Frieda Wiley, PharmD, BCGP, is a writer and pharmacist. 

Frieda Wiley, PharmD

Diversity and inclusion remain a hot topic, but the embers that continue burning into the American conscience far transcend race and ethnicity. Like minority communities, the LGBTQ+ community also wrestles with its own struggles as another medically underserved population smoldering under the ashes, and pharmacists and other health care professionals who serve the LGBTQ+ community are working to establish methods to address these patients’ needs better.

“Historically, the barriers to care for LGBTQ+ individuals are complex and encompass many determinants,” said Tam Phan, PharmD, AAHIVP, assistant professor of clinical pharmacy and clinical pharmacist at the Jeffrey Goodman Special Care Clinic at the USC School of Pharmacy in Los Angeles, California.

The underlying barriers hindering access to health care in the LGBTQ+ community are numerous. Discriminatory practices such as patients having been refused care simply because they are LGBTQ+ and individuals lacking access to affordable health care due to uninsured status (as a result of family rejection, unemployment, and requiring services not covered by insurance) are a few examples.

The number of individuals identifying as LGBTQ+ is on the rise, having increased from 3.5% in 2012 to an estimated 4.5% in 2017 in the United States, with millennials (defined here as individuals born between 1980 and 1999) as contributing to the majority of the uptick, according to Gallup.

Not only do these statistics indicate a growing number of those who identify as LGBTQ+, but they also highlight an opportunity for health care professionals to ensure the provision of inclusive services for this patient population. Pharmacists play an important role in the health care system and can work to address the health disparities that exist for their LGBTQ+ patients.

The factors that compromise health outcomes in the LGBTQ+ community mirror those famously noted in communities of color and exacerbate health disparities by amplifying medical mistrust within the community. Examples include societal stigmas and discrimination.

The sources interviewed for this article did not reach a consensus regarding pinpointing the most significant barrier to creating a quality health care experience in the LGBTQ+ community. However, all cited the lack of awareness regarding population-specific health challenges and negative health care provider interactions as underlying contributors in preventing the LGBTQ+ patient from experiencing an equitable and quality health care experience.

“In a busy clinic or health setting, there will be many staff members who can interact with the patient—all of [whom] can either affirm or hinder the patient’s experience,” Phan said. “In many cases, problems can come from simple oversights or mistakes [from health care staff] who lack understanding—patients having reported hearing jokes or slurs and/or having received insensitive criticism about their appearance or behavior.”

Scott Nass, MD, MPA, a family physician based in Santa Rosa, California, noted that only in recent years has this started to change.

“In this context, we can’t ignore the fact that homosexuality and gender dysphoria were, for so many years, pathologized by organized health care,” he said. Only recently has so-called conversion therapy been widely condemned.”

Nass also serves as the president of Health Professionals Advancing LGBTQ Equality (GLMA) and noted that survey data indicate that more than half of lesbian, gay, and bisexual respondents and nearly 3 out of 4 (70%) of all transgender and gender-nonconforming individuals reported having experienced some degree of discrimination when using the health care system.

Another element amplifying the complexities of serving the LGBTQ+ lies in the community’s diversity, as it transcends many other cultural identifiers such as race, ethnicities, religious affiliation, and socioeconomic class.

These complexities include lack of access to quality health care, lower rates of health insurance coverage, failure to routinely and comprehensively include questions about sexual orientation and gender identity in health surveys and other data collection, and lack of consistent nondiscrimination protections for LGBTQ+ individuals in health care, workplace, housing, and other areas of everyday life.

Although HIV/AIDs is often associated with LGBTQ+ health, the community faces increased risks for many other conditions beyond this infectious disease. LGBTQ+ face greater risks for substance use, obesity, cancers, sexually transmitted diseases, and cardiovascular diseases than the general population.

In particular, those who are gender transitioning encounter compounded complexities and often find themselves at increased risks for some of these health challenges.

“This process often involves hormone replacement therapy that helps in physical transformations, such as the development of breasts, widening of hips, and growth of facial hair, etc,” explained Maria Perez, PharmD, AAHIVP, a clinical pharmacist at Gateway Apothecary in St. Louis, Missouri. “Although these are desirable developments, some patients may develop [adverse] effects such as obesity and cancers or overdose by adjusting their medications.”

Mental health conditions affecting the community deserve special attention, as the circumstances under which the LGBTQ+ population grows up often weigh on their mental, emotional, and psychological health throughout their lives. Children are more prone to bullying, isolation, rejection, depression, and suicide than the general population and are more likely to report suicidal ideations (30% vs 6%; 

 < .0001) and engage in self-harm (21% vs 6%; 

 < .0001) than their heterosexual and non-transgendered counterparts. In addition, LGBTQ+ patients may face societal ostracism, which also predisposes them to circumstances that threaten their health and livelihood early in life. For example, LGBTQ+ youth comprise 40% of all young individuals who experience homelessness.

