on the nurse’s part (Mulia, 2002).
General attitudes of the patient toward the healthcare system,
healthcare workers, or self-care practices, can also be seen by
nurses as contributing to making the patient more difficult to
work with (Mulia, 2002).
Enactment of stigmatisation
One serious problem with stigmatisation is that the person
being stigmatised is often looked at as though any problems
that arise have been brought on himself or herself (Halter,
2008). When nurses have these feelings towards a patient, it
can result in devaluation of the patient as an individual and
inequitable treatment or suboptimal care.
According to the National Transgender Discrimination
Survey (Grant et al, 2011), the statistics of transgender people
experiencing discriminatory treatment by medical professionals
are substantial: 11% of participants in the survey reported being
given unequal treatment in a mental-health clinic; 13% were
treated unequally in an emergency department; 24% reported
experiencing unequal treatment in a hospital or doctor’s office;
and 19% of people taking part in the survey reported being
refused medical care due to their gender status.
Implications for nurses
Reserving judgement
The preceding discussion points to the need for all nurses to
support and advocate for the rights of TSWs who need health
care. Establishing a therapeutic and trusting relationship
with individuals who have experienced a large amount of
discrimination in their lifetimes can be challenging, but is of
the utmost necessity in order to provide optimal care. Part of
developing a trusting relationship is being non-judgemental
and open to the patient.
In the words of Zunner and Grace (2012: 62), the most
important thing to remember when treating any patient is
to ask oneself, ‘Who is this person in front of me? What has
brought her to these circumstances?’ While moving past one’s
own opinions, values and biases is not always an easy task, it
is a nurse’s professional responsibility to provide optimal care
1150
for each and every patient, no matter what the nurse thinks
of the patient’s experiences and characteristics.
It is crucial not to make assumptions when working with
TSWs, and to recognise that TSWs have as many unique
experiences as every other human being, and come from
all walks of life. Some are IV drug users, but many do not
touch drugs or alcohol, or use them only rarely. Some work
on the streets, some work in ‘agencies’ or in their own home;
some may have dropped out of secondary school, while
others might hold university degrees. While nurses need to
understand at least some of the social and health issues that
TSWs face, they also need to recognise that these factors are
not ‘one size fits all’. Each person has her own experiences;
assuming that everyone in a group has the same experiences
can be as condemnatory as not knowing anything about the
issues to begin with.
Because human communication is so much more than
simply verbal, nurses must be aware of their body language
and facial expressions, and try to avoid expressions that could
be interpreted as judgemental or uncomfortable. It has been
estimated that up to 80% of human communication relies on
non-verbal communication (Roberson, 2010). This includes
body language, facial expression and gestures; plus tone,
volume, speed and inflection of voice. Making eye-contact,
giving occasional affirmative nods, and avoiding bored or
nervous gestures such as fidgeting or allowing one’s eyes
to wander the room can help show patients that you are
interested in what they are trying to communicate (Preston,
2005). While this is important when dealing with all patients,
it has an especially strong effect when working with patients
who belong to marginalised groups.
According to the Canadian Mental Health Association,
gay, lesbian, bisexual and transgender youth are 14 times
more likely than heterosexual youth to develop substance
abuse issues (Canadian Mental Health Association, 2014).
For transgender patients who are struggling with addiction,
or who have a prior history of substance dependence, it
is important to be aware that increased tolerance to pain
medication is a possibility. In addition, those on methadone
treatment are likely to be even more difficult to treat
for pain. According to Hines et al (2008: 1), patients
on methadone maintenance programmes are sometimes
given less opioid analgesia than the typical patient who
is experiencing acute pain, ‘due to requests for analgesia
being misinterpreted as craving for drugs’, but pain studies
have shown that patients on methadone maintenance have
hyperalgesic responses to pain, and that the potential for
cross-tolerance to other opioids may exist. This suggests that
patients on a methadone programme, or who have a long
history of opioid use, do indeed require higher doses of
analgesia to achieve adequate pain relief. Hines et al (2008)
also showed that for patients on methadone maintenance,
insufficient pain relief can be a large factor in behavioural
problems and early discharge.
© 2014 MA Healthcare Ltd
Establish an environment of safety
Establishing an environment of safety for marginalised
patients is a critical factor for offering supportive care. This
contributes to developing trust and helping the patient to
British Journal of Nursing, 2014, Vol 23, No 21

