Nancy JW Lewis, Pharm.D., MPH
adjunct associate research scientist
University of Michigan College of Pharmacy
Consultant, Program Design and Research, Transcend the Binary
Stuart Rockafellow, Pharm.D.
Northern Physicians Organization
patient advocate and peer counselor
Transcend the Binary
Brayden A. Misiolek
Transcend the Binary
The existence of health inequities within the U.S. are well documented.1-3 Such inequities are common among transgender/gender non-conforming (TGNC) individuals.2 who often have limited financial resources, face a scarcity of competent, gender-affirming providers and have complex health needs.
The TGNC Community
Defined as persons whose gender identities, gender expressions or behaviors do not conform to that typically associated with the sex they were assigned at birth,4 TGNC individuals compose about 0.6% of the U.S. population.5 They express their gender identities across a diverse spectrum that ranges from, and outside of, male and female. Selected gender identity terms are defined in Table 1.
TGNC individuals often encounter discrimination.6-10 In the 2015 National Transgender Survey (NTS),10 27,715 self-identified TGNC individuals reported discrimination in schools, workplaces, housing situations, and/or public places. High rates of physical and mental abuse, homelessness, low employment and economic hardship were also reported.10
The risk for discrimination extends into healthcare settings.9,11-14 The NTS reported that a third of respondents who saw a healthcare professional in the past year had at least one negative experience related to being transgender.9 A 2016 survey of 316 TGNC adults found that 41 percent of respondents indicated some degree of worry about discrimination with pharmacists.12 Thirteen percent of respondents reported that past experiences of purposeful embarrassment at a pharmacy caused them to avoid seeking healthcare most or some of the time. Experienced discrimination or worry about discrimination in healthcare settings is associated with anxiety, depression and overall poorer self-reported health.12, 15-17
Fear of discrimination within the traditional healthcare system leads some to seek alternative sources of care from other sources.18,19 The prevalence of hormone use with medications obtained outside of legitimate pharmacies is estimated to be as high as 70 percent among studied populations with rates varying based on geographical location and gender identity.14, 18,19
Pharmacist and Pharmacy Technician Roles in Transgender Healthcare
Given that many (but not all) TGNC individuals seek hormone therapy to affirm their authentic gender (i.e., the gender to which they self-identify), pharmacy staff can play an important role in improving transgender healthcare.20-24 That role can be illustrated by the actions taken by one Michigan pharmacist, Darnell Jones. In 2013, Darnell began practicing in the Palmer Park area of Detroit. He soon realized he was serving a community of TGNC patients that desperately needed access to medical care. Many patients obtained hormones from black market sources and few knew health providers that offered affordable, gender-affirming care. Darnell educated himself about transgender health, counseled patients about hormone therapy, established a referral process to transgender specialists and co-founded a TGNC advocacy organization, Transcend the Binary. Within a few years, his actions as a pharmacist and ally touched the lives of hundreds of TGNC individuals.
Darnell’s path to care began with researching the literature and discussions with TGNC patients and medical specialists. It is not uncommon for health professionals to have little or no formal education in transgender health. One study found that over 60 percent of pharmacy residents surveyed felt unprepared to provide care to TGNC patients.25 Fortunately, resources are available to assist pharmacy staff gain competency. The World Professional Association for Transgender Health (WPATH) Standards of Care26 is a foundational document for understanding transgender health. Organizations such as The Endocrine Society,27 University of California, San Francisco Transgender Health Clinic, 28 Lorde-Callen Clinic 29 and Fenway Clinic30 have published therapy guidelines. The National Center for Transgender Equality (https://transequality.org), Fenway Health (FenwayHealth.org) and Rainbow Health Ontario (https://www.rainbowhealthontario.ca) have online health professional educational resources. In Michigan, the Oakland County Pharmacists Association has partnered with TGNC advocates to offer a transgender health continuing education program. Numerous articles discuss appropriate pharmacological care for TGNC adult and/or adolescent patients. 31-38
The most meaningful learning, however, may be gained through interactions with TGNC individuals. Spending time at transgender medical practices, meeting with TGNC community members, and attending advocacy events can provide insight into the daily lives and health needs of this community. These interactions will likely highlight the numerous health-related risks existing within the TGNC community including depression, anxiety, suicidality, interpersonal trauma, substance abuse disorder, smoking and HIV/AIDS. 10, 17, 39-41
The foundation for transgender care is a non-threatening pharmacy environment. Gender-affirming policies and practices respect the spectrum and fluidity of gender, protect patient confidentiality, engender trust in patient-pharmacy staff relationships and are responsive to patient needs. Table 2 lists actions that support a gender-affirming pharmacy practice and signal to TGNC patients that the pharmacy is a safe place to seek care. A gender-affirming pharmacy experience, however, begins when a patient walks through the building door. Therefore, all store staff should know how to provide gender-affirming service.