Unfortunately, inadequate data collection contributes to the inequities affecting the medical treatment for those who identify as LGBTQ+. Many state and national surveys fail to include questions regarding sexual orientation and gender identity.

The health issues impacting the community affect all members—regardless of age. However, LGBTQ+ youth wrestle with their own set of challenges, including increased susceptibility to substance abuse, sexually transmitted diseases, cardiovascular disease, obesity, cancers, isolation, bullying, rejection, depression, anxiety, and suicide.

Establishing Best Practices for Inclusive Care

Despite the barriers hindering the provision of LGBTQ+-inclusive care, sources say there are several steps clinicians and their organizations can take to better serve the community.

For example, Perez’s institution encourages patients to self-identify. The practice allows patients to express how they want to be addressed by elucidating the pronouns they prefer.

Phan also recommends incorporating certain elements into the practice setting that members of the LGBTQ+ community often seek out as indicators that the care they receive will meet their needs. Pharmacists can assess their practice site for nondiscrimination policies. 

Assessment may include examining whether specific needs are met in the daily course of practice, including the following:

Does the practice site include gender-neutral bathrooms?

Are questions on the registration forms and electronic health records tailored to collect information for this demographic?

Is Your Pharmacy Inclusive of the Transgender and Gender-Diverse Community?

The American Pharmacists Association and Human Rights Campaign Foundation recently released a new guide for pharmacies on transgender and gender-diverse inclusion. The guide, which was released on International Transgender Day of Visibility on March 31, serves as an educational tool and resource for pharmacists and pharmacy staff on how to be inclusive to transgender, nonbinary, and gender-diverse patients.

According to the guide, the 6 qualities of a pharmacy that are inclusive of transgender, nonbinary, and gender-diverse individuals are:

To help address mental health concerns, Perez encourages her pharmacist colleagues to establish a rapport with patients by engaging them in conversation. The discussions might reveal mental or psychological challenges.

“The feelings of rejection, unacceptance, confusion, and loneliness are common in this patient population,” she said. And such feelings can lead to psychiatric illnesses such as depression and anxiety, among many others. “A simple conversation can open up a [larger] conversation,” she added. 

Perez recommends pharmacists ask their patients the following questions:

To determine whether patients warrant referral:

“Do you feel little interest in doing things?”

“Are you feeling down and hopeless?” (

a component of Patient Health Questionnaire-2, a screening tool for depression)

Nass and Phan agree that continuing education ranks among some of the most critical strategies organizations can implement to help ease clinician bias and improve patient trust by building a better rapport. For nearly 40 years, the GLMA has offered its 

. The conference is just one of the organization’s initiatives aimed at improving LGBTQ+ health, and its programming includes workshops and research presentations for pharmacists. Phan emphasizes that all health care professionals must take steps to improve their ability to serve the LGTBQ and that these efforts begin with introspection.

“I think it starts with a reflection and reassessment of individual practice and conduct and then [transitions] to reflect on practice policies applied to all workers,” he said.

He encourages pharmacists to educate themselves and their colleagues about LGBTQ+-inclusive care, such as terminology and various social and health disparities. Once this has been accomplished, clinicians can then devise a plan to address these topics in their practice settings. Phan also noted that customizing care for this patient population often requires interdisciplinary and external collaboration, engaging the LGBTQ community itself to learn about patients’ individual experiences and needs.

However, education, training, assessment, and exploration are only part of the work. Successful implementation and practice of such LGBTQ+-inclusive policies require cadence and an ongoing commitment. Institutions must periodically reevaluate their new politics to determine how the practice has changed and the degree of effectiveness.

Check out the following materials for more information on providing LGBTQ+-inclusive care:

Learning resources from the National LGBTQ+ Health Education Center: 

https://www.lgbtqiahealtheducation.org/resources/

Transgender and Gender Diverse Pharmacy Resource Guide

 from the Human Rights Campaign Foundation and American Pharmacists Association: 

https://www.thehrcfoundation.org/professional-resources/transgender-pharmacy-guide

Providing LGBTQ-Inclusive Care and Services at Your Pharmacy

 from the Human Rights Campaign Foundation: 

https://www.thehrcfoundation.org/professional-resources/providing-lgbtq-inclusive-care-and-services-at-your-pharmacy

Newport F. In US, estimate of LGBT population rises to 4.5%. Gallup. May 22, 2018. Accessed May 1, 2021. 

https://news.gallup.com/poll/234863/estimate-lgbt-population-rises.aspx

Hafeez H, Zeshan M, Tahir MA, Jahan N, Naveed S. Health care disparities among lesbian, gay, bisexual, and transgender youth: a literature review. 