feel that she can be honest and open with her healthcare
providers. One of the best ways to achieve this is to include
the patient in her own care, and to ask her how she can best
be supported.
For example, gender pronouns are something in transgender
people’s lives that can make them feel excluded and
disrespected if used improperly. According to author and
trainer on transgender issues, Matt Kailey, generally it is
appropriate to use the pronoun that fits with the gender the
person is ‘presenting’ (Kailey, 2014). For example, if the person
is wearing a dress or is clearly dressed in clothes traditionally
thought to belong to women, it should be assumed that this
person would prefer to be referred to as ‘she’. However, the
very best thing is to ask the patient directly.
Some transgender individuals prefer male pronouns; some
prefer female; others prefer lesser-used, non-binary pronouns
such as ‘ze’ or ‘zir’ in place of ‘s/he’ or ‘his/her’. Non-binary
pronouns (i.e. neither definitively male nor female) can be
especially preferred by transgender people who do not present
in gender-normative ways. If other patients are around, bring
the patient to a private place to avoid making her feel
uncomfortable during the discussion. For the majority of
transgender people, being asked which pronoun they prefer
shows respect for the individual, and it shows them that they
have an ally among the staff, or at least someone with whom
they can feel safe (Kailey, 2014).
Discrimination or inappropriate staff comments
According to the Ethical Nursing Care of Transgender
Patients, if you witness discrimination or inappropriate
comments made by other staff or patients in front of the
patient, there are several things that can be done. The first
option is to speak privately with that staff member later in
the day and raise your concerns. If this is not possible, or
you do not feel confident addressing the other staff about it,
the unit manager should be asked to discuss the importance
of treating all patients with respect. Equally imperative, if
not even more so, is to discuss it with the patient, if she is
willing. Explain that you saw what happened, that it was
inappropriate, what you are going to do about it, and that
you are sorry it happened. Ask her what she needs to feel safe,
what you can do for her. Be sure to remind her to let you
know if she experiences anything else like that while there. If
this type of behaviour becomes a regular problem on the unit,
it is important to speak to the nurse manager of the unit, or
to the governing body of nursing in your province, state or
county (Zunner and Grace, 2012).
Know the issues
Awareness of the high rate of domestic and partner abuse,
as well as other forms of abuse, is key. Assessments for abuse
and for mental health should be conducted. Nurses should
discuss violence-prevention strategies with the patient and,
if the patient is suspected to have been abused, the nurse
may discuss it with the patient and, if appropriate, notify the
© 2014 MA Healthcare Ltd
on-staff social worker if one is available.
Having at least a preliminary understanding of the issues
mentioned in this article, and other issues that relate to
TSWs, as well as being aware of the barriers that TSWs
British Journal of Nursing, 2014, Vol 23, No 21 
PROFESSIONAL ISSUES
face when accessing health care and other resources, can
help to broaden nurses’ understanding of the challenges
this population faces and help them to see things from
a compassionate standpoint. Knowledge of some of the
resources that are available in a particular community to
transgender people and to sex workers is another important
tool that can assist each nurse in being able to connect TSW
patients with the support they need.
Finally, if a nurse finds herself unable for whatever reason
to provide compassionate and non-judgemental care to TSW
patients, it is important that she knows when it is time to get
another nurse to take over care of that patient.
Conclusions
Working with TSWs does not need to be difficult, but it does
require sensitivity, empathy and an interest in providing
optimal care to a population that has in the past been (and
continues to be) treated with prejudice and ignorance. Nurses
are in an excellent position to create positive, therapeutic
relationships with their TSW patients. Success in this area can
have an impact not only on short-term health outcomes, but
on relationships between the health profession and
marginalised populations as a whole. BJN
Conflict of interest: none
Bauer G, Scheim A, Deutsch M, Massarella C (2013) Reported emergency
department avoidance, use, and experiences of transgender persons in
Ontario, Canada: results from a respondent-driven sampling survey. Ann
Emerg Med 63(6): 713–20.e1. doi: 10.1016/j.annemergmed.2013.09.027.
Epub 2013 Nov 1
Blanchard J, Lurie N (2004) R-E-S-P-E-C-T: Patient reports of disrespect in
the healthcare setting and its impact on care. J Fam Pract 53(9): 721–30
Canadian Mental Health Association (2014) Lesbian, gay, bisexual and
