By: Kathryn Carson, PharmD Candidate
Now that I have finished my final year of pharmacy school and enter the workforce, I have become acutely aware of any potential gaps in my knowledge, and in my ability to provide high quality professional care to all persons.
As the transgender population becomes increasingly visible and integrated into mainstream society, I have realized that my mandatory pharmacy education and training have not sufficiently prepared me to provide them with the same care as their cisgender (i.e., persons whose sense of personal and gender identity agrees with their birth sex) counterparts. In fact, I am not alone. Multiple studies have indicated that medical providers, including pharmacists, have inadequate training in transgender health. My training thus far has only taught me that transgender persons represent a vulnerable patient group and that I should take extra care to ensure that they feel comfortable, safe and welcome in my pharmacy. But how do I really do this?
First Things First, Use the Proper Pronoun!
Every patient that walks into your pharmacy deserves to be treated equally, fairly and with respect, regardless of gender, race, ethnicity, religion, culture or political beliefs. To treat a transgender person with respect and establish a trusting relationship, it is imperative to use preferred pronouns (i.e. he/him, she/her, they/them). If you’re not sure of how a patient identifies with their gender, don’t assume! Instead, stick to gender neutral language, (i.e. they/them). Making space on pharmacy forms for patients to denote their preferred name and pronouns will also make your pharmacy more LGBTQ+ inclusive. Current gender identity aside, note that biological sex should still be used for calculations of creatinine clearance in transgender patients.
Hormones for Transitioning? You Know More Than You Think!
Recently I was faced with a prescription for estrogen in a transgender woman, and my first thought was, “I’m not an expert in transgender health, I have no experience using hormones for gender transitioning.” I was worried that I would not know how to counsel on her prescription. However, after some reflection, I realized that this is not true. Like all pharmacists, I have been trained to provide counselling on hormone therapy—just for different indications: estrogen for post-menopausal women and testosterone for male hypogonadism or hormone replacement in older men. The same principles of counselling that apply to these therapeutic situations can also be applied to transgender patients receiving hormones for transition (i.e. risk of deep vein thrombosis with estrogen and cardiovascular effects with testosterone). Having said that, educating yourself further on transgender care will allow you to provide more culturally sensitive care and higher quality follow-up for transgender patients (i.e., onset of breast tissue changes, cessation of menses, etc.).
Transgender patients face multiple health disparities compared to their cisgender counterparts, like increased rates of chronic conditions such as asthma and osteoarthritis, alcohol and substance abuse, smoking, depression, anxiety, suicidality and HIV transmission. Take time to offer transgender patients services such as smoking cessation. Refer them to centres for HIV testing and physicians for access to pre-exposure prophylaxis (PrEP). It should also be noted that transgender men still require counselling on teratogenic drugs and routine pap smears for cervical cancer screening, while transgender women require both prostate and breast cancer screening. In addition, for both transgender women and men, bone mineral density tests should be considered if baseline risk is high (family history, prior fracture, corticosteroid use). Make sure your transgender patients are receiving the appropriate referrals for care.
Even though I just graduated, I realize that my formal education did not cover all possible therapeutic topics and like all pharmacists, I will require continuing education to keep up with the ever-changing world of pharmacy. As pharmacists, we have the responsibility, and owe it to our patients, to be knowledgeable of their medical care. Too often, transgender patients report having to teach their healthcare providers about transgender health issues, but it is not the patient’s job to educate us on their care. Thankfully, there are several easy-to-use, and free resources for you to access in your pharmacy. A very useful and local resource is Rainbow Health Ontario – I highly recommend you check out their website for point-of-care counselling resources.
|Rainbow Health Ontario||https://www.rainbowhealthontario.ca/|
|Providing LGBTQ-Inclusive Care and Services at Your Pharmacy (HRC Foundation)||https://www.hrc.org/resources/providing-lgbtq-inclusive-care-and-services-at-your-pharmacy|
|Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline||https://academic.oup.com/jcem/article/102/11/3869/4157558|
|National LGBT Health Education Centre||https://www.lgbthealtheducation.org/|
|Center of Excellence for Transgender Health||http://transhealth.ucsf.edu/protocols|
|World Professional Association for Transgender Health||https://www.wpath.org/|
Faculties of pharmacy need to provide training on transgender health and pharmacotherapy, but until then, the next time a transgender patient walks into your pharmacy, ask for their gender identity, pronouns, preferred name, and be sure to provide private, thorough counselling on any hormone prescriptions, just as you would for any other prescription. We may not feel we are experts in transgender care, but we know more than we think. Combined with accessible resources and a little bit of empathy, caring for transgender patients in the pharmacy just got that much simpler.