. 2017;9(4):e1184. doi:10.7759/cureus.1184

Lesbian, gay, bisexual, and transgender health. HealthyPeople.gov. Updated October 8, 2020. Accessed April 30, 2021. 

https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health

Human Rights Campaign Foundation, American Pharmacists Association. 

Providing Inclusive Care and Services for the Transgender and Gender Diverse Community: A Pharmacy Resource Guide

https://hrc-prod-requests.s3-us-west-2.amazonaws.com/Transgender-Pharmacy-Resource-Guide.pdf?mtime=20210331072012&focal=none

Articles

Addressing the needs of LGBTQ+ patients requires insight, innovation, and introspection.

 Advancing LGBTQ+-Inclusive Care: How Pharmacists Can Better Support Patients

Stories about independent pharmacies not offering COVID-19 vaccines have flooded the local media in places like Philadelphia, Pennsylvania, and Colorado, but a different story is being told on the East and West coasts.

“Independent pharmacies and pharmacy owners can get the vaccine faster because it’s easier for them to communicate with county and city officials,” said Miguel Oseguera, CPhT, owner of Familia Farmacia in Modesto, California. “In fact, we get a lot of customers from chain pharmacies because they can’t get the vaccine there.”

Less than 2 weeks after having met with local government officials, Oseguera received his first batch of the COVID-19 vaccine. He believes the personal interaction helped increase his chances of getting the supply in his store.

Hossein Ejtemai, RPh, who owns Brookville Pharmacy and Wellness Center in Chevy Chase, Maryland, is still waiting for his first shipment, but he is ready to begin administering the vaccine as soon as it arrives. “I can vaccinate up to 500 patients a day if I get a vaccine,” he said.

Ejtemai has a plan that will allow him to immunize patients quickly and efficiently. His current strategy is to vaccinate 25 to 50 patients at the same time. His pharmacy has 2 rooms that can be used for the mass immunizations, where patients will be able to maintain a safe social distance. Each room will hold scheduled immunizations at least an hour apart.

Store owners offer tips for supplying and giving shots.

Independent Pharmacy’s Best Kept Secret in Administering COVID-19 Vaccines

Complementary and alternative medicine (CAM) has grown steadily over the last decade but surged in popularity in 2020—likely due to the coronavirus disease 2019 (COVID-19) pandemic.1 According to the results of a survey conducted by the Council for Responsible Nutrition, users cited overall immune support (57%) and health/wellness benefits (53%) as the most common reasons for increasing their supplement intake.1 With many individuals seeking additional ways to stay healthy, pharmacists are ideally positioned to help educate patients on the appropriate use of these products.

Despite the uptick in CAM use, misconceptions abound among health care professionals, including pharmacists. Two integrative pharmacists seek to dispel these myths and offer their colleagues tips to improve their ability to assist their patients in navigating complementary and integrative care.

"The biggest myth about CAM I keep hearing from medical professionals is that CAM and herbal products don't have evidence behind clinical use," said Marina Buksov, PharmD, health coach, nutritionist, and clinical herbalist based in Brooklyn, New York. "I think because of the lack of education, health care professionals and patients alike are wary of herbal medicine, and there's a general consensus that it's potentially dangerous to use—guilty until proven innocent."

For Hossein Ejtemai, RPh, owner of Brookville Pharmacy and Wellness Center in Chevy Chase, Maryland, the misconceptions surrounding CIM seem to be demographic- and geographic-based.

"People often think there's a [cultural] gap with CAM because people from overseas—especially from the Asian culture—are more likely to use supplements, natural products, and natural remedies," he said. "The younger generation in this country is also changing to CAM because of access to information [via the internet].”



Pharmacists Offer Key Counseling Points for CAM

To optimize their patients' experience with CAM, Ejtemai said pharmacists should seek training.

"Health care professionals are [generally] aware of CAM but most medical professionals, including pharmacists, lack sufficient training in CAM,” he said. "The 3 credits you get in pharmacy school is not enough to assist your patients."

Pharmacists looking to expand their knowledge can choose from numerous certifications, many that are available online and take 6 to 18 months to complete. "Get certified to better educate your patients," Ejtemai said. The Institute for Integrative Nutrition, Duke University, and The George Washington University are among the institutions that offer programs.