transgender people and mental health. http://tinyurl.com/oruqhq4 (accessed
6 November 2014)
Chapman R, Nicol P, Shields L, Watkins R, Zappia T (2011) Nursing and
medical students’ attitude, knowledge and beliefs regarding lesbian, gay,
bisexual and transgender parents seeking healthcare for their children. J Clin
Nurs 21(7–8): 938–45. doi: 10.1111/j.1365-2702.2011.03892.x
Dotinga R (2012) Biology Leaves Gay Men Highly Vulnerable to HIV: Study.
US News and World Report, 20 July. http://tinyurl.com/ctgmfs7 (accessed
6 November 2014)
European Network for HIV/STI Prevention and Health Promotion among
Migrant Sex Workers (2009) Sex work in Europe: a mapping of the prostitution
KEY POINTS
n Stigmatisation of transgender sex workers (TSWs) contributes to illness and
poorer health outcomes for this population
n Nurses, as leaders and as frontline staff, are in a unique and powerful
position to improve the quality of life and health outcomes for their clients
n Due to complex reasons including lack of opportunities and discrimination,
a higher proportion of transgender individuals are attracted to sex work
compared with other genders
n Not all transgender individuals involved in sex work are ‘victims’. Many
are highly-educated, have high self-esteem, and choose sex work as their
career. Reserving judgement is key to providing supportive nursing care to
these populations
n Knowing the issues facing transgender people and sex workers can help
health professionals provide competent care that meets the particular needs
of these populations
1151
 scene in 25 European countries. http://tinyurl.com/khcp673 (accessed 6
November 2014)
Foster J, Richmond I (2003) Negative attitudes toward people with co-morbid
mental health and substance misuse problems: an investigation of mental
health professionals. J Ment Health 12(4): 393–403
Gates G (2011) How many people are gay, lesbian, bisexual, and transgender?
The Williams Institute. http://tinyurl.com/77bdant (accessed 6 November
2014)
Gender Equity Resource Center (2014) Transgender. http://tinyurl.com/
qblhrrp (accessed 6 November 2014)
Grant J, Mottet L, Tanis J (2011) Injustice at Every Turn: A Report of the National
Transgender Discrimination Survey. National Gay and Lesbian Taskforce. http://
www.thetaskforce.org/static_html/downloads/reports/reports/ntds_full.pdf
(accessed 6 November 2014)
Halter M (2008) Perceived characteristics of psychiatric nurses: stigma by
association. Arch Psychiatr Nurs 22(1): 20–6. doi: 10.1016/j.apnu.2007.03.003
Hartney E (2010) What is Stigma? About.com. http://addictions.about.com/
od/glossar1/g/stigma.htm (accessed 6 November 2014)
Hines K,Theodorou S,Williamson A, Fong D, Curry K (2008) Management of
acute pain in methadone maintenance therapy in-patients. Drug Alcohol Rev
27(5): 519–23. doi: 10.1080/09595230802245519
Houston A (2011) Trans sex workers still most vulnerable. http://tinyurl.com/
plkqgew (accessed 6 November 2014)
Kailey M (2014) Trans etiquette for non-trans people. http://tinyurl.
com/697glgh (accessed 6 November 2014)
Klein A (2007) Sticking Points: Barriers to Access to Needle and Syringe Programs in
Canada. Canadian HIV/AIDS Legal Network (Réseau juridique canadien
VIH/sida), Toronto
Langille J (2014) Reducing stigma in health-care settings. http://tinyurl.com/
ldwhsfs (accessed 6 November 2014)
Maze CD (2005) Registered Nurses’ personal rights vs professional responsibility
in caring for members of underserved and disenfranchised populations. J Clin
Nurs 14(5): 546–54
Merriam-Webster (2014) Stigma. http://www.merriam-webster.com/
dictionary/stigma?show=0&t=1415014435 (accessed 6 November 2014)
Mulia N (2002) Ironies in the pursuit of well-being: the perspectives of low-
income, substance-using women on service institutions. Contemporary Drug
Problems 29(4): 711–48
Operario D, Soma T, Underhill K (2008) Sex work and HIV status among
transgender women: Systematic review and meta-analysis. J Acquir Immune
Defic Syndr 48(1): 97–103. doi: 10.1097/QAI.0b013e31816e3971
Overs C (2012) Sex workers: Part of the solution. World Health Organization.
http://www.who.int/hiv/topics/vct/sw_toolkit/115solution.pdf (accessed 6
November 2014)
Preston P (2005) Nonverbal communication: Do you really say what you mean?
J Healthc Manag 50(2): 83–6
Roberson C (2010) Nonverbal communication. Alabama Nurse 3(13): 13–18
Slamah K, Winter S, Ordek K (2010) Stigma and Violence Against Transgender
Sex Workers. RH Reality Check. http://tinyurl.com/2c4he3j (accessed 6
November 2014)
Thornhill L, Klein P (2010) Creating environments of care with transgender
communities. J Assoc Nurses AIDS Care 21(3): 230–9. doi: 10.1016/j.
jana.2009.11.007
Tucker E (2011) Job training programs on the rise for transgender workers.
Prince George Citizen, 7 October
Zunner B, Grace P (2012) The ethical nursing care of transgender patients: An
exploration of bias in health care and how it affects this population. Am J
Nurs 112(12): 61-4. doi: 10.1097/01.NAJ.0000423514.58585.a3

