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Education can help pharmacists feel more comfortable dispensing care.
About 1.4 million Americans identify as transgender (TG) or gender non-conforming. For many of these patients, pharmacotherapy is a part of their gender-affirming transition. Yet, research shows that transgender patients face significant barriers in obtaining healthcare, which can delay treatment and complicate existing conditions. Although pharmacists serve as an important link in providing necessary healthcare, many may not feel confident about dispensing care to transgender patients. Education is key.
The American Psychological Association defines transgender as “an umbrella term for persons whose gender identity, gender expression or behavior does not conform to that typically associated with the sex to which they were assigned at birth.”
“At birth, individuals are identified with a biological sex based on their reproductive organs, whereas gender identity refers to one’s self-identification of being a man or woman or non-binary (neither a man nor a woman),” says Cheyenne Newsome, PharmD, clinical assistant professor in the department of pharmacotherapy at Washington State University’s College of Pharmacy and Pharmaceutical Sciences. “Specifically, the term transgender is used to define people who identify with any gender that is different from their biological sex at birth.”
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Already feeling at odds with a body that does not reflect their identity, transgender patients may face daunting difficulties accessing healthcare. A 2015 U.S. Transgender Survey reported that a third of all transgender individuals who had recently seen a healthcare professional experienced harassment, denial of care, or problems getting reimbursed by their health insurance. Fearing mistreatment, transgender patients may delay getting treatment when they are sick or injured or put off getting necessary preventive care.
Financial challenges may also be a factor, with 50% of transgender persons estimated to earn less than 100% of the federal poverty level and at least 33% being on Medicaid. The 2015 U.S. Transgender Survey found the unemployment rate among transgender individuals to be 15%, three times higher than the national average, which is likely due to discrimination based on their gender identity.
“Many transgender individuals who seek care do not believe that they can receive or afford adequate services for their health, yet they often have pressing health issues that are unresolved,” says Newsome.
According to Michael W. Jann, PharmD, professor of pharmacotherapy at University of Northern Texas System College of Pharmacy, a multidisciplinary care model should include: primary care, family planning, medical procedures, HIV and STD care, medical subspecialties, behavioral health, speech therapy, dentistry, optometry, and community and clinical pharmacy services.
“Transition is a complex and individualized process to help the person transform their physical appearance to match their gender identity,” says Jann. “The time for maximal effects of antiandrogen and estrogen therapy may take as long as three years while testosterone treatments take five years with consistent usage.
Aside from the complex process of transition, transgender patients also need preventive services as well as treatment for various medical conditions. Hypertension, obesity, diabetes, heart disease, and dyslipidemia are also common medical conditions occurring with transgender persons and can be more complicated with long-term hormonal therapies.
Transgender patients also suffer disproportionately from conditions easily exacerbated by stress, such as asthma and gastrointestinal disorders. Due to the stigma and discrimination experienced by the transgender population-especially transgender youth-patients may also be more vulnerable to depression, anxiety, suicidal ideation, self-harm, STDs, alcohol and drug abuse and dependence.
“One of the most alarming statistics is the suicide attempt rate,” says Newsome. “Nearly half of all transgender people reported attempting suicide compared to 1.6% of the general population. This shows that the transgender community needs extra care, attention and support from healthcare providers to ensure we are meeting their healthcare needs and providing a safe environment for them to disclose their gender identity.”
HIV is another problem compounded by a lack of access. The CDC reported that in 2017, the percentage of transgender people who received a new HIV diagnosis was three times the national average. Yet, nearly two thirds of transgender women and men surveyed by the Behavioral Risk Factor Surveillance System (BRFSS) in 2014 and 2015 never got tested for HIV. If they do get tested some patients may wonder about getting treated because the medication might interfere with hormone therapy.
Current Systemic Problems
“Healthcare systems can be challenging, where routine laboratory assessments can be difficult for TG persons as the forms typically include only a male or female designation,” says Jann. “The laboratory interpretation can also be challenging (eg, hematocrit normal range). Electronic medical and pharmacy records may pose a problem as expanded identification beyond the male or female designation is necessary. Transgender persons may change their name, legal sex, and birth certificate, which can present problems in processing insurance claims.”
Anti-discrimination laws don’t always protect transgender patients. Several states have conscience or refusal laws that give pharmacists the right to refuse to perform services that they feel violate their religious or personal beliefs or values. Some of those laws incorporate patient protections, insisting that an objecting pharmacist seamlessly pass on the prescription to a fellow pharmacist who does not object; they may not obstruct the patient from getting a prescription.
In 2018, Hilde Hall, a transgender patient, tried to fill her first prescription for hormone therapy at her local CVS pharmacy in Fountain Hills, Arizona. In a statement to the American Civil Liberties Union, she related her excitement that day at starting therapy, but the pharmacist refused to fill her prescription. She also said he humiliated her, asking loudly, in front of other customers, why she was taking the prescription. Hall eventually filed a complaint with the Arizona State Board of Pharmacy.