After developing their CAM skills, pharmacists should keep several key concepts front of mind when counseling patients on CAM. Most importantly, pharmacists should take the time to ensure patients understand when and how to use these products.

"Natural products have a place in both Eastern and Western medicine, but you have to keep in mind that natural products are generally better for prevention than treatment," Ejtemai explained. "You cannot treat a disease with natural products in the late stages."

Ensure patients understand that, unlike many conventional medicines that often show results in a few days or weeks, natural products can take several weeks to months to work.

Below are more recommendations for pharmacists seeking to educate their patients on CAM use.

Use trustworthy sources to conduct your research.

"It's important to look to reputable resources on topics that we don't have enough education on," Buksov said. She recommends Lexicomp, the Natural Medicines database, and 

 by Memorial Sloan Kettering Cancer Center.

Educate patients taking nutrient-depleting medications on the importance of supplementation.

For example, Ejtemai recommended counseling patients taking metformin on the importance of vitamin B12supplementation to potentially ward off diabetic neuropathy.

Consult with a practitioner, educator, or

researcher who is an expert in the topic about which you are seeking information.

Conventional medicine has exchanged peer reviews for evidence-based medicine, but the sometimes nebulous nature of CAM sometimes warrants peer consultations.

Dietary supplement usage up dramatically during pandemic, new Ipsos-CRN survey shows. News release. Council for Responsible Nutrition. August 20, 2020. Accessed February 6, 2021. https://www.crnusa.org/newsroom/dietary-supplement-usage-dramatically-during-pandemic-new-ipsos-crn-survey-shows

Alternative healing approaches and therapies become increasingly popular among consumers. 

Pharmacists and Patients Navigating Complementary and Integrative Medicine 

Miguel Oseguera, CPhT, got his start in pharmacy by sweeping floors. Although he worked his way up to becoming a pharmacy technician, the first-generation Mexican American never envisioned owning his own pharmacy, let alone bridging the gap in culturally com- petent health care. But that is what happened in summer 2019, when he opened the doors to Familia Farmacia, which serves the Hispanic community of Modesto, California.

Oseguera saw an opportunity to fill a void when the only independent pharmacy in the South Modesto neighborhood

 closed after 34 years. The area, in California’s Central Valley nearly 100 miles from San Francisco, has a largely Mexican and Mexican American population.

“Let's face it: No chain pharmacies or other big businesses were going to come to this area,” he said. “Most of the businesses here are independently owned.”

Oseguera’s pharmacy has features that attract Hispanic patients, one being its location in their neighborhood. In addition, the staff provides service in English and Spanish, something Oseguera emphasized is essential in establishing strong patient rapport.

“Speaking the language is enough already,” he said. “But it’s also an important way to develop a sense of trust that helps your patients relate to you.”

Oseguera, a Modesto-area native, said his cultural ties give him another advantage. “I was born here and raised with Mexican values so that I can relate to the people here,” he said.

Not only are most of Oseguera’s patients Mexican or Mexican American, but many hail from the same region as his family, Michoacán. He equates the high concentration of immigrants from Michoacán in the Modesto area with those from Ireland, Italy, or Asian countries moving to specific regions.

The pharmacy’s inventory and layout reveal another draw for Oseguera’s patients: One wall houses a vast collection of prepackaged herbs used in traditional home remedies in the Mexican culture.

Oseguera’s initiatives are logical and appropriate to address health challenges in diverse populations, according to 

® Editorial Advisory Board member Lakesha Butler, PharmD, BCPS, clinical professor of pharmacy practice at Southern Illinois University Edwardsville.

Members of minority populations “understand the history of medical racism and mistreatment of people of color in this country, enduring it ourselves,” said Butler, who is African American. “This understanding often translates to providing compassionate care and advocating for minoritized communities.”

Innovative Pharmacist Uses Social Media to Reach Minority Populations

Frank North, PharmD, MPA, president-elect of the National Pharmaceutical Association and founder of Frank North and Associates, has dedicated his career to addressing disparities in the African American community. His family history—North’s father was among the first African American students to earn a PhD from the University of Colorado in Boulder—and professional goals illustrate a principle of cultural competency: valuing diversity.

“Many think all people of African descent have the same culture, but African Americans have their own subcultures within their families and throughout different regions of the United States,” North said. “Also, African American culture differs from Africans’ culture from other countries such as Ghana or Europe.”

As a clinical pharmacist for the Rowe Network, a company founded by Tisha Rowe, MD, North uses social media to reach out to African American patients. The company engages patients using a telemedicine network called RoweDocs. North addresses access and adherence issues. He also directs users to other health care providers.