Critiquing Nursing Research 2nd edition

About the book

John Cutcliffe and Martin Ward

This second edition of Critiquing Nursing Research retains the features which
made the original book a
best-seller while incorporating new material in order to expand its applicability.
In addition to reviewing and
Critiquing
Critiquing Nursing Research

updating the material of the original text, the authors have added two further
chapters: the first focuses on
how to critique research as part of the work of preparing a dissertation; and
the second on mental health
research agendas throughout Europe.

Nursing Research
The fundamentals of the book, however, remain the same. It focuses specifically
on critiquing nursing research
and the increasing requirement for nurses to become conversant with research
 This second edition retains all the successful
the use of evidence to underpin practice.
and understand its link with

Having read this book, nurses should be more familiar with the approaches
features of the first, plus additional material and techniques involved in
critiquing nursing research and be able to utilise some of these skills and techniques
critique. Accordingly, they will be better placed to make informed judgements
in their own efforts to
regarding the quality of the
on psychiatric research and critiquing nursing
research paper and the value of the evidence reported.
As nurse education around the world increasingly moves towards an all-graduate
discipline, it is vital for
research when writing a dissertation.
nurses to have the ability to critique research in order to benefit practice.
those seeking to gain or develop precisely that skill and is a must-have for
This book is the perfect tool for

2nd edition
all student nurses, teachers and
academics.

About the authors

 Very suitable
Dr John R. Cutcliffe holds the as
‘David G.students
Braithwaite’ Professor ofhave
Texas (Tyler); he is also an Adjunct Professor of Psychiatric
toChairundertake
Nursing Endowed at the University of
Nursing at Stenberg College International School
a dissertation where they critique three pieces
of Nursing, Vancouver, Canada and a Visiting Professor at the University of
Associate Editor for the Journal of Psychiatric and Mental Health Nursing
Ulster, United Kingdom. He is an
and an Assistant Editor for the
International Journal of Nursing Studies. John’s clinical background is in psychiatric
of nursing research.
worked as a clinician and then as an educator in the United Kingdom. He
worked in universities in four different countries: England, Northern Ireland,
and general nursing, having
is an international scholar having
Canada and the United States.
Martin Ward is an Independent Mental Health Nursing Consultant; he is also
Co-ordinator of Mental Health
Nursing Studies at the University of Malta and Chair of the Expert Panel
Nurses, based in the Netherlands. From 1995 to 2000 he held the post of
of Horatio - European Psychiatric
Director of Mental Health for the
John Cutcliffe and Martin Ward
ISBN-13: 978-1-85642-316-8; 234 x 156 mm; paperback;
Royal College of Nursing. Martin has been a Trustee of the English Health
member of the HAS Inspectorate and has also been involved with work with
Advisory Service (HAS) and a
the World Health Organisation.
Foreword by Professor Kevin Gournay
244 pages; publication November 2006; £25.99
In 1997, both authors were instrumental in designing and launching the NPNR
National Journal Club.
John Cutcliffe and Martin Ward

ISBN 978-1-85642-316-8

Order your copies by visiting

www.quaybooks.co.uk 9 781856 423168
© 2014 MA Healthcare Ltd

or call our Hotline www.quaybooks.co.uk The new and updated edition of the best-selling book
+44(0)1722 716 935
CritiquingNRes3.indd 1

25/03/2011 09:41

1152 British Journal of Nursing, 2014, Vol 23, No 21

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