Pharmacists' role in provision of transgender healthcare

Implementation of pharmacist-led services for sexual and gender minorities: A multisite descriptive report

PURPOSE

This paper compares and contrasts the implementation of pharmacist-led services for 3 different sexual and gender minority populations across California, Mississippi, and Florida.

SUMMARY

Implementation of pharmacist-led services tailored to sexual and gender minorities may be a potential mechanism to address health disparities in these populations. Clinical pharmacists have the potential to provide care with cultural humility and improve health outcomes by optimizing medication regimens, reducing adverse drug events, enhancing medication acquisition, and improving medication adherence.

CONCLUSION

The services provided by clinical pharmacists varied across sites and included management of gender-affirming hormone therapy, HIV antiretroviral medication adherence programming, primary care and chronic disease state management, and involvement in care related to mental health, psychiatry, and substance use as well as sexual health. Various legislative and regulatory barriers and differences in scope of practice for pharmacists were also identified. This paper advocates for the expansion of pharmacy-led services and the adoption of a culturally humble approach to patient care.

Gender-affirming pharmacotherapy and additional health considerations: A contemporary review

BACKGROUND

Transgender and gender-diverse (TGD) individuals in the United States face health care disparities compounded with discrimination and limited access to necessary medical services. Gender-affirming interventions have been shown to mitigate gender dysphoria and psychiatric comorbidities, yet United States legislation limiting such interventions has increased. As medication experts, pharmacists can facilitate access to care and appropriate use of gender-affirming hormone therapy (GAHT) and educate other health care providers on best practices for caring for TGD individuals in a variety of settings.

OBJECTIVES

To provide pharmacists with a contemporary review of GAHT and associated medication-related concerns.

METHODS

We searched PubMed for articles published until December 2022. MeSH terms such as transgender, transsexual, gender diverse, gender variant, or gender nonconforming in combination with phrases like gender-affirming care, treatment, pharmacotherapy, or hormone therapy were used to capture desired articles.

RESULTS

Feminizing hormone therapy (FHT), such as estrogen and antiandrogen agents, increases female secondary sex characteristics while suppressing male secondary sex characteristics. Masculinizing hormone therapy (MHT) achieves male secondary sex characteristics and minimizes female secondary sex characteristics using testosterone. For both FHT and MHT, the choice of therapy and formulation ultimately involves the patient's treatment goals, preferences, and tolerability. GAHT has additional health considerations pertaining to renal drug dosing, fertility, cardiovascular, and cancer risks. Pharmacists may provide crucial guidance and education to both patients and health care providers regarding risks associated with GAHT.

CONCLUSION

Many pharmacists feel unprepared to help provide, manage, and optimize GAHT. For many TGD individuals, GAHT is medically necessary and a life-saving treatment. Therefore, pharmacists should be provided tools to close knowledge gaps and improve their ability to care for these patients. By offering a thorough updated overview of GAHT, pharmacists can gain confidence to provide appropriate care for this increasingly visible population.

Ohio community pharmacists' provision of inclusive care for transgender and gender-diverse patients

BACKGROUND

Community pharmacists have potential challenges to overcome to care for transgender and gender-diverse patients properly. The American Pharmacists Association and Human Rights Campaign released a resource guide in March 2021 with best practices for gender-affirming care, yet there are no reports of community pharmacists' awareness or implementation of the guide.

OBJECTIVES

This study's primary objective was to assess community pharmacists' awareness of the guide. Secondary objectives were to determine whether their current practices align with the guide's recommendations and whether they are interested to learn more information.

METHODS

An anonymous, institutional review board-approved survey developed from the guide's framework was e-mailed to 700 randomly selected Ohio community pharmacists. As an incentive, respondents could select a charitable organization to receive a donation.

RESULTS

Of the 688 pharmacists receiving the survey, 83 completed it (12%). Only 10% were aware of the guide. A range in self-reported ability to define key terms was found, from 95% for "transgender" to 14% for "intersectionality." Among the guide's suggested practices, collection of preferred names (61%) and consideration of transgender, gender-diverse, or nonheterosexual patients in their staff training (54%) were most often reported. Fewer than 50% reported pharmacy software with key gender-related data management capabilities. Most respondents indicated an interest in learning more about components of the guide, but gaps remained.

CONCLUSION

There is a need to raise awareness of the guide and to provide foundational knowledge, skills, and tools to ensure culturally competent care for transgender and gender-diverse patients and improve health equity.

Educational intervention to improve pharmacist knowledge to provide care for transgender patients

BACKGROUND

Most pharmacists have not received formal training or education in the provision of care for transgender patients. Nonetheless, pharmacists have the potential to be valuable partners in the care of transgender patients, and a continuing education course might be valuable in addressing this knowledge gap.