“I try to connect with folks on social media and establish a rapport so I can direct them to health care services provided by people who look like them,” North said. 

Social media is hugely influential in the Black community. According to a 2020 report from Pew Research, 8 of every 10 Black social media users consider it an effective platform for raising awareness of social and political issues.1 Seven of 10 Black social media users view it as a useful tool in influencing decisions. The statistics in Hispanic and Asian communities are similar, and White social media users trail by roughly 10% in each category.

RoweDocs also disseminates information regarding health initiatives such as diabetes month

, breast cancer awareness, and the American Heart Association’s Go Red for Women. Prospective patients visiting the website may subscribe to the company’s newsletter, watch videos, and read blogs. The website also encourages users to leave comments—a feature North said creates opportunity for additional interaction.

Improving Health Literacy Helps Pharmacist Reach Non-English Speakers

Donney John, PharmD, uses his role as executive director of NOVA ScriptsCentral, a nonprofit pharmacy in Falls Church, Virginia, to improve health literacy in non-English-speaking communities. Like other charitable pharmacies across the nation, NOVA ScriptsCentral’s mission is to help underserved populations. John’s organization is predominantly grant-funded and focuses on providing uninsured patients prescriptions at little to no cost.

NOVA ScriptsCentral site users can choose to have the web copy translated from English into Spanish, Portuguese, Chinese, French, Hindi, or Vietnamese. The pharmacy’s efforts to connect with these patient populations do not stop there.

This year marks the launch of the NOVA ScriptsCentral’s Diabetes Access Pilot Initiative 2021

. NOVA ScriptsCentral will offer free insulin to uninsured patients who receive care at any of the 16 clinics with whom the pharmacy partners in northern Virginia.

“Virginia passed a law where the maximum co-pay for insulin is $50,” John told 

®. “This does nothing for people who have no insurance because they always pay cash.”

In addition to generating revenue from donors, NOVA ScriptsCentral is registered as a pharmacy allowed to accept old medications patients bring in and dispense them to others in need. John referenced a charitable pharmacy in California that dispenses medications it has repackaged from physician samples. However, he said, such a practice is illegal in many states. Other states observe a Good Samaritan law that allows them to engage in such activities to improve medication access for patients in need.

John traces his mission to his childhood, growing up among diverse cultures in New York City. Eventually, he would practice as a pharmacist working with underserved communities at a federally qualified health center in Boston. These experiences helped him recognize cultural nuances among minority communities.

“If people of color don’t have access to the right medical care or understand their health, they’ll never improve their health,” he said. “To change their behavior, you must first understand the people and where they’re coming from.”

Despite the efforts of Oseguera, North, and John, and other like-minded pharmacy professionals, Butler said pharmacy practice has yet to master authentic cultural competence.

“Unfortunately, cultural competency in pharmacy has only scratched the surface in addressing the pertinent factors contributing to health disparities,” she said. “There has been a significant gap in addressing racism in pharmacy and health care, resulting in health inequities that persist.”

For example, the coronavirus disease 2019 (COVID-19) pandemic challenged many aspects of the health care system while magnifying disparities regarding access to care, supplies, and mortality in minority communities.

“You see a level of disbelief about the coronavirus and the hesitancy around getting the vaccine that’s more prominent in communities of color—especially in African American communities,” North said. “Minority groups tend to respond better to health care providers who look like them, have their best interest at heart, and are able to break down barriers.”

Unfortunately, the odds that a minority patient can navigate the health care system by only interacting with minority professionals belonging to their communities is statistically impossible

. Consequently, all health care providers and clinicians must improve their skills in serving patients outside their own communities.

Butler emphasized the importance of building trust when bridging cultural gaps, regardless of whether the health care professional shares the same background.

“Patient-provider trust is critical when serving communities of color,” she said. “Trust can be built by addressing unconscious biases, using inclusive language that does not cause further marginalization, and taking the time to build relationships with communities of color, to name a few.”

In the meantime, pharmacies that serve minority communities remain steadfast in their efforts. “If we don’t help our people, who will help our people?” Oseguera asked.

For more information on cultural competency and the pharmacies mentioned in this story, please see the following resources:

http://www.hpoe.org/Reports-HPOE/becoming_culturally_competent_health_care_organization.PDF

Auxier B. Social media continue to be important in political outlets for Black Americans. Pew Research Center. December 11, 2020. Accessed January 7, 2021. https://www.pewresearch.org/fact-tank/2020/12/11/social-media-continue-to-be-important-political-outlets-for-black-americans/. 

Pharmacy professionals serving minority populations aim to bridge gaps in health care access.