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By Arizona state law, a pharmacist cannot be terminated for refusing to fill a prescription that goes against personal religious beliefs; however, the pharmacist did not comply with CVS company policies, resulting in his termination. CVS apologized to Hall for the way she was treated.
“The conduct of the pharmacist, who is no longer employed by CVS, violated company policies and did not reflect our values or our commitment to inclusion, nondiscrimination and the delivery of outstanding patient care,” says Mike DeAngelis, senior director of CVS Corporate Communications.
Since then, CVS pharmacists have been directly involved in the development of a resource guide for providing pharmacy care and services to LGBTQ patients for the Human Rights Campaign (HRC). The guide provides information on LGBTQ identities and terminology, as well as the unique needs of LGBTQ patients.
“We are very proud to have earned a perfect score on the Human Rights Campaign’s Corporate Equality Indexfor the past four consecutive years for our policies and practices related to LGBTQ equality,” says DeAngelis.
The chance to consult with a professional, non-judgmental pharmacist tends to improve adherence for any patient’s treatment, yet many pharmacists who would like to help transgender patients feel unprepared to do so.
“In a recent survey of pharmacists, 83% agreed that pharmacists play an important role in TG healthcare, but only 36% reported confidence to treat TG persons,” says Jann. “Further, 71% of the respondents reported not being educated about TG persons in their pharmacy education. A recent pharmacist’s survey reported that 52% rated their competency to treat TG persons as “very little” or “not at all” while only 15% stated “a lot.”
Alexander Gilmer, PharmD, a clinical pharmacist at New Hanover Medical Center in Wilmington, North Carolina, graduated pharmacy school in 2014. At that time, his education on transgender care was minimal.
“They basically said transgender people are out there and we use hormones with them,” Gilmer says. “There was nothing on how to interact with transgender patients or how to treat these patients with respect. As humans, we worry about accidentally disrespecting people and getting a negative reaction if we say the wrong thing. Without education, it’s this wild west frontier, there’s no idea what to do.”
Improving Awareness & Education
One way to make a pharmacy more gender affirming is to properly address transgender patients, to ask what name they like to use or their preferred pronouns. Addressing patients in the way that feels best to them demonstrates respect.
“You cannot know for certain by someone’s appearance what gender identity they have or what pronoun they use, so you must ask them,” says Newsome.
Pharmacies can also advertise that they are an ally.
“You can add additional signage or displays stating you are transgender or LGBTQ friendly,” says Newsome. “You can personally choose to wear a small emblem that displays a rainbow, inclusivity symbol, or the colors of the transgender flag.”
Ideally, community pharmacy and hospital settings should have gender-neutral bathroom facilities and private rooms for patient consultations.
“Transgender patients may not share their gender transition process or gender identity with all of their social circles due to fear of loss of social relationships, being fired from employment, or physical harm,” says Newsome.
According to Jann, pharmacy, like other healthcare providers, should lead and set an example for its professionals in providing inclusive and competent care for LGBTQ persons.
“Some states (eg New York Council of Health-System Pharmacists have published a position statement supporting education on transgender patient care in pharmacy schools,” says Jann. “Professional education and professionalism are excellent initiatives taken by pharmacy schools and organizations. Further publications in pharmacy including pharmacotherapy, best practices, and research are needed.”
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A recent survey of AACP-accredited pharmacy programs found that half of pharmacy schools addressed the needs of transgender patients in their curriculum.
“This is encouraging, but that also means that half of our pharmacy graduates have no training about the needs of transgender patients and how to provide quality care to them,” says Newsome, who teaches sessions on transgender care to three doctorate of pharmacy programs. “Many large pharmacy meetings have hosted sessions on pharmacists’ role in caring for patients who are transgender. There are webinars available specifically for pharmacists and transgender patient care is also making its way into pharmacy school curricula.”
According to Newsome, providing information on transgender terminology and health disparities as well as how to create a welcoming environment for transgender patients, and providing clinical information about hormone therapies for gender affirmation, definitely delivers results.
Newsome is the author of Addition of Care for Transgender-Related Patient Care into Doctorate of Pharmacy Curriculum: Implementation and Preliminary Evaluation, a study that documented the result of providing three hours of information about transgender healthcare to pharmacy students. Before the class, the median confidence level was 4/10; after the class, the confidence level had risen to 7/10.
Gilmer has also seen a positive response after teaching pharmacists about transgender care. Attending pharmacists said that as a result of the sessions they knew what to do and could more comfortably interact with their patients.
“It made them realize they can’t go into every prescription assuming they have all the info,” said Gilmer. “Maybe look a little further into the patient’s profile. Education can be as simple as learning what transgender people face, what it means to be transgender.”
Gilmer shared the story of a friend who opened a pharmacy that is slowly becoming a trusted resource for transgender patients
“In a short time, she had her transgender patient population go from not having any cases to now having five or six cases,” says Gilmer. “What happened is that people are talking to other people in the community, saying this pharmacy is cool, it’s safe to go to. They are helpful and super respectful.”
Creating a warm and welcoming pharmacy essentially comes down to treating patients with respect.