OBJECTIVE

The aim of this study was to examine the impact of a three-hour continuing education course in improving the knowledge of pharmacists to provide pharmaceutical care for transgender patients.

METHODS

A quasi-experimental, one-group pre-test/post-test study design was used to measure the impact of a three-hour continuing pharmacy education course on the knowledge of pharmacists on transgender care. The course was divided into three units: (1) Transgender Patient Care Introduction, (2) General Health Issues of Transgender Patients, and (3) Gender Affirming Hormone Therapy. A total of 68 pharmacists participated in the study, of which 54 completed both the pre- and post-test. An ANOVA was used to compare differences in knowledge in the group before and after the educational intervention.

RESULTS

The majority of the participating pharmacists were cisgender, heterosexual women who had not received any formal training related to transgender care. Participants demonstrated the largest increase in execution score in the third unit, with a percent improvement of 25.22% (pre-test 45.06%, post-test 70.28%; p<0.001). The average total execution score was 52.15% in the pre-test and 72.89% (p< 0.001) in the post-test.

CONCLUSIONS

Pharmacists benefited from a three-hour continuing education course with an increase in knowledge regarding transgender patient care and hormone therapy for gender affirmation. As this study only evaluated the effect in short term memory, further studies are needed to assess long term impact of the continuing education course on transgender care knowledge.

Pharmacists perceptions and preparedness regarding gender-affirming hormone therapy

BACKGROUND

As the transgender and gender non-conforming (TGNC) population in the United States continues to grow, there is a need for health care providers who are competent in managing gender-affirming therapy (GAT) for these individuals.

OBJECTIVES

The purpose of this study was to assess practicing pharmacists' readiness to care for transgender and gender nonconforming (TGNC) patients and to compare the perceptions between pharmacists who have received formal education about gender-affirming therapy (GAT) and those who have not received such training.

METHODS

This was a cross-sectional study that was conducted online over 4 weeks (January 2019-February 2019). A survey was distributed to pharmacists in the United States. Distribution of the survey was conducted through professional pharmacy social media groups. Respondents were asked to anonymously rate their perceived preparedness to care for a TGNC patient and to disclose any formal GAT training they had received during pharmacy school or through continuing pharmacy education. Responses were further stratified on the basis of self-reported completion of GAT education taken after pharmacy school. The responses of those who had received GAT training were compared with the responses of those who had not received GAT training.

RESULTS

The results of this survey indicated that few pharmacists felt prepared to care for TGNC patients. Furthermore, few pharmacists report receiving formal education over GAT during pharmacy school or postgraduation. Approximately 41% and 40% of respondents, respectively, reported that they did not feel prepared to make recommendations to other health care providers on GAT and counsel TGNC patients about GAT regimens. However, the self-reported GAT-trained pharmacists showed a significantly increased level of perceived preparedness in caring for TGNC patients when compared with pharmacists who did not receive such education.

CONCLUSION

Increased accessibility to GAT education for pharmacists may be associated with a significant growth in pharmacists' perceived ability to provide care for and interact with transgender patients.

Intersecting Experiences of Healthcare Denials Among Transgender and Nonbinary Patients

INTRODUCTION

Transgender and nonbinary individuals experience high levels of health disparities and are more likely to experience denials of health care than their cisgender (nontransgender) counterparts. There is a lack of evidence on how healthcare denials vary by gender identity and other intersecting identity characteristics in the transgender and nonbinary populations.

METHODS

Using data from the 2015 U.S. Trans Survey (n=27,715), multivariate logistic regressions were used to analyze (in 2019) the increased likelihood of experiencing denials of trans-related care and standard care across socioeconomic and identity characteristics among the transgender and nonbinary population, including race, age, educational attainment, disability, income, and gender identity.

RESULTS

Almost 8% of the participants had been denied trans-specific health care, and >3% had been refused general health care. Transgender (compared with nonbinary), older, biracial, or multiracial, and lower-income participants, as well as those with less than a high school diploma and those with disabilities, were significantly more likely to experience refusal of care in general or trans-specific healthcare settings.

CONCLUSIONS

There is a need for better training of healthcare providers to be inclusive and reduce denial rates of their transgender and nonbinary patients. However, it is also clear that current rates of denial must be considered through a whole-person lens, considering the experience of concurrent oppressed identities and recognizing the increased risk those with multiple marginalized identities experience in being denied needed health care.

Student pharmacists' perceptions of transgender health management

INTRODUCTION

To measure the general perceptions and attitudes of pharmacy students toward transgender patients and health and evaluate students' level of support for receiving education in transgender healthcare.