Potential services that pharmacy staff can implement to improve transgender care are described in Table 3. Pharmacists and pharmacy technicians wishing to establish gender-affirming practices should do so in consultation with individuals and organizations from the TGNC community so that services reflect an informed, intentional effort to respectful care.
Transgender healthcare requires a skilled combination of evidence-based practice and culturally responsive care. It must understand and respond to the intersecting impacts of medical care, discrimination and social determinates that influence the health of this population. Pharmacists who undertake this challenging responsibility can improve the health of one of our most vulnerable populations.
Table 1: Common Gender Terms
Agender: genderless, internally identifies as neither male or female
Authentic gender: self-conception of gender identity
Bigender: gender identity is a combination of male and female
Cisgender: gender identity aligns with sex assigned at birth
Gender fluid: gender identity and presentation shift across gender spectrum
Genderqueer/gender nonbinary: identity lies along or outside the gender spectrum
Transgender (or trans) female: identifies as female but assigned male at birth
Transgender (or trans) man: identifies as male but assigned female at birth
(Adapted from references 4,36)
Table 2: Actions for Implementing a Gender-Affirming Pharmacy Practice
Post a notice that gender-inclusive care is provided, have LGBTQ-friendly pamphlets in the waiting area, or wear a lapel pin that has LGBTQ colors or indicates your chosen pronouns (e.g., she/her)
Establish a relationship with individual TGNC patients by letting them know that you wish to assist and support them in their therapy decisions
Connect to the TGNC community by attending local TGNC events to gain first-hand knowledge of the needs and culture of this community
Visit the offices of local transgender specialists. Ask for opportunities to learn about their services and let them know that patients referred to you will receive respectful care
Establish gender-affirming policies
Collect and document preferred name and pronouns in the pharmacy profile for all patients and apologize immediately if the wrong name or the wrong pronoun is used
Ensure that patients receive respectful care even if a specific staff member is uncomfortable dispensing hormone prescriptions for physical, mental and/or emotional alignment
Create a consistent pharmacy policy about the dispensing of syringes and communicate that with all TGNC patients
Establish a gender-neutral bathroom or a bathroom use policy that allows people to use the bathroom that is right for them
Create a safe environment for patient care
Use private areas for counseling
Ask, don’t challenge, patients about doses, dosage schedules or administration instructions that differ from general guidelines. These prescriptions offer opportunities for discussing patient therapy goals.
Document verification of hormone prescriptions in the pharmacy profile so patients are not re-questioned about therapy appropriateness on future pharmacy visits.
Avoid unnecessary personal questions that are not pertinent to patient care
Table 3: Potential Services to Offer within a Gender-Affirming Pharmacy Practice
Information and counseling about hormone therapy effects and side effects for patients who are considering whether such therapy is appropriate for them
Information, education and therapy management for those prescribed hormone therapy
Education about hormone injection techniques and assistance/coaching with initial hormone injections
Assistance with obtaining hormone therapy at an affordable price, especially for those who have high co-payments or who lack prescription insurance
Counseling about the use and safety of non-traditional health interventions commonly used by the TGNC community
Referral information for gender-affirming medical providers and other health professionals or service and navigation organizations such as Trans Lifeline (1-877-565-8860), a national suicide and support hotline or Transcend the Binary (info@TranscendtheBinary.org), a Michigan-based advocacy and service navigation organization
Offering of telephone or telecommunication counseling as an addition or substitute to in-pharmacy counseling
HIV screenings, counseling related to HIV pre-exposure prophylaxis (PrEP) and counseling and drug therapy management related to HIV treatment
Tobacco cessation counseling
Hepatitis C screenings, counseling and drug therapy management related to Hepatitis C treatment
Hepatitis A immunizations
Screenings, brief interventions and referrals to therapy for depression and substance abuse disorders
(References 12, 20-24)
Nancy JW Lewis, PharmD, MPH
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