METHODS

This study was a cross-sectional survey delivered online to approximately 60 s-year pharmacy students enrolled in a required pharmacotherapy course at the University of Maryland School of Pharmacy. Students received a survey link, with five questions for completion prior to the "Gender Transition Therapeutics" lecture and a separate link with 11 questions for completion post-lecture. Responses were anonymous with no identifiers collected and multiple-choice, using Likert-scale questions aimed at gathering respondents' perceptions of managing transgender patients and support for receiving additional education in transgender healthcare.

RESULTS

Survey results indicated that students' cultural competency and confidence in managing transgender patients increased after lecture, and that they support integrating transgender health into pharmacy education. Significant findings include: 67% of students lacked confidence in their ability to treat transgender patients prior to the lecture while only 20% of students reported this lack after the lecture. 51% of students reported being aware of barriers-to-care experienced by the transgender population compared to 92% of students after the lecture. After the lecture, 87% agree pharmacists need more education in transgender health, and 74% support integrating this education into pharmacy curricula.

CONCLUSIONS

Students' confidence in managing transgender health increases after didactic education, and overall, students support integrating transgender health education into pharmacy school curricula.

Pharmacists' acceptability of a men's mental health promotion program using the Theoretical Framework of Acceptability

INTRODUCTION

Community pharmacists are accessible, knowledgeable, and capable of providing mental health promotion and care in communities. This may not be a role that is recognized by the public, and men in particular. Differences between men and women exist in help seeking practices. Headstrong-Taking Things Head-On is a men's mental health promotion program for community pharmacies that was designed to increase the capacity of community pharmacists in caring for men with lived experience of mental illness and addictions. The program's core components included signage in pharmacies, education and training for pharmacists, and a website for use with patients.

METHODS

We applied the Theoretical Framework of Acceptability as the coding scheme to pharmacists' qualitative interviews to examine the acceptability of Headstrong for pharmacists.

RESULTS

Nine pharmacists consented to participate and all chose telephone interviews. With the exceptions of ethicality, affective attitude, and opportunity costs, all components from the TFA were coded in each of the nine transcripts. The most frequently coded constructs were perceived effectiveness of the intervention, burden, and self-efficacy. These were coded at least 20 times. The remaining categories ethicality, intervention coherence, affective attitude, and opportunity costs were coded between 11 to 17 times. Pharmacists' perceptions of the effectiveness of the program was mixed. The overall burden was perceived to be low, but opportunity costs appear to have limited the participation of some pharmacists in the program.

CONCLUSION

Use of the Theoretical Framework of Acceptability as a coding scheme for qualitative data from community pharmacists in a men's mental health program was helpful for identifying issues with the program that may require redesign (e.g., signage). Program design should consider how services are advertised in the pharmacy setting, how personal values of pharmacists influence intervention coherence, and whether minimizing the burden of an intervention negates issues related to opportunity costs.

The Evolving Role of Pharmacists in Transgender Health Care

Pharmacists are increasingly part of a multifaceted team providing health care to members of the often marginalized transgender (TG) community. Some pharmacists, however, may feel unprepared to care for and interact with TG individuals. By providing comprehensive, respectful, and gender-affirming support, improving physical pharmacy environments with policies and procedures, pharmacists can be trustworthy providers for TG patients. This review focuses primarily on the health issues of TG persons and the pharmacist's role in promoting health, identifying barriers to health care, and providing health care resources for TG persons. The evolution of psychiatric diagnostic criteria, access to health care, and inclusion of TG, lesbian, gay, and bisexual topics in the educational curriculum are presented. Cultural competency and diversity training that addresses gender identity and sexual orientation issues should be important interdisciplinary and interprofessional activities for all health care professional education programs. Pharmacists play a key role in the health care needs of TG persons that include appropriate laboratory monitoring, complex pharmacotherapeutic challenges, and providing unbiased gender-affirming interactions. The pharmacy's physical environment, staff training, and policies and procedures can offer unique services to TG persons.

Illness Management in Older Lesbian, Gay, Bisexual, and Transgender Couples: A Review

More openly sexually and gender diverse people are aging into later life across the world as generational transitions occur. People identifying many different ways beyond cisgender and heterosexual are diverse with respect to many other characteristics and sociopolitical locations across the globe and may thus experience a wide array of health journeys both individually and as partners in intimate relationships. In this review article, we summarize the major contributions of and ongoing gaps in existing studies about such couples’ experiences of chronic disease management in later life. We focus on three key groups of findings from prior research about the health of older sexually and/or gender diverse couples: care practices, unmet needs, and diverse resources. We outline priorities for future research within and across these topic areas and in varied locations, with unique recommendations for scholars in both academic and clinical settings. These recommendations support greater integration of such populations, topics, and needs in existing discourse on aging and late life. Likewise, recommendations from this review illuminate potential best practices for engaging and serving these elders in both academic and applied settings.